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PROGRAM AND ABSTRACTS ANNUAL CLINICAL MEETING

SOCIETY OF PERINATAI. OBSTETRICIANS

JANUARY 22 - 24, 1981

San Antonio, Texas

Hilton Palacio Del Rio

PROGRAM AND ABSTRACTS ANNUAL CLINICAL MEETING

SOCIETY OF PERINATAL OBSTETRICIANS

JANUARY 22 -- 24, !981

San Antonio, Texas

Hilton Palacio Del Rio

FRIDAY, JANUARY 23, 1981

7:00 - 8:00 A.M. Continental Breakfast Corte Real

8:00- 8:15 A.M. Donald M. Sherline, M.D. President

8:15- 8:45A.M. Introduction and Background "Consensus Development and Cesarean Birth": An Obstetrician’s perspective of the process and its’ medical implications.

Mortimer G. Rosen, M.D. Moderator

8:-1-5 - 9:15 A.M.

9:15 - 9:30 A.,~I.

A review of the National and the New York City Data: The problems and need for improved data sets.

Audience Discussion

Diana Pettiti, ~d.D. Department of Medical .~lethod Research, The Permanente Medical Group, Oakland, Ca.

9:30 - 10:15 A..~I. Obstetrical Instruments for Data Acquisition: Two different community experiences.

Cal Hobel, ,~t.D. Robert J. Sokol, M.D.

10:15 - 10:30 A.M. Audience Discussion

10:30 - 11:00 A.M. Coffee Break

11:00 - 11:30 A.M. A [:lesponse to the Consensus Development - Conference on Cesarean Childbirth: Areas for needed research to answer questions.

John Hobbins , .~I.D.

11:30 - 11:45 A.M. .Audience Discussion

11:45 - 12:30 P.M. Round Table Moderator: Mortimer G. Rosen, M.D. Diana Pettiti, M.D. Cal Hobel, M.D. John Hobbins, Robert J. Sokol, M.D.

NOTE: All members may obtain a copy of report and final Consensus Statement by writing to:

Duane Alexander, M.D.* Assistant to the Director, NICHD National Institute of Child Health and Human Development Building .31, 2A16 9000 Rockville Pike, Bethesda, Maryland 90205

*Flequest current Consensus Statement plus old report.

The Annual Business Meeting will follow the conclusion of this program.

SATURDAY, JANUAR’i 24, 1981

7:00 - 8:00 A.3I. Continental Breakfast Corte Real

8:00 - 12:30 A.M. Work in Progress - Abstracts of Current Investigation Robert Sokol, ~I.D.

SATURDAY, JANUARY 24, 1981 (Cont.)

8:00 - 10:00 A.M. Moderator: Donald M. Sherline, M.D.

Selecting Thresholds for Further Testing in a Screening Test for Gestational Diabetes Carpenter, M.~’., Coustan, D.R. Discussant: M. Carlyle Crenshaw, M.D.

2, The Assessment of Gestational Age in the Second Trimester by Real Time Ultrasound 31easurement of the Femur Length

O’Brien, G.D., Queenan J.T., Campbell, S. Discussant: Richard Depp, ~t.D.

) Fetal Echocardiography: A Tool for Prenatal Cardiac Diagnosis and Monitoring of Cardiac Function Kleinman, C.S., Hobbins, J.C., Lynch, D.C., Iaffee, C.C., Donnerstein, R., Talner, N.S. Discussant: Frank H. Boehm, M.D.

Effect of Passive Cigarette Smoke Exposure on Maternal and Fetal Thiocynanate Levels

Bottoms, S.F., Kuhnert, B.R., Kuhnert, P.M. Discussant: Roy Petrie, ~I.D.

5. Maternal Serum Alpha-Fetoprotein Levels in the Pregnancy Complicated by Hypertension

Nagle-Olsen, P., Gibbons, It., ].M., Hopkins, Discussant: 5tan Gall, ~,I.D.

Fibrinogen Degredation Products and Factor VII1 Consumption in Normal and Pre-Eclamptic Pregnancies" Role of the Placenta

Keane, M.I~".D., Burdash, N., Faulk, W.P. Discussant: Gary Cunnin~ham, ~t.D.

10:00 - 10:30 A.M. Coffee ’Soft Drink Break Corte Real

!0:30 - 12:30 P..M. Moderator: loseph Seitchek, M.D. San Antonio, Texas

7. Vitamin B12 Binding in Amniotic Fluid (AF) Gross, T.L., Bacon, B.R., Sokol, R.]., Hines, I.D., Giroski, P.M. Discussant: John Queenan, M.D.

Effects of Hexoprenaline on the Lecithin/Sphingomyelin Ratio and Pressure-Volume Relationships in Fetal Rabbits

Lipshit:, 1., Broyles, K., I-Iessler, J.R., Whybrew, W.D., Ahokas, R.A., Anderson, G.D. Discussant: Tom P. Barden, ~.D.

Effects of Intra-Cervically Administered PGEo on Cervical Compliance and Uterine Blood Fto~ in Pregnant Ewes ~

5tys, N.J., Dresser, B.L., Otto, T.E., Clark, K.E. Discussant: AI Killam, M.D.

10. A Review of Formation and Regulation on Gap Junctions of ~lyometrium During Labor Garfield, R.E., Hayashi, R.H. Discussant: J. Gerald Quirk, M.D.

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SATUFIDAY, JANUAHY 24, 1981 (Cont.)

_11. Computerized Data Quantitation in Labor Surviellance Bieniarz, 1., Rabin, S., ~tercado, R., kltamirano, Z., BuM, L., 5commesna, A. Discussant: Barry Schifrin, M.D.

12. Continuous Fetal pH and pO2 with Variable Decelerations of the Fetal Heart Rate

Young, B.K., Antoine, C., Silverman, F. Discussant: John Hobbins, ~l.D.

Society of Perinata! Obstetricians

Annual Meeting San Antonio, Texas

January--1981

~ELECTING [H-:~ESHOLDS FOR Fb~I-H~R T~S:~N~~ ~ ~ I-N-A SCREENING TEST FOR GESTATiONAL ~IA- BET!CS. M~rshal! W. Carpenter, M.D. ~d ~nald R. ~ustan, M.D. (~partm~t of Ob- stetrics and G~ecolo~ and the Robert Woo~ Jonson Clinical Scholar Program, Yale ~.-~ve. sity School of Medicine, New Haven, ~ectlcut) A screening ~est (S~) is used to iden=ify as~p~o~ic patients ~th disease.

7he choice of the test threshold value de=e~nes the tes=’s sensiti~=y, specificity, and the likelihood of false results. Several STs have been proposed for identifying gestational diabetes in gra~dae at risk. ~thou~h e~ch ST must est~ !ish ates= ~hresho!d above which further~ more costly tes=ing is s~ggesse~, the me~hods used for choos~g the threshold are unclear and were the subject of this research. 381 ~s~pto~tic gravldae, ~25 years of age, ~thout kno~ diabetes wer~ screene~ by ~asuring plas~ glucose concentra=ion obtained one hour ~f~er ~ 50~ glucose challenge. ~ose with an S~ value of _13~g%,> ~’ plas~ (llgmg%, ~ole blood were tested further with a 3 hour, i00~ glucose ~tolerance test (GTT). Using an abhor! ~T (O’Sulliv~, 1973) to identify "~e" gestation~ diabetes, ST sensitivity ~d specifici=y were calculated for the entire r~nge of ST glucose values (~ig. i). ~e ST sensitivity increased as =he test threshold was progressively lowered to 135mg% (plash), where the sensitivity bec~e unity. The specificity (which is 1-fraction of f~se positive dia~oses) always remained above 0.8 regardless of the threshold value. ~ne choice of the ~s= appropriate threshold value is aided by constructing a receiver operator ¢haracteris=ic (ROC) curve (Fig. 2). ~e proxi~y of this cu~e ~o the upper left of the graph indicates =he test’s efficiency, achie~ng a high sensitivity a= low fa!se positive ra~es. ~my poin= on ~his cu~e ~y be chosen to dete~ine the diabetes screening test’s ~hresho!d glucose value. ~ operating position which ~ni~zed both false positive and false negative results is Point A, which also, however, produced a fairly insensitive (0.5) tes=. ~s= writers wo~d suggest a more sensitive tes~ (Point B, for ex~ple) at =he cost of more false positive resul~s. For ~king clinical decisions, however, one ~shes to know the likelihood of true diabetes given an "abno~i" ST result. Plot~ing this likelihood (posterior probabilicy of diabetes) against =he possible tes~ threshold values helps dete~ne the best demarka- =ion for clinic~l use (Fig. 3). ~e likelihood of t~e ges~a=ional diabetes is uni~y if the ~es~ threshold is set mt 185mg%~ pl~s~. ~ indicated in F~g. i, a m~i~ (i.0) sensi=ivity is achieved a~ a =hreshold of 135mg%, and Fig. 3 demonr s~rates ~hat with this ~hreshoid~ we still identify a group of gravidae wi~h a 25% likelihood of ges=a~ional diabetes in whom the costs and discomfor= of a GTT are justified. B~ed on these results, a ST ~h~eshold of 13~g~, plas~ (l!gmg%, whole blood) seems warranted, and a GTT is probably un~ecess~ in gravidae whose ST val~e is >190~, plas~ (172mg%, whole blood).

FIG. i SCREENING TEST T~RESHOLDS

FIG. 2

k-SPECIFICITY ;

ROC CURVE

POINT B

POINT A

o FALSE POSITIVE FRACTION

i FiG. 3

POSTERIOR PROBABILITY

,POSITIVE ST AT DIFFEREN$~

~t,.~ i THRESHOLD

120 155 180 205 230

PLASMA GLUCOSE m~%

1 1 1 1

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Society of Perinatal Obstetricians Annual Meeting

San Antonio, Texas January--1981

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THE ASSESSMENT OF GESTATIONAL AGE IN THE SECOND TRIMESTER BY REAL TIME ULTRASOUND MEASUREMENT OF THE FEMUR LENGTH

O’Brien, G.D., Queenan, J.T., Campbell, S. (Department of Obstetrics & Gynecology, Georgetown University Medical School, Washington, D.C.)

A technique for the measurement of femur length by real-time ultrasound is described and its ability to predict gestational age in the second trimester is assessed.

A qrowth curve of ultrasound femur length in the second trimester was constructed and it was found that gestational age could be predicted with 95% confidence limits to + 6-7 days. This hypothesis was tested on 47 "blind" case~ and found to be reliable. (r = 0.998, p <0.001)

A test of the reproducibility of this measurement gave a mean standard deviation in 30 experiments of 0.8 mm. Ultrasound measurements were also compared with an anatomic model and significant correlation obtained (r= 0.998, p <0.001).

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Society of Perinatal Obatetricians Annt!al Meeting

San Antonio, Texas

J~nuarv--19$1

FETAL ECHOCARDIOGRAPHY - A TOOL FOR PRENATAL’CARDIAC DIAGNOSIS AND MONITORING OF CARDIAC FUNCTION

Charles S. Kleinman, M.D., John C. Hobbins, M.D., Diana Co Lynch, Co Carl Jaffe, M.D., Richard Donnerstein, M.D. and Norman S. Talner, M.D., Departments of Pediatrics, Obstetrics and Gynecology ’and Diagnostic Radiology, Yale University School of Medicine, New Haven, CT 06510

Advance knowledge of cardiac disease may influence the outcome for affected neonates by allowing parents and physicians to alter manage ment plans for the remainder of pregnancy, delivery and the post- natal period. "By adding echocardiographic imagin~ techniques to our obstetrical ultrasound studies we have evaluated the cardiac structure and function of more than 500 fetuses of pregnancies at "high- risk" for cardiac disease between 16 and 41 weeks gestation. Struc- tural deformities were accurately diagnosed in four fetuses including two cases of right heart hypoplasia0 one univentricular heart and one primitive tubular heart in a "parasitic" hemiacardiac twin. Two of the fetuses were stillborn but in the two with hypo- plastic right heart pediatric cardiac evaluation and therapy was provided at birth, before severe hypoxemia and acidemia could occur. Cardiac ~hythm disturbances have been analyzed in 26 fetuses including 2 cases with congestive heart failure secondary to supra- ventricular tachyrrhythmias. One of these infants was stillborn and the other was electrically cardioverted at birth. Echocardio- graphy offers a means of following cardiac chamber growth and function during therapeutic manipulations. We are currently monitoring the cardiac status of the hydropic non-immunized fetus of a 14 year old woman referred at 26 weeks gestation for evaluation of polyhydramnios. The fetus was judged to be in severe congestive heart failure on the basis of gross fetal edema with ascites, edema- tous placenta, and a grossly dilated heart (total cardiac dimension well above the nintieth percentile for gestational age). Fetal b~adycardia secondary to complete heart block was documented at presentation. Obstetric ultrasound suggests fetal abdominal situs in- versus and echocardiography suggests an atrioventricular canal defect. Fetal digitalis therapy is being monitored following "digi- talization" of the mother. Initial data suggests slight improvement in the fetal status judging from a decrease in cardiac dimension and extent of edema over a 3 week period. The ability to diag- nose cardiac abnormalities in utero has been well established. Using ultrasonic studies to longitudinally monitor cardiac status offers a means to evaluate efforts at in utero treatment of abnormalities - such as the case above or for in utero treatment of dysrhythmiaso Cardioactive agents used durin~ pregnancy may be evaluated. These techniques further the inclusion of prenatal cardiology as a part of the management of patients enr~lled in high risk perinatal programs.

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EFFECT OF PASSIVE CIGARETTE SMOKE F~XPOSURE ON}~TERNAL .~ND FETAL THIOCYANATE LEVELS

Sidney F. Bottoms, M.D., JFACOG, Assistant Professor of Reproductive Biology, Betty R. Kuhnert, Ph.D., Paul M. Kuhnert, Ph.D.

Passive exposure to cigarette smoke has recently been related to increased fre- quencies of respiratory infections and diminished pulmonary function among non- smokers. These studies suggest the possibility that passive smoking exposure during pregnancy might affect the fetus. However, it has been difficult to ciarif" possible effects of passive smoking exposure, in part due to an inability to accurately assess the degree of exposure outside of carefully controlled laboratory settings. Several researchers have advocated the use of serum thiocyanate (SCN) levels to better evaluate the degree of smoking exposure among smokers. The purpose of this study was to determine if passive smoking exposure has measurable effects on SCN levels in the mother and fetus.

To accomplish this, the results of detailed smoking histories were correlated with maternal and fetal cord serum SCN levels in 112 low risk patients. Smoking histories and SCN assays (by the method of Pettigrew and Fell) were performed by independent observers blinded to the other findings. Patients were classified into three mutually exclusive groups on the basis of smoking histories, as follows:

Active Exposure-smokers (N=46) 2. Passive Exposure-non-smokers living in the same household with at least one regular smoker (N=36) 3. No Exposure-neither active nor passive exposure (N=30). Statistical analysis was performed using t-test and linear regression where appropriate.

Analyses showed that the Active Exposure Group reported smoking an average of 14 cigarettes/day, and that the Passive Exposure Group reported that smokers living in the same household smoked an average of 26 cigarettes/day. SCN levels(zmoles/l mean + 1 standard deviation) were as follows:

No Exposure Passive Exposure Active Exposure Materna<SCN 31.1+13.0 41.6+25.8 . 102.2+47.4 Fetal SCN 25.0+11.9 36.5+24.9 87.3+41.1

Maternal and fetal SCN levels were significantly higher in the Passive Exposure Group than in the No Exposure Group (p< 0.05). Fetal and maternal SCN levels were closely correlated (r= +0.94, p< 0.01). SCN levels correlated well with the number of cigarettes actively smoked per day (maternal, r= +0.79, p< 0.01; fetal, r= +0.78, p< 0.01).

The association of increased SCN levels with passive smoking exposure suggests that SCN may be a practical method of assessing passive smoking exposure, and that passive smoking exposure can result in fetal biochemical changes. Moreover, since SCN has previously been demonstrated to be an effective marker of smoking exposure among smokers, and since both SCN and cyanide (which in the body is in dynamic equilibrium with SCN) have been implicated as two of the mechanisms in reduced birthweight from smoking, these findings suggest that future studies might relate passive smoking exposure to reduced birthweight. Finally, these findings suggest that previous studies may have systematically underestimated the effects of smoking due to passive smoking exposure in control groups (non-smokers).

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Society of Perinata! Obstetricians Annual Meeting

San Antonio, T~xas January--1981

MATERNAL ~i~.UM ALPHA-~TOPRO£~IN ~VELS IN’TME PREGNANCY ’Cd~PLICATED BY HYPER- ’ TENSION. Pauline Nagle-Olsen, M.D., John M. Gibbons, Jr., M.D., and Judith C. Hopkins, Ph.D., with the technical assistance of Anne Blake, Department of Obstet- rics and Gynecology, Section of Maternal FeCal Medicine, Saint Francis Hospital and Medical Center, Hartford, Connecticut and Section of Immunology, Center for Disease Control, Atlanta, Georgia

Maternal serum alpha-fetoprotein (AFP) has been determined by RIA in over i000 pregnancies. Analysis of results with regard to medical conditions that complicated many of the pregnancies revealed that women with hypertension had significantly higher levels of circulating AFP (219.4 + 104.7 kU/l, median = 207.5, n = 189) than controls (98.7 + 39.5, median = I00.0, n = 152) after 32 weeks gestation (P<O.O001, ChiSq = 14~.16, by the Kruskal-Wallis test).

The hypertension was classified according to that proposed by the Committee on Terminology of the American College of Obstetricians and Gynecologists, in which hypertension is considered in four categories: (I) Pre-eclampsia, (2) Chronic hypertension, (3) Chronic hypertension with superimposed pre-eclampsia, (4) Late or transient hypertension. The control group comprised one hundred subjects with the following characteristics: Accurate gestational age, normal liver function and glucose tolerance, normal growth pattern, singleton pregnancy and no identifiable ante-partum risk factors. One hundred and fifty two samples were obtained from these patients between thirty two and forty weeks of gestation. The study group comprised seventy one subjects whose pregnancy was complicated by hypertension, distributed as~ follows: twenty five patients with pre-eclampsia, twenty five with chronic hypertension and twenty one with chronic hypertension and superimposed pre-e¢lampsia. A total of one hundred and eighty nine samples were obtained from the hypertensive population.

AFP was significantly elevated in 62 sera from women with pre-eclampsia (239.5 + 87.7, median = 232.0), 70 from chronic hypertensives (159.3 + 73.0, median = T34.0) and 57 from chronic hypertensives with superimposed pre~eclampsia (278.1 + 120.1, median = 240) compared to levels in 152 sera of un¢o~plicated pregnan- lies (P ~0.0001, ChiSq = 102.99; P<O.0001, ChiSq = 38.43; P <0.0001, ChiSq =

103.95 respectively.

The results show that there is a striking elevation of alpha-fetoprotein (AFP) in patients who develop pre-eclampsia. On the contrary, chronic hypertensives who did not develop pre-e¢lampsia or whose blood pressure was well controlled did not have an elevation of AFP. This elevation was noted prior to deterioration in the clinical condition and with reactive non stress tests. Also, there was a group noted with initial elevation of AFP, who were placed on bed rest with subsequent improvement in hypertension and a decrease in AFP values.

The perinatal mortality rate in the study group was 56 per I000 and 0 in the control group.

The elevated levels of AFP associated with pre-eclampsia are striking, as is the associated high perinatal mortality. If AFP is elevated in the pregnancy complicated by pre-eclampsia, it could be a useful test of fetal surveillance.

These studies were supported by a research grant from Pharmacia Diagnostics, Piscataway, New Jersey.

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FIBRINOGEN DEGREDATION PRODUCTS AND FACTOR VIII CONSUMPTION IN NORMAL AND PRE-ECLAMPTIC PREGNANCIES: ROLE

bF THE PLACENTA

Moulton W. D. Keane, M.D., Nicholas Burdash, Ph.D., W. Page Faulk0 M.D. (Depart- ments of Obstetrics and Gynecology, Laboratory Medicine and Basic and Clinical Immunology, Medical University of South Carolina, Charleston, South Carolina)

Fibrin degredation products (FDP) and factor VIII (FVIII) consumption in maternal blood are common concommitants of normal pregnancy. These biochemical findings are amplified in pre-eclampsia, and the degree of amplification is a useful index of the severity of the disease. Several investigators have interpreted these findings as signs of disseminated intravascular coagulation (DIC), but it is not known whether these coagulation changes are etiological or con- sequential. A central role for the placenta in the pathophysiology of FDP gener- ation and FVIII consumption in normal and pre-eclamptic pregnancies is suggested by the return of clotting factors to normalcy following delivery. Immunohisto- logical studies on mature and immature placentae suggest the involvement of clotting processes in normal pregnancies. The present report involves similar studies to determine if these processes are amplified in placentae from pre- eclamptic pregnancies.

Placentae were obtained from 30 healthy women who gave birth to healthy babies and from 20 women who developed pre-eclampsia during the third trimester. Cryostat sections of these placentae were incubated with fluoresceine-labeled antisera to fibrin, plasmin, FVIII, and the protease inhibitors ~2 macroglobulin (A2M) and ~i antitrypsin (AIAT). Serum levels of the protease inhibitors were obtained and consumption of FVIII (AFVIII) was determined by the difference between plasma FVIII antigen (FVIIIag) and FVIII activity (FVIIIac). Our results indicate that these coagulation factors as well as the protease inhibitors are located in intervillous fibrin (IVF) and fibrinoid areas (FA) in both normal and pre-eclamptic placentae, but in greater amounts in the latter. On the other hand, ~erum levels of protease inhibitors are significantly reduced whereas the plasma AFVIII is significantly increased in pre-eclampsia. This suggests seques- tration of protease inhibitors to the placenta. Localization of coagulation factors and protease inhibitors within identica! areas of the placenta suggests a functiona! relationship. Protease inhibitors modulate the fibrinolytic activity of plasmin which could produce FDP from IVF and FA. Imbalances in sub- strate (IVF and FA) formation, plasmin production or protease inhibitor modula- tion could account for elevated FDP in maternal blood. Indeed, increased amounts of fibrinoid have been reported in pre-eclamptic placentae. The increased AFVIII in pre-eclampsia is puzzling. However, in vitro experiments indica£e that digestion by plasmin results in rapid inactivation of FVIII ac, hence an increase in ~FVIII. The in vivo interaction of plasmin in IVF and FA with materna.l FVIII in the intervillous space could similarly produce an increase in AFVIII. Our results indicate that the fibrin degredation and FVIII consumption seen in pre-eclampsia could reflect amplification of normal physiologic events within the placenta without invoking the concept of DIC.


Socicty of Perinatal Obstetricians Annual Meeting

San Antonio, Texas~ January--1981

VITAMIN BI2 BINDING IN ~MIqlOTIC FLUID (AF)

Gross, T.L., M.D., Bacon, B.R., M.D., Sokol, R.J., M.D., Hines, J.D., M.D., Giroski, P.M., B.S. (Department of Obstetrics and Gynecology, The Perinatal Clinical Research Center, and the Department of Medicine, Cleveland Metropolitan General Hospital, Case Western Reserve University).

The fetal gastrointestinal (g.i.) tract has been relatively inaccessible to study

and clinical assessment. Important g.i. secretions include the vitamin BI2 binding proteins, cobalophilins and intrinsic factor. Cobalophilins are proteins previously found in saliva, tears, granulocytes and maternal serum. Since intrinsic factor is secreted by parietal cells of the stomach into the gut lumen and is not found in peripheral blood, intrinsic factor if present in AF would presumably be fetal in origin and a potential measure of fetal g.i. maturation

and function. Our purpose in this exploratory study was to relate vitamin BI2 binding in AF with modified Dubowitz gestational age as a basis for further hypotheses concerning fetal goi. development.

AF was obtained upon clinical indication with informed consent from 109 gravidas. Total vitamin B 2 binding capacity and B.2 binding due to intrinsic factor were determined by the albumin-coated charcoal method of Gottlieb, et al.

Linear regression revealed a strong positive correlation between total B!2 binding concentration and gestational age from 16-&2 weeks (r = .83, p < .001), which was not improved by polynomial regression beyond a linear fit. Intrinsic factor also increased significantly with gestational age ( r = .27, p< .01), but relatively high levels were present in some fluids as early as 16 weeks and none was detectable in some fluids obtained at full term. AF vitamin B.^ binding appeared unrelated to the presence of meconium in AF or altered fetal growth. In one near term patient with antenatally diagnosed fetal small bowel obstruction and polyhydramnios, the level of AF intrinsic factor was more than fourfold higher than

that found in any other term fluid (ii.0 ng. BI2 bound/ml. AF) o Total BI2 binding was not increased in this patient’s AF.

These results are consistent with the following interpretation: Fetal saliva and tears both have direct access to AF. Since fetal lacrimal glands are probably not functional, fetal salivary gland cobalophilins may be the major contributor

to BI2 binding in AF. Their observed appearance and increase with gestational duratlon may be a reflection of the turning on and maturation of enzyme systems necessary for their secretion. Increasing levels of intrinsic factor in AF are consistent with increasing parietal cell number and/or function. Intrinsic factor has previously been found in homogenates of feta! stomach at the end of the first trimester; and although it was found in this study in some AF samples at 16 weeks, it was absent from others at term. This suggests that additional factors must control the AF intrinsic factor concentration. That intrinsic factor concentration was found not to be increased in meconium stained fluids, but was markedly elevated in the presence of fetal bowel obstruction, suggests it is metabolized in the fetal g.i. tract and that its major route of egress may be via fetal regurgitation.

This study provides new information relating to the development of another important fetal system and leads to hypotheses concerning fetal g.i. function that will require further study.

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San Antonio, Texas

January--1981 I I

EFFECTS OF HEXOPRENALINE ON THE LECITHIN/SPHINGOMYELIN RATIO AND PRESSURE- VOLUME RELATIONSHIPS IN FETAL RABBITS

Jeffrey Lipshitz, M.B.Ch.B., Karen Broyles, B.S., Jack R. Hessler, D.V.M., W. D. Whybrew, M.S., Robert A. Ahokas, Ph.D. and Garland D. Andersen, M.D. (Department of Obstetrics and Gynecology, Division of Maternal/Fetal Medicine, The University of Tennessee Center for the Health Sciences, Memphis, Tennessee)

A placebo-controlled, double-blind trial was carried out on 74 New Zealand White rabbit fetuses from 15 does to assess the effect of a fetal injection of Hexoprenaline (B2-sympathomimetic drug) on surfactant release. After exposing the uterus, half the fetuses received 0.i ml (0.25 ~g) hexoprenaline injected intraperitoneally through the intact uterine wall; the other half received an equivalent volume of placebo. After 3 hours, the abdomen was reopened and the fetuses surgically delivered and killed before breathing. The L/S ratios, obtained from lung washings, revealed a mean of 1.59:1 for the placebo group and 1.92:1 for the hexoprenaline group (p < .001).

Pressure/volume curves were generated from the lungs of 24 fetuses from i0 does and the volume of air in the lungs for each pressure was analyzed in four ways: total volume; volume per gram of fetal body weight; volume per gram of dry lung weight; and as a percentage of total lung capacity at 40 cm/H20 pressure. A first and second inflation-deflation curve was obtained for each experiment. The lungs from the hexoprenaline treated group retained significantly more air than the placebo group. The most significant comparison was obtained when lung volume was expressed per gram of dry lung weight. The possibility of administering a B2-sympathomimetic drug to the mother in advanced preterm labor, specifically to release surfactant in the feta! lung, is suggested.

40 40-

T T

T/

0 0 0 5 I0 ~5 20 25 50 55 ~0 0 5 IO 15 20 25 30 55 40

PRESSUR£ CM H20 PRESSURE CM H20

Comparison of Inflation-Deflation Curves between Hexoprenaline and Placebo groups. Standard Errors included were Hexoprena!ine and Placebo groups are significantly different (p < 0.05).

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San Antonio, Texas January--J981

THE EFFECTS OF INTRA-CERVICALLY ADMINISTERED PGE2 ON CERVICAL COMPLIANCE AND UTERINE BLOOD FLOW IN PREGNANT EWES

Stanley J. Stys, M.D., Betsy L. Dresser, Ph.D., Thomas E. Otte, B.S., and Kenneth E. Clark, Ph.D. (Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine, Cincinnati, Ohio 45267)

During the last decade several clinical trials have demonstrated the effectiveness of prostaglandin E2 (PGE2) in inducing labor or abortion. Whenever these studies have given any consideration to the mechanisms of action of PGE2, most attention has been paid to the effects of PGE2 on myometrial contractility. Several in vitro and animal studies have suggested that PGE2 may also act to decrease intrinsic cervica~ance. The effects on the clinical state of the cervix of PGE2, when administered vaginally or intracervically, also provide some evidence that PGE2 may induce cervical changes as well as myometrial activity. In addition, recent studies of PGE2 production by the cervix of humans and sheep add support to the concept that PGE2 may be important in the biophysical changes which occur in the cervix at parturition.

’ The purpose of this study was to determine whether PGE2, administered intracervically, induces changes in cervical compliance independent of uterine activity and/or changes in uterine blood flow. A chronically instrumented pregnant sheep model was used which allows the measurement of cervical compliance throughout the intracervical administration of test compounds such as PGE2. A substantial parturitional change in cervical compliance has been demonstrated previously by the investigators using this model. Because of the potential effect of PGE2 on uterine contractility and blood flow, these parameters were also measured routinely during the study.

Eight ewes of mixed breed with pregnancies of known gestational length were studie~d. All animals were chronically instrumented with pressure balloon catheters in .the cervical canal, to measure cervical compliance, and in the amniotic cavity, to measure uterine contractility and with an electromagnetic flow probe on a uterine artery to measure blood flow. In addition catheters were placed in the cervical canal, to administer PGE2, in maternal femoral artery and vein, uterine and cervical veins and fetal hindlimb vein to measure various cardiovascular and metabolic parameters of mother and fetus.

PGE2 (10 rag) was administered in a water soluble gel into the cervical canal every four hours times three doses beginning at least five days post surgical preparation (124-142 days gestation). Cervical compliance, uterine blood flow, uterine contractility, and maternal and fetal cardiovascular parameters were measured at regular intervals throughout the administration of the PGE2 and for several days after.

In all eight ewes cervical compliance increased significantly within eight to twelve hours ~ost treatment to levels comparable to that seen at spontaneous parturition (Baseline: 0.08 -+ ~.02 cm3/torr; Peak: 0.58 ± 0.08 cm3/torr). Five of the ewes did not progress into labor; cervical ~ompliance in these animals returned to baseline 24-72 hours after the peak compliance measurement. Uterine blood flow was measured in five ewes during PGE2 treatment and Jemonstrated no significant alterations. Maternal cardiovascular and fetal respiratory parameters were monitored throughout the experiment and remained stable. The present data ~uggest that PGE2 may be an important regulator of the biochemical and physical changes which ~ccur in the cervix at parturition.

(Supported in part by the Whitaker Foundation, Camp Hill, Pennsylvania)

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$OCJcLy o[ l’crina[al ~b~tctricia:~s Annual Mceting


A REVIEW OF FORMATION AND REGULATION OF GAP JUNCTIONS @F MYOMETRIUM ~URING LABOR 1

R.E. Garfield and R.H. Hayashi2,M.D. Department of Neurosciences, McMaster Univer- sity, Hamilton, Ontario, Canadal: The University of Texas Health Science Center

at San Antonio2.

Gap junctions are specialized cell-to-cell contacts which are thought to lower the impedence to current flow between cells. Gap junctions are present in increased frequency between smooth muscle cells of the myometrium of animals and humans during spontaneous labor and parturition. The junctions are also present in increased numbers in tissues from animals made to deliver prematurely. The development of these contacts between smooth muscle cells may synchronize and coordinate the muscle activity of labor while the absence or scarcity of the junctions prior to labor may maintain the muscles in an inactive state and thus maintain pregnancy. An understanding of the mechanism which control the formation of gap junctions and regulate their function may lead to a rational basis for therapy to initiate and prevent labor. We will review I) evidence that gap junctions form in increased numbers in human myometrium during term and premature labor, and 2) the mechanisms responsible for stimulating gap junction formation and regulating their permeability.

We have quantitatively examined myometrial tissue from women undergoing cesarean section at various stages of labor for the presence of gap junctions. Gap junctions were present between smooth muscle cells in low frequency in women with closed cervix and infrequent ~ontractions of the uterus. There was good correlation between

increased cervical dilitation or increased frequency of uterine contractions and increased area of gap junctions. There were more gap junctions in the tissues from women at term who failed to progress in labor than in tissues from women with repeat or elective cesarean section. Also there were significantly more gap junctions in tissues from women with premature labor with failure to arrest than tissues from

similar women with abruptio placenta and premature rupture of the membranes. We propose that the d~Jelopment of gap junctions may be one of the final steps in the sequence of events leading to labor. If these events occur early, they may lead to premature labor.

Our studies have suggested that changes in concentrations of steroid hormones and prostagl~ndins that preceed labor may lead to gap junction formation. Estrogens stimulate gap junction formation in animal tissues in vitro; whereas, progesterone in the presence of estrogen inhibits junctional formation. Also, there is good correlation between changes in estrogen and progesterone and the increase in gap junctional formation. Also, there is good correlation between changes in estrogen and progesterone and the increase in gap junctional area in sheep myometrium during spontaneous parturition and rat myometrium during premature parturition. Cyclom hexamide treatment prevents gap junction formation in vitro and thus, steroid hormones may control synthesis of gap junction proteins. Prostaglandins may also control gap junction formation as indomethacin and several prostaglandin analogs inhibit myometrial gap junction formation. Other studies indicate that channels created by gap junctions may be either an open or closed configuration de~ending on the concentration of intracellular calcium. Although gap junctions are formed during labor, they disappear following delivery of the fetus. We propose that the gap junctions are degraded by an endocytotic lysosomal mechanism. Thus, we suggest a dynmaic system of gap junction formation and regulation that indicate i) a role of steroid hormones in controlling gap junction protein synthesis, 2) a role of prostaglandins directly affecting gap junction structure, 3) a role of calcium in controlling channel opening and functional coupling, and 4) a degradative pathway.

Acknowledgment: Support by Medical Research Council of Canada.

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San Antonio, Texas

January--1981

COMPUTERIZED DATA QUANTITATION IN LABOR SURVEILLANCE. Joseph Bieniarz, Steven Rabin, Ruperto Mercado Zenaida Altamirano, Laurence Burd, and Antonio Scommegna Dept. of OB/GYN, Michael Reese Hospital and University of Chicago, Chicago, IL

Automated quantitation of uterine contractility (UC) and fetal heart rate (FHI tabulated in half hour averages throughout labor could improve human expertise in early diagnosis of fetal distress. Such continuous 24 hr/day surveillance system is being developed in our laboratory for simultaneous monitoring of up to i0 women in labor.

The voltages moving the UC and FHR pens are fed into a 2100 Hewlett-Packard minicomputer. The following parameters are being calculated and tabulated in half hour averages: UC: resting tone, intensity, frequency of contractions, uterine activity and area below the pressure curve. FHR: baseline level, variability, num bet of variations/min. Accerlerations and decelerations: number per 30 minutes (early, late, variable, combined) as well as percentage of contractions accompanie by early or late decelerations, and by artefacts. A videoscope at the nursing sta tion sweeps from one patient to another presenting the computer analysis of UC and FHR graph for the last 30 minutes. Tabulation of all parameters for the last two hours follows. The whole labor progress can be recalled from a keyboard and compared with the present status of labor.

During the last year we have monitored 3,228 patients in labor, using direct internal methods in 492. Apgar score below 6 at five minutes was observed in 41

newborns, while score of 3 and below in 71. Several software modifications were needed including a major recent one. It resulted in 76 percent agreement of compu ter data with human expertise and 72 percent correct recognition of fetal distress

Clinical reliability and usefulness of data supplied by the computer are bein validated now by comparing with:

(a) Human qualitative evaluation of fetal condition from stripcharts, by experts

(b) Biochemical assessment of f~tal and neonata! condition obtained by fetal scalp blood sampling during labor, as well as by umbilical arterial and

venous blood sampling for pH, PO2, pCO2 and BE (c) Apgar score at I and 5 minutes (d) Follow-up of infant’s physical and neurologic condition and future de-

velopment. Using a discriminate function analysis, which weighs each calculated UC and

FHR parameter according to its predictive power, a general index of fetal condition in utero is being developed. We hope to substitute the complex table by a simple numerical value which could provide an ongoing assessment of fetal risk during labor. Treatment could be initiated at the most appropriate time, before irreparable damage to the fetus is done. The subjective visual interpretation of monitored data by the obstetrician will be efficiently complemented by computerize data free from human error resulting from exhaustion, emergency situations in a busy labor unit and varying expertise of the resident.




CONTINUOUS FETAL pH AND p02 WITH VARIABLE DECELERATIONS OF THE FETAL HEART RATE

Bruce K. Young, M.D., Clarel Antoine, M.D., and Frank Silverman, M.~ (Department-of Obstetrics and Gynecology, Division of Maternal- Fetal Medicine, New York University School of Medicine, New York, New York)

Recent development of miniature electrodes for continuous measurement of tissue pH (TpH) and cutaneous p02 (Cp02) has permitted study of the relationship of fetal heart rate (FHR) patterns to pH and p02. Simultaneous determination of continuous FHR, TpH, and Cp02 was performed in 15intrapartum fetuses with variable decelerations of the FHR. Feta! scalp blood samples were obtained just prior to application of the electrodes, and umbilical artery (UA) and umbilical vein (UV) samples were taken at delivery. Blood samples were analyzed for pH and p02. The data show a minimal change in Cp02 with variable decelerations, returning rapidly to baseline values as the deceleration vanishes. No significant change in TpH occurs with variable decelerations. There was a significant decline seen in UA blood pH and p02 with variable decelerations. Intrapartum TpH and Cp02 correlated very well with scalp blood and UV pH and p02. The. changes in Cp02 and TpH suggest that Cp02 rapidly reflects fetal cardiovascular changes, while TpH responds more slowly and less sensitively.

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ABSTRACTS SUBMITTED BUT NOT PRESENTED

t Society of Perinatal

Annual Clinical

Obstetricians

Meeting

January, 1981



A COMPARISON OF TISSUE pH MONITORING WITH A STANDARD BLOOD pH ANALYZER

Clarel Antoine, M.D., Frank Silverman, M.D., and Bruce K. Young, M.D., F.A.C.O.G. (Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, New York University School of Medicine and Bellevue Hospital, New York, New York)

Continuous TpH monitoring requires comparison with intermittent fetal blood samples measured by a standard pH analyzer. In this study, three Roche TpH microelectrodes, two Roche TpH monitors and a Coming oH analyzer were compared. Each system was used to measure four buffer solutions of known pH and two unknown solutions. Using different TpH monitors, the correlation is excellent when compared to each other, with r=0.980 (P<0.0001). In vitro characteristics of the pH electrodes are quite comparable In vitro, the TpH microelectrodes and the Coming 165 Analyzer produce measurements which are nearly identical, r=0.998. Differences between the pH of fetal scalp samples as measured by the Coming 165, and the fetal scalp TpH measurements are observed in vivo. This study demonstrates that such differences are not due to the assay systems. They may be due to biological variation, problems of application of the TpH electrode, or to true differences between blood and tissue pH.

TABLE I - COMPARISON OF ELECTRODES

Buffer Solutions

RANGE OF READINGS

TpH Monitor I , TpH monitor II Corninq 165

6.838 7.00

Unknown I Unknown II 7.382 7.40

6.84-6.86 7.00 7.11-7.12 7.22-7.23 7.38-7.39 7.40

6.82-6.87 6.99-7.01 7.10-7.12 7.21-7.22 7.38-7.39 7.40

6.836-6.840 6.997-6.999 7.121 7.228 7.381-7.384 7.393-7.394



PROPHYLACTIC ANTIBIOTICS FOR CESAREAN SECTION: A COMPARISON OF HIGH RISK PATIENTS VS. LOW RISK PATIENTS FOR THE DEVELOPMENT OF ENDOMYOMETRITIS

Joseph J. Apuzzio, M.D., Christine Reyelt, M.D., Gary Frisoil, M.D., and Donald Louria, M.D. (Departments of Obstetrics and Gynecology and Public Health and Preventive Medicine, College of Medicine and Dentistry of New Jersey, New Jersey Medical School in Newark)

We prospectively and randomly evaluated the efficacy of ticarcillin in preventing post-cesarean section endomyometritis in patients at high risk for the development of such, and compared them to patients who were at low risk for the development of endomyometritis (e.g. elective repeat sections). Patients were randomly placed into a prophylactic group or into a placebo group. Patients were excluded from the study if any antibiotic was given in the two week period preceding the cesarean section. The prophylactic group received ticarcillin 6 grams intravenously after delivery of the baby. Ticarcillin was selected because of its broad spectrum activity against anaerobes especially Bacteroides fragilis.

Patients developing clinical evidence of infection, e.g. fever of 100.4 F or more on any two occasions excluding the first 24 hours, uterine tenderness, foul smelling lochia, and had no other source of fever or infection were classified as endomyometritis and failure of prophylaxis or placebo. The high and low risk factors were determined from a previous prospective study done at our institution.

The latest tabulation of this study indicated 236 patients totally, of which 124 (52%) were classified as high risk, and 114 (48%) were classified as low risk. Of the high risk patients, 52 were randomly placed in the placebo group and 37 of the 52 patients (71%) subsequently developed endomyometritis. Of the high risk patients who received p~ophylaxis, 26 of 72 subsequently developed endomyometritis (36¢) p=.O02 X~.

Of the low risk patients, 24 of 60 placebo patients (40%) developed endomyometritis, whereas only I0 of 54 patients who received prophylaxis (19%) developed endomyometritis p=.0215 X2.

The highly significant p values (X2) indicates that prophylactic ticarcillin if effective in limiting post-cesarean endomyometritis in both high risk and low risk patients.

HIGH RISK FACTORS FOR ENDOMYOMETRITIS

I. Age less than 17. 2. Rupture of membranes more than 8 hours before delivery. 3. Greater than 7 vaginal examinations during labor. 4. Labor lasting more than 12 hours.

LOW RISK FACTORS FOR ENDOMYOMETRITIS

I. Age greater than 17. 2. No labor (e.g. elective repeat cesarean section). 3. No ruptured membranes before delivery. 4. Few or no vaginal examination during labor.

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PREMATURE LABOR INHIBITION WITH SUBCUTANEOUS TERBUTALINE: FETAL AND MATERNAL OUTCOME

Thomas J. Benedetti, M.D., Candan Cengiz, M.D., Durlin Hickok, M.D. (Department of Obstetrics and Gynecology, Division of Perinatal Medicine, University of Washing- ton, Seattle, Washington 98195)

The pharmacologic inhibition of premature labor has gained widespread acceptance in the United States and Europe. Beta adrenergic receptor stimulation is currently the most common pharmacologic method of labor inhibition. This report details a review of 20 months experience with the use of subcutaneous terbutaline for the inhibition of premature labor using a standardized protocol. Patients admitted for treatment fulfilled the following criteria: I) gestation between 24 and 36 weeks, 2) intact membranes, 3) regular uterine contractions at an interval of less than I0 minutes for at least 30 minutes, and 4) cervical dilatation of < 4 cm. Terbutaline was administered in the following schedule: O.25mg subcutane--ously - if contraction frequency had not decreased within 30 minutes another O.25mg was given. Total dose was not to exceed O.5mg in 4 hours. Sub- cutaneous administration was continued for 24 hours after cessation of contractions. Oral terbutaline (2.5mg) was begun after cessation of contractions and alternated with the subcutaneous dose every 6 hours for 24 hours. Oral terbutaline was then continued every 6 hours until 36 weeks gestation or until labor recurred. Standard criteria were used for the definition of respiratory distress syndrome (RDS). The gestational age of the neonate was confirmed by Dubowitz examination or autopsy. For data analysis, patients were divided into high risk for delivery (cervical dilatation > 2 cm + > 50% effacement or cervical dilatation > 1 cm + 100,% effacement). L~ risk p~tients were those not satisfying these criteria.

RESULTS

One hundred eleven patients were treated according to the described protocol. There were 95 singleton pregnancies and 16 twin pregnancies. Gestational age at onset of treatment was as follows: l) 24-29 weeks = 24 patients, 2) 30-32 weeks = 47 pmtients, 3) 33-35 weeks = 35 patients, 4) 36 weeks = 5 patients. Forty- seven percent of the patients were considered at high risk for delivery. In that group, the incidence of successful delivery delay (> 48 hours) was directly pro- portional to gestational age. The success rate at 2-4-29 weeks was 17% (n=12); at 30-32 weeks 57% (n=23); and at 33-35 weeks 75% (n=16). In the low risk group, no effect of gestational age was seen with success rates between 83-89% in all groups. Overall, delivery delay was accomplished for 48 hours in 71% of patients. In singleton pregnancies < 33 weeks gestation, 37% achieved 36 weeks gestation. Sixty-one patients were ~eated with betamethasone for acceleration of pulmonary lung maturity while 50 patients were not treated with betamethasone. In the untreated group, there were 9 patients with singleton pregnancies between 30-33 weeks who delivered within 7 days of the onset of therapy. Six of the 9 infants developed RDS including 2 cases of severe RDS. There were II perinatal deaths for an uncorrected perinatal mortality rate of 90/I000. The causes of neonatal death were as follows: intracranial hemorrhage - 3, RDS - 3, immaturity (500g fetus) - 2, congenital anomaly - I. There were two fetuses who died during labor. One infant had Turner’s Syndrome and one patient had an unrecognized concealed abruption. No instances of maternal hypotension were observed during therapy. One mother who received betamethasone and terbutaline developed pulmonary edema during therapy. She was successfully managed with oxygen administration and discontinuation of the betamimetic.

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Society of Per±natal Obstetricians Annual Meeting


EFFECT OF MgSO4 ON THE ACID-BASE BALANCE AND HEMODYNAMICS OF CHRONICALLY

INSTRUNENTED PREGNANT SHEEP.

Jahangir Ayromlooi, M.D., Mitchell Tobias, B.S., and Denise Desiderio, B.A., Dept. Obstetrics & Gynecology, Long Island Jewish-Hillside Medical Center, New Hyde Park, N.Y., 11042.

Ten infusions of MgSO4 (loading dose: 4 gms/4 minutes (min); maintenance dose: 1.5 gms/60 min) in 7 ewes at 109 to 126 days of gestation, were evaluated for effects on maternal (M) and fetal (F) physiology. M (n=10) and F (n=7) aortic (A) b!ood samples (0.5cc) were drawn at O, 5, 15, 30, 60 and 90 min from the

start of infusion. M & F free Mg++ did not correlate significantly. M Mg++ rose from 2.73±0.32 (Mean S.E.) to 9.5010.95 mg% (p<0.01) at 5 min, remaining elevated for the duration of the experiment. F Mg++ did not differ from the control value at any observation. MA PCO2 rose from 24.6±1.5 to 26.9!1.3 mm Hg (p<0.025) at 5 min, remaining elevated at 60 min. The derived HCO3 and Base Excess concomitant- ly rose with MA PCO2. MA pH, however, did not change. MA PO2 transiently decreased from 89.212.0 to 82.512.8 mm Hg (p<O.005) at 15 min. MA blood pressure (BP) fell transiently from 85.3±1.7 to 74.812.9 mm Hg (p<0.001) at 5 min. Uterine blood flow increased throughout the infusion to a peak of ÷13.915.3% (p<0.025) at 60 min. A reduction in M hemoglobin was seen from 8.010.3 to 7.410.2 gm% (p<O.02) at 15 min, returning to baseline by 60 min. Fetal effects

of MgSO4 were transient. FHR increased from 164±6 to 19117 beats/min (p<0.005) at 30 min only. FA PCO2 rose from 30.3!2.5 to 36.8±1.8 mm Hg (p<0.01)

at 60 min only. No change was seen in FA PO2, 02% saturation or BP. All M & F values returned to control levels by 90 min.

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THE EFFECT OF HYDROSTATIC PRESSURE ON THE INTERPRETATION OF THE SUPINE PRESSOR TEST

Thomas J. Benedetti, M.D., John A. Read, M.D., University of Southern California, Los Angeles County Women’s Hospital, Los Angeles, California.

Blood pressure (BP) measurements were made with a sphygmomanometer in 35 normotensive primigravid patients between 28 and 32 weeks gestation. BP was recorded in the left lateral recumbent position (LLRP) every 5 minutes for at least 15 minutes until stable. BP was recorded simultaneously in the upper arm (right) and the lower arm (left). After stable BP had been achieved, each observer confirmed the others readings. After the patients assumed the supine position, BP was recorded in both arms immediately and at 5 minutes. Both diastolic phase 4 (D-4) and phase 5 (D-5) pressures were recorded. A positive supine pressor test (SPT) was defined as a diastolic BP rise of 20mmHg. Blinded review of obstetrica records used ACOG criteria for the diagnosis of preeclampsia (PE).

RESULTS:

Pressure Recorded SPT + PE + SPT - PE +

Upper D-4 12 2 23

Upper D-5 16 3 19

Lower D-4 l 0 34

Lower D-5 0 0 35

6

5

8

8

There were no positive SPT’s when D-5 BP was recorded in the lower arm, despite the development of PE in 8 patients. When upper arm, D-5 BP was corrected for hydrostatic effect of position, no correlation was seen between position change and blood pressure in patients who developed preeclampsia or in patients who re~ained normotensive (p > .05). Although all patients were normotensive when tested, the diastolic phase 5 blood pressure was significantly higher in patients who later developed preeclampsia than in patients who remained normotensive (69.8 + 7.6 mmHg vs. 56.8 + 14.1 mmHg, p < .OOl).



MATERNAL EI~NOL INFUSION AND THE EXTREME PREMATURE

Samir N. Beydoum, M.D., Manoj K. 8iswas, M.D., and Dina R. Chung, M.D., (Department of Obstetrics and Gynecology, Division of Maternal-fetal Medicine, University of Miami at Miami)

Matemal ethanol infusion is used universally for the arrest of premature labor. Its imnediate effects on the very small neonate if therapy fails is still unclear. In this study, charts of all babies whose mothers recieved alcohol for that purpose in 1978 and 1979 were retrospectively analyzed. The study group was selected according to the following criteria: Birth weight between S00 and 1500 gms. ; no medical complications; "idiopathic" premature labor; absence of PROM; and delivery occurring within 24 hours of alcohol infusion. Controls were matched according to gestationai age within one week; weight within i00 gms. ; fetal presentation; and type of delivery and anesthesia used. 19 study, and 24 control babies satisfied the selection criteria. The fo!lowing parameters were compared: The vital signs, hematocrit, blood glucose, and serum Ca++, Na+, and K+ were similar in both groups and fel! within the mormal range. The mean Apgam Scores + S.D. at i minute (4.10 + 3.03 v.s. 4.87 + 2.49) and 5 minutes (6.50 + 2.39 v.s. 7.50+ 1.69)-were low in both--groups. Mean blood gases + S.D. Within one hour ~f birch fell in the metabolic acidosis range:

Alcohol 7--~. ~ + 0.’75 8 + 14.59 97~0 + 75.21 .-1!.38 +-8.49 Controls 7.24 + 0.13 46.80 + 12.36 92.78 + 43.03 -9.69 +.8.19

Serum. bilirubin values, were compatab!e with pr~ma~ority. ~il the above parameters were statistically similar when compared with the student t test. More alcohol babies needed intubation at birth (11/19 v.s. 8/24), and 5/19 alcohol babies expfred v.s., 5/24 controls. The principa! causes of death in both groups were related to pr~maturity.

In conclusion, the results of this study suggest that alcohol, when used in recommended doses for the arrest of premature labor does not exert any additional deleterious effects on the extreme premature neonate ( if therapy fails ) over and above those of pre~rity..

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UTILIZATION OF FBS AND 2 HR PPBS INSTEAD OF STANDARD 3 HR GTT FOR SCREENING AND CLASSIFICATION OF THE GESTATIONAL DIABETICS

Amrutha Bhakthavathsalan, M.D., Perinatologist (With data collection assistance from Dr. Thomas Kirkhope, DME), Northwest Ohio Regional Perinatal Center, Toledo Hospital, Toledo, Ohio.

In an indigent population, problems with a 3 hour GTT such as time factor, sched- uling and transportation problems, patient resistance to the I00 grmo oral glucos etc. necessitated a protocol to be developed forutilizing fasting blood sugar (FBS) and 2 hour postprandial blood sugar (2 hr PPBS) (Following a test breakfast consisting of 50 grams sugar and 50 grams carbohydrate) for screening as well as diagnosis of the gestational diabetic. Patient compliance improved remarkably with this approach. The patients were classified as Class A IFBS normal 2 hr PPBS elevated) Class B - non-insulin dependent (B-NI - FBS elevated) to differentiate from the Class B-insulin dependent (B-I) of white classification. Outpatient management on an appropriate diet, and serial blood sugars and nonstress tests and estriols near term were instituted, the latter earlier in the B (NI) than in the A group.

The following table lists the maternal and fetal data in 119 patients managed in this manner and compared to a group of Class-B-insulin dependent diabetics.

Total Obesity Unexplained Primary C/S for Apgar RDS Conq. PNM No. (~200 Ibs) term stillbirth Cesearan fetal 1 min. Anom-

in a previous Section distress < 6 alies pregnancy Rate

A 41 34.6% 0% 14.6% 4.8%

B-NI 78 64.9% 14.8% 15.3% 6.4%

22% 9.8% 7.3% *Non~

15.4% 5.1% 6.4% *None

B-I 21_ 41.7% 9.5% 19.1% 4.8% 33% 9.5% 19.1% Non~

*One neonate in each group transferred and lost for follow-up.

The following observations are made:

The B (NI) differs from the group "A" in the large number of grossly obese mothers as well as the large number of term stillbirths in a previous pregnancy during which these patients were not screened for diabetes and not placed on a diet. When managed on an appropriate diet, the average blood sugar increased slightly toward late pregnancy but none needed insulin. By screening for placental insufficiency near term, it was possible to reduce the very high stillbirth rates from the previous pregnancies.

Thus, in the B (NI) gestational diabetic with elevated FBS the fetus is seen to be at significantly high risk similar to the BI groups but this can be reduced by outpatient management. In a control population where such attention is not paid to elevated FBS levels, continuing stillbirths were noted. Blood sugar level criteria as well as specific management protocols used in,is study will be presented.



BACTEREMtA IN AN OBSTETRICAL POPULATION

J.D. Blanco~, R.S. Gibbs, Y. Castaneda, University of Texas Health Science Center at San Antonio

We reviewed the results of 2,396 blood cultures obtained from obstetrical patients between 1975 and 1979. We found a total of 183 patients with a pathogenic organism in the bloodstream. One hundred and thirty-eight cultures had contaminants (5.8%). The incidence of bacteremia was 7.3/1000 obstetrical admissions, and 10.3% of those sampled. The clinical diagnoses of the patients with bacteremia were: endoparametritis (125), Pyelonephritis (27), chorioamnionitis (17), and others (14). The temperature distribution at the time of obtaining the blood cultures was as follows: =<100.9°F, 2! (11 101.0°-101.9°F, 70 (38%); 102.0°-102.9°F, 54 (30%)3 103.0°-103.9°F, 21 (11.5%) and >104.0°F, 17 (9%). The most common bloodstream isolates were: E. coil (55), Group B streptococcus (31), Bacteroides sp. (29), Peptococcus sp. (16), Clostridium perfringens (11), Peptostreptococcus sp. (8), S. aureus (8), enterococcus (5), and Group A streptococcus (4). We found no deaths, no clinical evidence of septic shock, and no post-infection endocarditis. We compared various measures of morbidity of the bacteremic patients with those of our general hospital population with the same diagnosis.

Post C/S Endoparametritis and Bacteremia

Post C/S Endoparametritis

General Population Significance

Fever Index (F° - hours)

Average Hospital Stay (days)

Complication Rate (~)

Failure ~f Primary Antibiotics (~)

98.5 + 41.5 106 + 73.5 NS

7.0 + 3.0 7.5 + 4.1 NS

6 4 NS

22 22 NS

A comparison of fever index, average hospital stay, complication rate, and failure of primary antibiotics in those patients with post-cesarean section endoparametritis reveals no difference between the two groups.

C ho r loam n ion iti s and Bacteremia C ho rioam n ion iti s Significance

Fever Index (F° - hours) 35.9 + 46.8 30.8 + 43.9 NS

Average Hospital Stay (days) 4.9 + 2.1 4.5 + 2.4 NS

A comparison of fever index and average hospital stay in those patients with chorioamnionitis shows no significant difference. We, therefore, conclude that in this obstetrical population with prompt, vigorous treatment, the clinical course of bacteremic patients with genital infections is remarkably similar to that of non-bacteremic patients with the same .kind of infection.

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RISK" BENEFIT CONSIDERATIONS FOR THE SAFE USE OF ISOXSUPRINE IN THE TREATMENT OF PREMATURE LABOR

Jane E. Brazy, M.D., Virginia Little, M.D., Judy Grimm, R.N., and Marcos Pupkin, M.D., F.A.C.O.G. (Division of Perinatal Medicine, Departments of Pediatrics and Obstetrics and Gynecology, Duke University, Durham, NC)

Seventy patients treated with isoxsuprine for premature labor were studied. In patients with intact membranes, successful prolongation of pregnancy > 7 days occurred in 77% of women ~ 50% cervical effacement and ~ 3 cm dilatation at the initiation of therapy, and in none with > 50% effacement and > 3 cm dilatation. Cervical effacement was the primary factor in determining success. Cord isoxsuprine concentrations averaged 90% of maternal concentrations at delivery. Maternal and cord isoxsuprine concentrations at delivery were inversely correlated with the drug-free interval before delivery. An interval > 5 hours was necessary to attain a cord concentration of < 2 ng/ml, a level .not associated with neonatal problems. Drug-free intervals ~ 2 hours usually resulted in cord isoxsuprine values > I0 ng/ml, levels associated with severe neonatal problems. Since 17 of the 22 infants with cord isoxsuprine concentrations > 2 ng/ml and eight of nine with values > I0 ng/ml were delivered of mothers with > 3 cm dilatation or ~ 50% effacement at the initiation or reinstitution oF intravenous therapy, most severe neonatal problems are preventable.

~oczeny of Perinatal Obstetricians Annual Meeting

San’Antonio, Texas January--1981

NEONATAL EFFECTS OF SEVERE MATERNAL HYPERTENSION BEFORE 36 WEEKS GESTATION

Jane E. Brazy, M.D., Virginia Little, M.D., and Judy Grimm, R.N. (Division of Perinatal Medicine, Departments of Pediatrics and Obstetrics and Gynecology,

Duke University, Durham, NC)

Neonatal problems associated with an abnormal fetal environment have been well documented for infants of diabetic mothers, but the effects of severe hypertension upon the infant have not been well defined.

Twenty-eight infants 27-35 weeks of gestation, delivered of mothers with diastolic hypertension ~ llO mmHg and 28 gestational age-matched control infants delivered of normotensive mothers without tocolytic therapy were compared to determine the effects of severe hypertension and its therapy on the preterm neonate. Eight mothers were eclamptic. All mothers received magnesium sulfate; 32% sedatives; and 79% antihypertensive medications. Thrombocytopenia and marked LDH elevation occurred in 50% of hypertensive mothers. Thirty-nine percent of infants of hypertensive mothers were small for gestational age (p < .OOl); 29% were micro- cephalic at birth (p < .Ol). Other significant differences between the two groups of infants were noted in the incidence of hypotonia, ileus, delayed stooling, delayed respiratory adaptation, thrombocytopenia, leukopenia, neutropenia, patent ductus arteriosus and birth asphyxia. ~laternal thrombocytopenia and enzyme elevations w~re significantly associated with growth retardation, microcephaly, thrombocytopenia, neutropenia and birth asphyxia in the infant. Gastrointestinal hypomotility and hypotonia were probably drug induced.

Severe maternal hypertension has unique and significant effects upon the preterm neonate which reflect the severity of the maternal disease process.

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TERBUTALINE SULFATE IN THE PREVENTION OF RECURRENCE OF PRE- MATURE LABOR

Stanley M. Brown, M.D. and Nergesh A. Tejani, M.D. (The Depart- ment of Obstetrics and Gynecology, Nassau County Medical Center, East Meadow, N.Y., and the Health Sciences Center, State Univer- sity of New York at Stony Brook.

Initial arrest of premature labor may be equally achieved by a variety of agents such as ethanol, betamimetic agents, magnesium sulfate and prostaglandin synthetase inhibitors. Re- currence of premature labor after the initial arrest is a frequent occurrence. It is the purpose of this study to determine if recurrences may be prevented or postponed by the prolonged oral use of~2 agonist terbutaiine sulfate after initial therapy with ethanol.

Forty-six patients in premature labor were initially successfully treated with ethanol infusion. Twenty-three of these patients were then put on prolonged oral terbutaline sulfate until 38 weeks gestation, and the remaining 23 patients were given a placebo. The treated group gained significantly more time in gestation than the placebo group (P < .05) in spite of starting with a higher Bishop score. In addition, idiopathic respiratory distress (IRDS) was seen significantly less often in the treated group. There was no perinatal mortality in either group.

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GLYC~MIC CONTROL IN PREGNANT DIABETIC WOMEN USING A CONTINUOUS SUBCUTANEOUS INSULIN INFUSION PUMP

Arnold W. Cohen, M.D., Robert M. Liston, M.B., Ch.B., M.R.C.O.G., Michael T. Mennuti, M.D., Steven G. Gabbe, M.D. (Department of Obstetrics and Gynecology, Jerrold R. Golding Division of Fetal Medicine, Hospital of the University of Pennsylvania)

Meticulous control of maternal blood sugar in the pregnant diabetic has resulted in reduced perinatal mortality and morbidity. The continuous subcutaneous insulin infusion pump (CSIIP) is an "open loop" system without feedback control that has been used to normalize diurnal glucose concentrations in juvenile onset diabetics. We have evaluated the usefulness and safety of this system in five pregnant insulin-dependent diabetics. All patients were admitted to the Clinical Research Center at the Hospital of the University of Pennsylvania during the third trimester of pregnancy. Four of five patients had been followed in our clinic and had been controlled with a morning and evening injection of a combination of long and short acting insulins. These patients were monitoring blood sugars at home using a glucose reflectance meter. One patient was referred to our service because of difficulty in controlling her blood sugar. All patients were treated with 2 injections of a combination of NPH and regular insulins. Blood sugars were determined hourly from 7 a.m. to 7 p.m. and then every 2 hours from 7 p.m. to 7 a.m. After glycemic control was established, the patients were started on the CSIIP (Auto Syringe--Model AS2C). Basal dosages were administered every 4-16 mins., while preprandial dosages were given 15-30 minutes before each meal and snack. Serum lactic acid, acetoacetate and ~-hydroxybutyric acid were measured before and after CSIIP usage. Mean blood sugar values, mean amplitude of glycemic excursions, hypoglycemic and hyperglycemic time intervals were also calculated.

The CSIIP did not improve glycemic control parameters in the group as a whole but 2 of 4 patients had a significant decrease in their mean blood sugar. There was a trend in all patients towards a decrease in mean amplitude of glycemic

excursions and hyperglycemic time intervals. No significant change in lactic acid or ketoacid levels was found. Two patients had clinically significant hypoglycemic episodes because they forgot to reset the pump dosage selector after giving themselves a preprandial dose. One episode of hyperglycemia resulted because of mechanical problems with the pump system.

This short term trial of the CSIIP confirms the safety of the device as well ~s its ability to maintain and possibly improve glycemic control in pregnant insulin-dependent diabetics.

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Society of Perinatal Obs=etricians Annual Meeting


DETECTION OF GESTATIONAL DIABETES USING HEMOGLOBIN Alc

Arnold W. Cohen, M.D., Bharat D. Shah, M. D., Carolyn B. May, M.S., Steven G. Gabbe M.D., Department of Obstetrics and Gynecology, Jerrold R. Golding Division of Fetal Medicine, University of Pennsylvania School of Medicine

Detection of gestational diabetes requires screening with a blood glucose measured after a carbohydrate load and further evaluation by an oral glucose tolerance test (GTT). These procedures are expensive, time-consuming and often difficult to apply

to a large obstetrical population. Hemoglobin Alc (HbAlc) is a glycosylated hemoglobin which, when elevated, reflects a state of chronic hyperglycemia. A prospec-

tive study was undertaken to evaluate the use of HbAlc as a screening method for gestational diabetes.

Forty-three patients in the final trimester of pregnancy were evaluated for gestational diabetes using a 50 gram glucose load followed by a blood sugar determination one hour later. Patients were selected for screening using established historica!

or clinical risk factors. All patients had a HbAIc determination made at the time of the glucose screen and all were subsequently evaluated with a 3-hour GTT after consuming a I00 gram glucose load. The accepted limits of normal for both the 50 gram glucose screen and GTT were those of O’Sullivan. HbAI determinations were made by column chromatography with the range of normal values being 6.0 - 8.8%.

Of 43 patients undergoing glucose screening, 38 had abnormal l-hour results. Four of these patients had elevated HbA~ values and 3 of these 4 women also demonstrate~

abnormal GTTs. Only one of 34 patients with abnormal 1-hour tests but normal HbAIc ivalues, had an abnormal GTT. Thus, the combination of an abnormal l-hour glucose

screen and abnormal HbAlc predicted the presence of gestational diabetes in 3 out iof 4 women. On the other hand, an abnormal l-hour screen in association with a normal HbAI was associated with gestational diabetes in only I of 34 women. Of 5 pat-

~C ¯ ents with normal l-hour screening results, all had normal HbAlc values and all wer~ found~to have a normal GTT. Therefore, the combination of a normal l-hour screenin value ~n~ a normal HbAlc predicted normal carbohydrate tolerance.

These data demonstrate that an effective screening approach for gestational diabete

may be the combination of a 50 gram oral glucose load with a HbAI . An abnormal l-hour result in association with an abnormal HbAlc may be effective in predicting the presence of gestational diabetes while a normal 1-hour screening test with a

normal HbAlc appears to rule out this disorder. This approach is presently being explored in an expanded research study.



EFFECT OF EXERCISE ON MATERNAL AND FETAL WELL BEING

Luis B. Curet, M.D. and Catherine Collins, M.S., Department of Obstetrics and Gynecology, University of Wisconsin

During 1978-79 twenty pregnant women were enrolled in a pilot study, described below, designed to study the effects of exercise during pregnancy.

Twenty pregnant women volunteered to participate in the study. All women, 8 control and 12 experimental, were given submaximal bicycle ergometry tests in their 2nd trimester of pregnancy (X = 22.5 weeks of gestation), 3rd trimester of pregnancy (X : 34 weeks of gestation), and 6.5 weeks postpartum. In these tests, in which the women pedaled at 2-3 submaximal workloads, heart rate (HR) was quantitated from electrocardiogram recordings of oxygen consumption (V09), carbon dioxide production (VCO~), and ventilation (VE) were determined from expired

air collection and gas analysis. Cardiovascular fitness, defined as the maximal VO2 was predicted by the HR/VO2 response to the exercise workloads in these tests.

The experimental group trained on bicycle ergometers at 70% of their maximal VO2 for 3 half hour sessions per week for an average of 14 weeks while the control group was not involved in any regular exercise program. Neither group participated in exercise postpartum.

For women in the training group, the acute effect of exercise on the fetus was determined by auscultation of the fetal heart rate (FHR) at each exercise session before exercise, I0 minutes and 20 minutes into the exercise, and 5 minutes into recovery. Chronic effects of exercise to-the newborn were determined by comparing birth weight, placental weight, placental weight, birth length, gestational age, and Apgar scores of newborns in the training and control groups. Chronic effects of exercise to the mother were determined by comparing fitness level and duration of labor in the training and control groups.

Statistical significance was computed using analysis of variance or t-test procedures.

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UMBILICAL VEIN DILATATION IN FETAL RHESUS HEMOLYTIC DIS~ASE. Greggory R. DeVore, M.D., Kara Mayden, RT., RDMS, Marge Tortora, RDMS, and John C. Hobbins, M.D., Department of Obstetrics and Gynecology, Yale University School of Medicine, New Haven, Connecticut 06510.

Rhesus (Rh) negative sensitized pregnant women with a suspected Rh positive affected fetus usually undergo serial amniocentesis beginning at v~ek 20 of gestation. The amniotic fluid bilirubin is quantitated and ccrnpared to a nomogram which allows for the prediction of the severity of Rh fetal hemolytic disease and guides the clinical management.

Since fetal umbilical vein hypertension and obstruction occur in Rh sensitization and are thought to result from an increase in hepatic eryd~ropoiesis, the umbilical vein diameter (UVd) was studied using ultrasound in normal as well as Rh sensitized fetuses.

Using a Picker Digital B-scanner and an ADR Real-Time scanner the ~T~ilical cord was imaged in the amniotic fluid (AF) and the umbilical vein in the liver (L) from weeks 18 ~ 37 of gestation. The UVd ~smeasured frcm leading edge to leading edge in 1 nullimeter Lncrements in both the AF and the L.

Ninety-four normal non-~n sensitized fetuses were studied. Table I lists the mean diameter + 2 S.D. above the mean in both the AF and L. In these normal fetuses, d~e Vgd increased as a function of gestational age and was significantly larger (p<0.001) in the AF than in the L from weeks 20 thru 37.

TABLE I ~eks Gestation 18-19 20-21 22-23 24-25 26-27 28-29 30-31 32-33 34-35 36-37

A~.niotic FI. Mean (m) 45 55 64 70 83 83 92 93 94 97 + 2 S.D. 26 i0 16 22 16 i0 09 i0 20 18

Liver Mean (m) 43 38 43 52 56 57 58 60 73 78 + 2 S.D. 22 14 ii i0 i0 15 12 14 15 25

Fifteen fetuses with confirmed fetal Rh sensitization were studied. At our institufion, if a fetus~has a rise of the A OD (450 mu) ~ich falls into Zone III of .the Liley cuz-ve before 32 weeks gestation intrauterine transfusion is done. If the rise in the A OD occurs after 32 weeks, the fetus is delivered and undergoes neonatal exchange transfusion. The UVd was normal in both the AF and the L in four fetuses which did not require either intrauterine nor neonatal exchange transfusion. Of seven fetuses which required only neonatal exchange transfusions, only one fetus demonstrated a significant increase mn the UVd in the L. This fetus had a corresponding A ODwhich fell into Zone III of the Liley curve at 32 weeks gestation and was therefore subsequently delivered by cesarean section. Three of four fetuses who required intrauterine transfusions because the A OD rose into Zone III of the Liley curve before 32 weeks gestation demonstrated significant elevations of the UVd in the AF and/or the L prior to die rise of the ~ OD.

We conclude that the UVdmight be one of the first indicators of severe fetal compromise in ~h hemolytic disease. It appears that the umbilical vein often dilates within t2~e liver and the amniotic fluid prior to the rise of the i OD into Zone III of the Liley curve. Serial measurements of the Vgd in d~e mmiotic fluid and liver may, therefore, provide another param~eter in which to identify the Rh sensitized fetus who might ultimately require intrauterine transfusion.

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San Antonio, Texas

January--1981

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EVALUATION OF CEFOXITIN PROPHYLAXIS FOR CESAREAN SECTION

William P. Dillon, M.D., Mark S. Seigel, M.D., Amol S. Lele, MoD and James A. O’Leary, M.D. (Department of Gynecology/Obstetrics, State University of New York at Buffalo)

Prophylactic cefoxitin was evaluated in i01 patients undergoing cesarean section. A three dose regimen of either cefoxitin or placebo was administered randomly in a double- blind manner, 46 patients receiving cefoxitin and 55 placebo, with the first dose given after the cord was clamped. In the placebo group, 29 percent of the patients developed pelvic or wound infection, compared to 4 percent in the cefoxitin group (P < 0.003). No patient required re-operation, re-admission, or had a life threatening infection. Ten risk factors for infection were analyzed to help ascertain which patients would benefit from prophylaxis. Cefoxitin, with a broad spectrum of aerobic and anaerobic coverage, was found to be an effective and safe prophylactic agent when given to all patients undergoing cesarean section.

COMPARISON OF RISK FACTORS AND RATES OF INFECTION

Number of Patients

Subgroup Placebo Cefoxitin

(n = 55) (n = 46)

General Anesthesia 34 32 Labor 34 23 Primmry C/S 27 26 _> 2 Pelvic Exams 27 20 ROM 19 17 No Labor, No ROM 20 18 Labor, No ROM 16 ii Labor, ROM 18 12 Meconium 5 3 Clinic Patient 26 19 Obesity 7 9 Race (black) 14 14 Internal Monitoring ii I0

Pelvic or Wound Infection

Placebo Cefox~_~n P

12 (35%) 2 (6%) 0. 010

12(35%) 2(9%) 0.048

11(41%) 2(8%) 0.013

11(41%) 2(10%) 0.046

8 (42%) 2 (12%) N.S.

4(20%) 0(0%) N.S.

4(25%) 0(0%) N.S. 8(44%) 2 (17%) N.S.

3(60%) 0(0%) N.S. 9(35%) 2(11%) N.S.

2(29%) 1(11%) N.S.

4 (29%) 2 (14%) N.S. 3(27%) 2(20%) N.S.

TOTAL 55 46

Significant P < 0.05, Chi-square Test N.S. = Not Significant

16 (29%) 2 (4%) 0. 003

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CHLAMYDIA SCREENING IN PREGNANCY: G. Frisoli, M.D.; R. Cooper, M.D., Jersey City Medica! Center, Saint Michae!’s Medical Center, Newark, New Jersey.

The rate of cervical colonization of Chlamydiatrachomatis was investigated for the Jersey City pregnant clinic population. Routine screening was instituted for all patients attending the antepartum clinic at the 36th week of gestation during a three month period from January 1 to March 31, 1980. All patients were asymptomatic. A sterile technique and calgi swabs were utilized to obtain the specimens which were then immersed in Viral transport media and Chlamydia isolation was attempte~ within 48 hrs. using McCoy Cells incubation and iodine staining for inclusion bodies. Of 103 specimens processed 13 were isolation positive giving an incidence of 13.26%. Altho~gh final incidence of neonatal chlamydia conjunctivitis and/or pneumonitis is being tabulated, four of the 13 babies developed clinical conjuntivitis which were GC negative and which responded to tetracycline therapy, thus highly suggwstive of Chlamydia etiology. The high incidence of Chlamydia cervical colonization and neonatal attack rate suggest that screening and appropriate therapy be instituted in high risk clinic pregnant population.



RAPID ANTEPARTUM DIAGNOSIS OF GROb~ B BETA HENOLYTI~ STrePTOCOCCAL A~Z!ONITIS BY COUNTER I}~L~E ELECTROPHORESIS (C.I.E) OF A~,~IOTIC FLUID. G. Frisoli, M.D.; R. Cooper, M.D.; J. Oleske, M.D.; C. Palmieri; B.S, Saint Michael’s Medical Center, Newark, New Jersey.

Rapid antepartum diagnosis of Group B beta hemolytic streptococcal amnionitis by C.I.E. of amniotic fluid was estabilished in a 38 y.o., G6, P&, with premature rupture of membranes (PROM). Utilizing Group B streptococcus antibody, a strikingly positive agglutination reaction was obtained by C.I.E. within two hours of amniotic fluid processing. The patient was still asymptomatic, but within 24 hours developed clinical signs of chorioamnionitis and treated with IV Ampicil!in before being delivered of an infant who developed non-fatal infection. All cultures from placenta, baby’s skin, hypopharynx and tracheal aspirate were positive for Group B Strept. To date ten other C.I.E. have been performed on similar patients with PROM, all being negative for Group B Strept, and none of the infants developing neonatal Group B Strept sepsis. This suggests that C.I.E. on amniotic fluid is a valid procedure for rapid diagnosis in patients at high risk for Group B Strept perinatal infection.

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HYPOVOLEMIA AND POOR PREGNANCY OUTCOME

Robert C. Goodiin, M.D. Department of Obstetrics and Gynecology

The University of Nebraska Medical Center Omaha, Nebraska 68105

After informed consent, plasma volumes were measured, using the 1125 RISA

technique, in 120 gravidas at risk for premature labor, fetal growth retardation and]or toxemia, There are wide variations in normal values; however, of gravidas with diagnoses of toxemia, 88% had plasma volume which were three standard deviations below the mean (64 + 8 ml]kg), Fifty-four percent of those in premature

labor, 7096 of those with premature rupture of the membranes and 82% of those

with fetal growth retardation had plasma volume values of three standard deviations below the mean, Approximately 50% of gravidas at risk declined to have measurements done,

Indirect indicators of plasma volume expansion such as hematocrit, chest x-rays, and creatinine clearance values also correlate with these abnormalities of

pregnancy,

Bed rest, tranquilizers, and B-agonist agents appear to increase plasma volume in mild disease. For severe illness, I.V. 5°,6 or 2596 albumin is slowy infused. Good pregnancy outcome shows positive correlation with increase in plasma volume.

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San AntoniO, Texas January--1981

THE ROLE OF REAL TIME SCANNING IN ~NTENATAL FETAL SURVEILLANCE

Vildan G~ntes, M.D., Barry S. Schifrin, M.D., Robert C. Gergely, M.D., Kay RolI,RN and Jane Jacobs, RN (Departments of Obstetrics and Gynecology, Cedars-Sinai Medical Center and Los Angeles County/University of Southern California Medical Center, Los Angeles, California)

The value of real time ultrasound scanning (RTBS) in antepartum assessment of fetal well-being was studied in 158 high risk patients following non-stress testing (NST). The presence of fetal breathing movements (FBM), fetal movements (FM), tonus (TON) and normal amniotic fluid volume (AFV) were reliable signs of fetal well-being. These ultrasound markers of fetal well-being appeared as reliable indicators of good outcome as the reactive NSTo Multiple indicators did not improve the accuracy of the prediction of normal outcome. All tests were normal in only about 50% of patients. In general, abnormal test results were poor indicators of poor outcome. Only when all parameters were abnormal were babies invariably affected. Five of six major anomalies showed increased AFV and seven of 13 growth retarded or postmature babies demonstrated decreased AFV.

The parameters obtained on RTBS appeared far more reliable than the contraction stress test (CST) in discriminating the truly abnormal fetus. Three babies with an equivocal or positive CST in this study had normal outcomes.

These results, if confirmed in larger studies, suggest that RTBS following a non-reactive NST is an effective and potentially economical method of fetal assessment.


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Socieny of Perinatal Obstetricians Annual Meeting

San Antonio, ,Texas January--1981

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FETAL HEART RATE REACTIVITY BEFORE AND AFTER MATERNAL JOGGING DURING THE THIRD TRIMESTER

John C. Hauth, M.D., LtC, Larry C. Gilstrap,.III, M.D., LtC, and Karen Widmer, R.N. 0 Major.

There is a paucity of data concerning the fetal effects of exercise during pregnancy. Seven women who jogged at least 1.5 miles three times week prior to and during pregnancy were studied during the third trimester of pregnancy (28 to 38 weeks gestation). Fetal status was evaluated by the non- s~ress (NST) before and i~miediately after jogging at least 1.5 miles.

The seven pregnant women had a total of 30 NSTs 15 prior to and 15 immediately after jogging. All 30 tests were reactive and there was no significant difference in the monitoring time required to obtain a reactive NST before and after jogging. The prejog fetal heart rate (FHR) ranged from 140 to 150 bpm, and the postjog FHR ranged from 180 to 204 in 9 of the 15 NST’s. It took a mean of 20 minutes (range 12 to 30 minutes) for the FHR to return to the prejog baseline on nine of these testing occasions.

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January--1981

USE OF ULTRASOUND BPD IN TIMING OF REPEAT CESAREAN SECTION

Robert H. Hayashi, M.D. Department of Obstetrics and Gynecology The University of Texas Health Science Center at San Antonio

The aim of this study was to evaluate the use of ultrasound biparietal diameter (BPD) in the timing of elective repeat cesearn section on a large indigent service. A BPD reading of 9.3cm was the composite mean reading at 38 weeks’ gestation from 5 large published studies when corrected for difference in methodology. The mean BPD of a term birth weight fetus delivered within 14 days of that reading in our lab was 9.383cm. The median and mode were 9.3cm with a coefficient of variation of 1.9% for 186 patients. We elected to use the attainment of a BPD of 9.3cm or more in the timing of elective repeat cesarean section. An L:S ratio was to be obtained if the BPD was less than 9.3cm when the clinical data suggested fetal maturity and in those patients who were diabetic despite a BPD of 9.3cm or more.

One hundred and sixty five patients were evaluated over 2 years. The patients were analyzed in the following groups: (I) Patients in whom timing of repeat cesarean section was dependent on a BPD of at least 9.3cm, (2) Patients who were at term by clinical parameters, but in whom the BPD was less than 9.3c~ within 14 days of delivery, (3) Patients who had undergone earlier BPD readings but in whom none was repeated within 14 days of delivery, and (4) Diabetic patients. In group I, no patient underwent an amniocentesis. There were 91 patients in this grou~. No neonate developed hyaline membrane disease. Four neonates developed transient tachypnea of the newborn. In group 2, 30 of 40 patients (73%) underwent amniocentesis. In group 3, 6 of 19 patients (32%) underwent amniocentesis. In group 4, II of 15 patients (74%) underwent amniocentesis. Those patients in groups 2 to 4 who did not undergo amniocentesis had their repeat cesarean section done for reasons that obviated an amniocentesis such as: labor, rupture of membranes or worsening medical disease status. The overall use of amniocentesis for these patients was 28%. Undesired complications, including fetal bleeding, ruptured membranes, and induced labor occurred in 11% of these (all groups)’. Only one neonate developed a mild episode of hyaline membrane disease. The mother was in group 2 and an amniocentesis initiated labor. The L:S ratio was 2:1. There were no perinatal deaths in this study.

Since many of our patients interface with health care late in their pregnancy, we have depended on late tests of fetal maturity in timing of a repeat cesarean section. The data presented support the continued use of a management format for this group of patients that is reliable, cost-effective and beneficial to the patient and her child.




San Antonio, Texas January - 1981

USE OF ULTRASOUND IN DIAGNOSIS AND MANAGEMENT OF INTRAUTERINE GROWTH RETARDATION

B. Hays, MD, L. Cecil, MD, C. Hinkley, MD (Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas)

Attempts to characterize and follow intrauterine growth has provided us with an overabundance of confusing terminology. Premature, dysmature, small for gestational age (SGA), small for dates (SFD), large for gestational age, and symetric and asymetric intrauterine growth retardation (IUGR). In an attempt to untangle this confusion many ways of assessing previous growth in utero at the time of birth, by measuring various parameters of weight, length, head size, and skin fold thickness, have developed. Now ultrasound has begun to allow similar measures to be made in utero in an attempt to identify different growth patterns. Herbert Miller, by measuring ponderal index and head circumference has identified six types of growth patterns in human fetuses: symetric IUGR, asymetric IUGR, normal obese intrauterine growth acceleration (IUGA), large non-obese IUGA, dysproportionate growth and congenital malformations. An understanding of the normal pattern of growth suggested by Winnick consisting of hyperplasia, hyperplasia and hypertrophy, and hypertrophy alone, suggests that insults occuring at different times during gestation will have different effects on the growth pattern. Knowledge of the fetal compensatory mechanism for dealing with low oxygen states, knowledge of normal and premature placental maturation, and information about the normal pattern of brain growth in the human fetus support the suspicions of Greenwald that asymetric IUGR is a late pregnancy event whereas symetric IUGR has its origins early in pregnancy. Although attempts to identify IUGR infants by a single ultrasound using varying measurements has shown a high rate of both false positive and false negative results, serial ultrasound using head and abdominal circumferences and estimated weight provides a developing picture of fetal growth which allows the obstetrician to identify and differentiate different growth patterns in high risk pregnancies. By following developing head and abdominal growth as a reflection of the nutritional function of the placenta, in combination with other placental function tests, prognostic signs can be identified which help in allowing the growth retarded infant to attain maximal maturity without the risks of intrauterine demise or neurologic deficit reported in previous studies of growth retarded infants. Ultrasound serial growth curves and subsequent perinatal outcome will be presented to support the ability to identify infants in several of Herbert Miller’s growth type categories. Evidence to support the idea that ultrasound growth curves can be used to time delivery appropriately in the IUGR fetus will be offered and the prognostic value of the growth curve will be discussed.




PREDICTING THE RISK OF INTRAUTERINE GROWTH RETARDATION IN INFANTS OF MOTHERS WITH PREECLAMPSIA

Durlin E. Hickok, M.D., Judith E. Levison, M.D. and Thomas J. Benedetti, M.D. (Department of Obstetrics and Gynecology, Division of Perinatal Medicine, Univer- sity of Washington, Seattle, Washington)

Intrauterine growth retardation (IUGR) is a potentially serious consequence of maternal preeclampsia. IUGR infants are at increased risk of stillbirth, birth asphyxia, and developmental delay in childhood.

To develop a model for the prediction of IUGR, we collected clinical and laboratory information on consecutive women admitted to the U.W~ Hospital orior to labor who developed preeclampsia during pregnancy. Eighty subjects were studied of whom 15 delivered infants with IUGR. 3 of 58 (5.17%) subjects with mild Dre- eclampsia delivered infants with IUGR, while 12 of 22 (54.55%) subjects with severe preeclampsia delivered infants with IUGR (p < .OOl).

On cross-tabulation, three significant risk factors were identified - gestational age on admission < 36 weeks, proteinuria > 2+, and blood pressure > 150/lO0. If no risks were ores-ent, 5.9.% of infants ha# IUGR. With one, two, o~ three risks, the percentage with IUGR and relative risk (RR) increased respectively to 8.7%, RR=l.48; 35.7%, RR=6.07; and 75.0%, RR=12.75. The relative importance of these three risk factors was confirmed by multivariate analysis. Thirty-two and two- tenths percent of IUGR variance was accounted for by the three risk factors. The addition of up to six additional variables did not significantly imorove the ~re- dictive function.

These results suggest that readily available clinical characteristics can be utilized to develop a predictive risk model for IUGR. Identification of those at risk can facilitate greater attention to antepartum testing and intraoartum surveillance.

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REDUCTION OF PERINATAL MORBIDITY WITH INSULIN TREATMENT OF GESTATIONAL DIABETICS

Joseph E. Imarah, M.D., Donald R. Coustan, M.D. (Department of Obstetrics and Gynecology, Yale University School of Medicine, New Haven, Connecticut)

With proper management, pregnant women with Class A diabetes may anticipate a perinatal mortality rate similar to that experienced in the general population. Morbidity, however, remains a serious problem for the infant of the Class A dia-

betic. Much of the perinatal morbidity appears to be related to birth trauma, a consequence of macrosomia.

Previous studies (O’Sullivan et al, Obstet. Gynecolo, 27:683, 1966; Coustan and Lewis, Obstet. Gynecol., 51:306, 1978) have demonstrated a reduction in the incidence of fetal macrosomia when gestational diabetics are arbitrarily treated with insulin (despite relatively normal fasting and postprandial plasma glucose values). No effect on morbidity was demonstrated, and insulin therapy for Class A diabetes has not been widely prescribed.

The current study is a retrospective chart-review of all gestational diabetics delivered at Yale-New Haven Medical Center during the four years ending in July 1979. A total of 390 such patients were identified. Eighty-seven of the patients were arbitrarily treated with ~nsulino These included all Class A diabetics on the University Service diagnosed prior to 36 weeks’ gestation. The remaining 303 patients were not treated with insulin, either because their private physician did not practice prophylactic insulin therapy or because they were diagnosed at or beyond 36 weeks’ gestation. Of the non-insulin-treated patients, 188 were treated with a diabetic diet, while 115 were not.

Table 1 depicts the incidence of macrosomia, the mode of delivery, and the incidence of traumatic morbidity in each group. As is evident, macrosomia, operative delivery, and birth trauma were all significantly lower in the insulin- treated group. Mean gestational age was similar in all 3 groups (39.0 to 39.4 weeks) and labor was induced in 19.5% of the insulin-treated group, and 27.0% of the non-treated group. Thus, more active intervention was not responsible for the decline in morbidity in the insulin-treated patients.

It is concluded that prophylactic insulin therapy can reduce the incidence of macrosomia, operative delivery, and birth trauma in Class A diabetic pregnancies.

Birthweight ~4000 grams Spontaneous or Low Forceps Delivery Mid Forceps or Vacuum Delivery Primary Cesarean Section Shoulder Dystocia Erb’s Palsy Soft Tissue Typing Cephal hematoma

losul#n Diet Neither

87 188 115

9.2% 25~5% 39.1%

79.3% 71.3% 64.3% 12.6% 16.0% 19.1% 5.7% 11.2% 14.7% 2.3% 4.8% 8.7%

0 1.6% 3.5% 0 4.8% 6.1%

1.1% 4.3,% 6.9,%

Table I. Outcome Characteristics

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CLINICAL MENSURATION IN THE DETECTION OF INTRAUTERINE GROWTH RETARDATION.

Timothy R. B. Johnson, Jr., M.D., Norman H. Daikoku, M.D., Jose Villar, M.D., Rafael C. Haciski, M.D., Victor A. Khouzami, M.D., John W. C. Johnson, M.D. (Division of Maternal-Fetal Medicine, Department of Gynecology and Obstetrics and Department of Maternal-Child Health, School of Hygiene and Public Health, The Johns Hopkins University and Hospital, Baltimore, Maryland.)

The association of IUGR with perinatal morbidity/mortality and long-term adverse sequelae is well recognized, but the detection of IUGR remains difficult for the clinician. Symphysis-fundal measurements (SF) have long been a basic tool for IUGR diagnosis, and recent studies from Sweden (Acta Obstet Gynecol Scand 56:273, 1977) and Argentina (Am J Obstet Gynecol 131:643, 1978) report 75%-86% sensitivity with SF. To test this method a normal prenatal fundal heiQht curve was derived from IOC women spontaneously deliverina infants weighing over i,500 grams with normal growth characteristics. Various criteria (one measured value less than 2 S.D. below the mean, two values below 2 S.D., a downward trend in SF crossina over 2 S.D., and an analysis of graphic characteristics as suggested by Villar (E~rly Human Development in press)) were then assessed using a population of growth retarded and hiah-risk infants Previously reported (Obstet Gynecol 54:211, 1979). This group inciuded Io~ birth weight IUGR (LBW-IUGR) as well as other infants with abnormal growth characteristics (short crown-heel length and low ponderal index), but otherwise "normal" weight (non-LBW IUGR). One value less than 2 S.D. below the mean was the most Useful screening tool:

ALL LBW- non-LBW IUGR IUGR IUGR

Sensitivity 50% 64% 40% Specificity 63% 63% 56% Predictive value 56% 40% 38%

Meticulous measurement, as espoused by the Argentine group, might well improve :he sensitivity in detection of LBW-IUGR to the 75%-80% range. We conclude that the high false-negative and false-positive findings do not appear to be due to non-LBW IUGR groups. Although graphic techniques are not helpful in recognizing specific-patterns of IUGR, they may be useful in detecting some cases of IUGR.

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IDENTIFYING THE PREGNANCY AT RISK FOR INTRAUTERINE GROWTH RETARDATION (IUGR): POSSIBLE USEFULNESS OF THE INTRAVENOUS GLUCOSE TOLERANCE TEST (IVGTT)

George Kazzi, M.D., Robert J. Sokol, M.D., Satish Kalhan, M.D. and Sasi Pillay, Ph.D. (From the Departments of Obstetrics and Gynecology and Pediatrics and the Perinatal Clinical Research Center, Cleveland Metropolitan General Hospital/Case Western Reserve University, Cleveland, Ohio)

IUGR is a major source of perinatal and long term neurodevelopmental morbidity, but its antenatal detection remains problematic. Additional readily available predictors would be useful. Previous animal and human studies have confirmed the association of maternal hyperglycemia in diabetes mellitus with the birth of large for-gestational age infants and suggested that when decreased fuel is available for fetal growth, e.g., related to maternal hypoglycemia or to decreased uteroplacen- tal blood flow, IUGR may result. To examine whether determining maternal glucose tolerance might be of value for the prediction of IUGR, a random sample of 55 infants with recorded birthweights and Dubowitz gestational ages, whose mothers had had IVGTT’s performed during the third trimester was selected retrospectively for study. IVGTT’s had been performed for the presence of one or more risks for dia-

betes mellitus, e.g., age >35 years, weight >200 pounds, history of macrosomia, etc. Glucose (25 gm) had been injected intravenously as 50% solution and blood glucose concentrations (mg/dl) determined at fasting and q I0 minutes for 1 hour after injection. The glucose disappearance rate (kt), in loge %/rain, and concentrations at fasting, i0 and 60 minutes after injection were related to infant birthweight, normalized for gestational age, using polynomial and stepwise multiple regression, as well as contingency table analysis.

Correlation Coefficient (r) kt -. 55 .0~ Blood glucose concentration at Fasting +.50 I0 minutes -.31 .0 60 minu~e~ +.52

As shown in the table, an increased kt and i0 minute blood sugar concentration and decreased blood sugar concentrations at fasting and 60 minutes were found to be significantly associated with decreased normalized birthweight. Even when pregnancies complicated by gestational diabetes mellitus (n=lb, kt<l.O) were excluded from th% analysis, these relationships remained significant. For the entire sample, the multiple r for IVGTT parameters and normalized birthweight was .53 (p<.01) with the kt, i0 and 60 minute blood sugar levels contributing significantly to the regression, indicating that 40% of the variance in normalized birthweight was ex-

plained by these IVGTT parameters. When the kt was >2, 6 (27%) of 22 infantswere small-for-gestational age (SGA); when the kt was <--2, 0 (0%) of 33 infants were SGA. In the pregnancies resulting in the birth of SGA infants, the IVGTT’s were characterized by kt > 2 and blood sugar levels at fasting of <64, at i0 minutes of >103 and at 60 minutes of <82.

The physiologic explanation for these findings remains speculative. The findings are equally consistent with the alternate hypotheses that maternal hypoglycemia has a deleterious effect on fetal growth or that preceding abnormalities of the f etoplacental unit may fail to elicit the normal appearance of pregnancy associated alterations in glucose metabolism. Regardless of the underlying reason, the present results suggest that findings on an IVGTT, performed during the third trimester, may be useful in identifying patients at risk for delivering SGA infants. Because the !VGTT is an inexpensive and safe test, this potential clinical application for the IVGTT requires further evaluation.

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January--1981

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SELECTIVE BIRTH IN ~IN PR_ECN~NCY WI~H DISCORDANCY FOR DOWN’S SYNDROME

Thomas D. Kerenyi, M.D. and Usha Chitkara, M.D., Division of Perinatology, Department of Obstetrics and Gynecology, The Mount Sinai Medical Center and The Mount Sinai School of Medicine, New York, New York

The discovery of twins at the time of genetic amniocentesis poses several problems when discordancy for an abnormality such as Trisomy 21 is detected. Problems in counseling these patients have been addressed in several recent publications, but innovative therapeutic approaches to solve the problem have not been defined or carried out by those confronted with such discordancy.

We believe that an aggressive approach to selective termination of the abnormal fetus under specific circumstances is justified. The recent case history of a 40 year-old nulligravida with twin pregnancy and discordancy for Trisomy 21 will be discussed. Specifically, the medical aspects and considerations, anticipated complications and perinatal resources available and improvised, as well as the legal implications and decisions in this case are detailed.

Selective termination of the abnormal fetus in this case was carried out by intracardiac puncture and exsangination, under real time ul~ound monitoring. Videotape sonographic recordings of the actual procedure will be presented, and subsequent clinical course of the patient discussed. FHR tracings, color- motion picture of the surviving twin at full-term birth, and color-slides of the placenta and the fetus papyraceous will be included also in the presentation.

Specifically, the implications of this aggressive approach to discordancy in multiple gestation, its risks, drawbacks, patient evaluation and applicability-- are outlined, perinatologists involved in genetic counseling can expect to be confronted with increased incidence of discordancy in a maternal population which continues to delay childbearing into the thirties.

The necessary multi-disciplinary approach requiring legal, medical, and laboratory expertise is possible only~in ~ ~ledical Center wherein such a procedure can be carried out with the highest expectation of success. The role of the Perinatologist, as the team head of such an approach, is pinpointed as the. critical figure in the decision-making, planning, performance, and follow-up care provided in such endeavors.

The use of abortion as a constructive and positive medical technique in the hands of the Perinatologist is emphasized.

A review of the literature previously available also will be provided as a background perspective and the relative absence of precedents in the United

States for such an approach to discordancy in twin pregnancy is traced. The projected patient need for such options will be estimated and the potential refinements inherent to such an approach will be suggested.

The feasibility of such an approach and procedure as a viable medical alternative for the Perinatologist is indicated.

: ~’~ety of Pcrlnat,~l Obstetrlc~.~n~; Annual M~.eting

San Antonio, Texas

January--1981 i

CONTINUOUS FETAL MONITORING FOLLOWING THIRD TRIMESTER AMNIOCENTESIS

Steven A. Klein, M.D., Stephen J. Wilson, M.D., Miriam Katz, M.D., and Bruce K. Young, M.D. (Department of Obstetrics and Gynecology Division ofMaternal-Fetal Medicine, New York University School of Medicine, New York, New York)

One hundred forty-six patients were monitored for up to two hours after third trimester amniocentesis. The patterns of uterine and fetal activity, as well as fetal heart rate were analyzed using the criter£a for nonstress testing and contraction stress testing. There was a clear relationship between these observations and perinata.l outcome. Post amnioce~tesis monitoring was associated with an Apgar of six or less in only 10% of cases with reactive patterns, compared to 75% of cases with nonreactive and reduced variability and all the cases with late component decelerations. All cases of immediate fetal jeopardy were detected, without feta! loss. Post amniocentesis monitoring appears to offer significant prognostic information for perinatal outcome in high risk pregnancy.

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REAL TIME ULTRASONOGRAPHIC DIAGNOSIS OF NEONATAL INTRACRA~NIAL HEMORRHAGE AND INTRACRANIAL ANOMALIES

Marc R. Lebed, M.D., Feizel Waffarn, M.D., Barry S. Schifrin, M.D., Charles W.

Hohler, M.D. and Lawrence D. Platt, M.D. (Departments of Obstetrics & Gynecology and Pediatrics, LAC/USC Medical Center, USC School of Medicine, Los Angeles, Ca.

Intracranial hemorrhage (ICH), including intraventricular (IVH) and subarachnoid hemorrhage (SAH) contributes heavily to neonatal mortality and morbidity statistics, especially in the premature infant. The diagnosis of ICH, when suspected on clinical grounds, is generally confirmed by CT scan which is an expensive and cumbersome technique requiring neonatal transport, sedation and radiation. To determine the feasibility and accuracy of real-time ultrasound B scanning (RTBS) in screening for neonatal ICH, we have examined 107 neonates with this technique. This group contained 13 neonates with clinically evident ICH, 44 neonates considered to be at risk for ICH but who were asymptomatic at the time of scan, and 50 infants studied as controls. Gestational ages ranged from 28 to 42 weeks with 48% being less than 37 weeks.

The incidence of ICH decreased progressively with increasing gestational age irrespective of route of delivery. ICH was found in about 85% of those less than 33 weeks gestation, 45% of those 33-36 weeks gestation, and 30% of those neonates greater than 36 weeks gestation. ICH was found more commonly with vaginal delivery than Cesarean section at less than 33 weeks or more than 36 weeks; but there was no difference between vaginal and abdominal delivery between 33 and 36 weeks. Sixteen of 55 babies (29%) at 37 weeks gestation or beyond showed ICH. Only 8 of these were symptomatic or had medical problems requiring an intensive care admission. The remaining 8 were asymptomatic infants with 5 minute Apgar scores of greater than or equal to 7 and admitted to the normal nursery. Overall, clinical findings were suggestive in only about 60% of babies who were found to have ICH.

The severity of symptoms in babies with IVH was not directly related to ventricular size, but rather to location of the bleed and evidence of thalamic/brain stem compression. Bleeding around the thalamus or the internal capsule was usually associated with marked signs and symptoms.

RTBS confirmed i0 of ii cases of SAH found on CT scanning. The location of the SAH depended somewhat upon gestational age.

Two cases of IVH were seen during the intrapartum period. One neonate subsequently developed a SAH approximately 24 hours post delivery.

These results suggest that intracranial RTBS is a practical technique for the diagnosis of IVH as well as SAH. The frequency with which asymptomatic ICH has been found suggests that correlations with obstetrical and neonatal practice may require routine neonatal screening.

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OXYTOC!N CHALLENGE TEST AND INTRAUTERINE GROWTH RETARDATION

Chin-Chu Lin, M.D., Lawrence D. Devoe, M.D., Philip River, B.S., and Atef H. Moawad, M.D. (From the Section of Fetal-Maternal Medicine, Department of Obstetrics and Gynecology, The University of Chicago Pritzker School of Medicine and The Chicago Lying-In Hospital)

Over the past decade, intrauterine growth retardation (IUGR) has emerged as an

important clinical entity accounting for high rates of perinatal morbidity and mortality. During the same period of time, the oxytocin challenge test (OCT)

has gained popularity in anterpartum evaluation of feto-placental reserve of the high risk patient. Among all the different high risk conditions, IUGR has the highest yield of positive OCTts. Based on analyses of the non-stressed fetal heart rate testing (NST) and OCT in 85 IUGR infants, the predictive power of NST-OCT on fetal outcome and the mechanism of a positive OCT in IUGR were investigated. The incidence of positive OCT and that of non-reactive fetal heart rate (FHR) pattern among the 85 IUGR infants were 40% and 35.5% respectively. Thus, there was a three-folds increased risk of positive OCT’s (p~O.001) and twice the risk of non-reactive FHR pattern (p~0.02) in IUGR as compared to the total series of high risk patients. The 85 IUGR infants were divided into four groups (positive non-reactive, positive reactive, negative non-reactive, and negative reactive according to NST-OCT pattern) for comparison. The statistical compar-

ison between the negative reactive group and the combination of the three groups with abnormal FHR patterns was highly significant for the incidence of maternal hypertension (p~O.001), intrapartum fetal distress (p~0.001), and low one minute Apgar score of ~ 6 (p ~0.01). Over 50% of IUGR infants with a non-reac-

tive positive pattern were associated with maternal hypertension, abnormal estriol values, intrapartum fetal distress, and low one minute Apgar scores. The predictive values of the four NST-OCT groups on fetal outcome are shown in the following table.

Table: Predictive value of NST-OCT on poor fetal outcome in 52 IUGR infants

NST - OCT Poor Fetal Outcome*

Non-reactive ~ Positive 13 (65%) ’ ¯ 12/13 (92%)

20 (39%) Negative 7 (35%) ~ --> 2/7 (29%)~

Reactive ~ Positive 5 (16%) ~ 2/5 (40%) 32 (61%) ) Negative 27 (84%) ~ 5/27 (18%) p~O.001

* Includes intrapartum fetal distress, low Apgar scores, neonatal complications and perinatal deaths.

A non-reactive NST followed by a positive OCT provides the strongest predictive power for poor fetal outcome as compared to the other three groups (p~0.001). Three out of four perinatal deaths in this series were associated with a positiv non-reactive pattern; the fourth perinatal death was associated with a negative non-reactive pattern. The high inc.idence of non-reactive NST and positive OCT in IUGR is attributed to the clinical characteristics of IUGR: a combination of both compromised placental function and a compromised fetus (lack of fetal reserves). To those IUGR fetuses which exhibit a positive OCT or intrapartum late deceleration, more liberal use of cesarean section to assure a good fetal outcome is recommended.

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Society of Perinatal Obste=ricians Annual Meeting


THE RELATIONSHIP BETWEEN A~IOTIC FLUID OPTICAL DENSITY, LECITH!N/SPH!NGOMYEL!N RATIO, PHOSPHATIDYLGLYCEROL ~ND THE RESPIRATORY DISTRESS SYNDRO~

Robert M. Liston, M.B., Ch.B., M.R.C.O.G., Steven G. Gabbe, M. D., Arnold W. Cohen, M. D., Michael T. Mennuti, M.D., Jerrold R. Golding Division of Maternal-Fetal Medi- cine, Department of Obstetrics and Gynecology, Hospital of the University of Pennsy- lvania, Philadelphia

Previous studies have related the optical density (O.Do) at 650 nm. of amniotic fluid to the lecithin/sphingomyelin (L/S) ratio. We hav~ explored the correlation between the 0.D.650, the L/S ratio, and phosphatidylglycerol (PG) and have evaluated the ability of these parameters to predict the occurrence of neonatal respiratory distress syndrome (RDS). All amniotic fluids were obtained by transabdominal amniocentesis performed for assessment of fetal lung maturity. Only specimens uncontam- inated by blood or meconium were studied. After centrifugation at 2000 g. for I0 minutes, the 0.D.650 was read in a spectrophotometer. The L/S ratio and PG determination were performed using the methods of Gluck.

Of 212 fluids, 106 had an 0.D.65N equal to or greater than 0.15 and were deemed mature (Table I). i01 of these ~ad an L/S ratio of 2 or more, a false-positive rate of 4.7% with respect to the L/S ratio. 62 of these 106 fluids were assayed for PG. PG was present in 41, a false-positive rate of 33%. k~en the 0.D.650 was mature, only 3 of 105 liveborn infants developed RDS.

78 of 106 fluids with an irm-nature 0.D.650 had an L/S ratio less than 2.0, a false- negative rate of 26% Of 52 fluids assayed for PG, only 3 contained this phospho- lipid. 19 patients with an immature 0.D.650 were delivered within 48 hours of amniocentesis and 4 of these neonates developed RDS.

A mature 0.D.650 is, therefore, highly predictive of a low incidence of RDS (2.9%). An immature value, although associated with an increased risk of P~DS (21%), has a false-negative rate too high to permit its use as the sole measure of fetal pu!monary maturity.

TABLE

O.D.650

> 0.15 < 0.15 _~ ture Immature

Numb er

L/S > 2.0

L/S < 2.0

PG+

RDS

106 106

i01 (95.3%) 28 (26%)

5 (4.7~o) 78 (74%)

41/62 (66%) 3/52 (5.8%)

3/I~5 (2.9%) 4/19 (21%)

Society of Perinatal Obstetricians Annua! Mee ting

San Antonio, Texas

January--1981

ENDOTOXIN SHOCK IN BEAGLE DOGS PRETREATED WITH METHYLPREDNISOLONE

SUCCINATE.

Georgina Makabali, M.D., Ashis Mandal, M.D., Juan J. Arce, M.D. and John A. Morris, M.D. (Department of Obstetrics and Gynecology, Divigion’of Reproductive Sciences and the Department of Surgery, The Charles R. Drew Postgraduate Medical School, Los Angeles, California)

Recent studies in Beagle dogs pretreated with indomethacin (I) and then shocked with e.coli lipopolysaccharide endotoxin (i mg/kg), demonstrated that I significantly modified the typical hemodynamic responses. Since corticoids are known to inhibit the release of arachidgnic acid (AA) from cellular phospholipids in vitro, the hemodynamic and metabolic responses after pretr~eatment with corticoid~ might be similar to that seen after pretreatment with I. Further, clinical consensus is that steroids may have value in the management of septic shock. Accordingly, Beagle dogs, prepared as previously reported (Am. J. Obst. & Gynec. 134:120-126, 1979) were pretreated with i.V.omethyiprednisolone succinate (Solu-Medrol, 30 mg/kg), then shocked with endotox.in. Hemodynamic parameters (systemic and pulmonary arterial blood pressure, right and left atrial pressure, heart rate and cardiac output) as well as selected metabolic i~dices

(arterial blood pH, P02, pC02, base excess, lactate, pyruvate) were measured periodically. Systemic and pulmonary vascular resistance~ as well as "excess" lactate were derived from standard formulas. None of the hemodynamic and metabolic parameters differed statistically (p<0.05) between the control (untreated) and pretreated animals. Both groups of animals survived 24h post endotoxino This study does not support the reported therapeutic value of steroids in management of septic shock and suggests that the steroid, in contrast to indomethacin, may not interfere significantly with the biosynthesi of prostaglandins in vivo.

Supported by DHHS #2-SO6-RR08140-06SRC

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Joseph M. Miller, Jr., M.D., Department of Obstetrics and Gynecology, }.~dical University of South Carolina, Charleston, South Carolina

Alpha thalassemia occurs when one or more of its four structural genes are de- leted or when globin s.vnthesis is reduced. In its most severe form, it may result in a hydropic stillborn. Alpha thalassemia minor (~ thai minor) may cause a mild microcytic, hypochromic anemia whirl% can be mistaken for iron deficiency. Wqnile more comTon among far eastern populations, it occurs in 5% of A~erican Blacks. Little is known about the management of such patients when pregnan~l occurs, other than the need to provide genetic counselling. .To this end, we present our experience.

439 prenatal registrants were screened with a CBC and a hemoglobin electrophoresis between Dec. i, ]979 and March i, 1980. Transferrin saturation (T.S.) was determined if the mean corpuscular volume (MCV) < 80 fl. Patients with abnormal red cell configuration, hemoglobin variants on electrophoresis, or iron deficient (T.S. < 15% and serum iron < 50 ~g/dl)were excluded. 17 patients with a normal hemoglobin electrophoresis, T.S. > 15%, serum iron > 50 ~g/dl and ~"V < 80 fl were identified as having e thal minor. All 17 were Black. 24 patients with a normal hemoglobin electrophoresis and a MCV > 80 fl and without iron deficiency were randomly as controls from the 309 Black prenatal registrants.

Data are expressed as the mean i 1 standard deviation. Differences are statistically not different unless noted.

Prenae~ ! Begistration

thal minor n=17 control n=24

Ces tational Hemoglobin ~.~V MCH Age in Weeks in gm/dl in fl in

16.0±6.5 11.2-+i.0 73.9-+3.5* 24.9-+1.3* 16.3-+8.3 11.4-+1.3 86.6-+4.2 29.6-+1.5

Deliveql Ces tational Hemoglobin MCV [~H Age in Weeks in gm/dl in fl in pg

e thal minor n=17 38.9-+5.4 11.7-+0.8 74.7-+3.9* 25.1fi.4" con_trol n=24 37.8-+4.3 ii. 4-+1.3 88.3-+5.0 29.8-+2.2

Delivery Birth Weight Pre term Growth in gm < 37 Weeks Retarded

e thal minor n=17 3043+822 I 0 control n=24 29 i0-+ 788 2 1

*Value significantly different from controls, p < .01 by student t-test From these data, e thai minor is not associated with poorer pregnancy outcome.

Hemoglobin concentrations are similar, while MCV and MCH are clearly different. Neither prematurity nor growth retardation are associated with ~ thai minor.

Asyr~ptomatic bacteruria occurred in one patient with ~ thai minor and two control patients. Pyelonephritis occurred in a third control patient. Hence, urinary tract infections are not increased with e thai minor, p > .05, Yates’ exact test. This is in variance with the proposed correlation of 8 thalassemia minor and urinary tract infection.

Alpha thalassemia minor is a benign condition to be distinguished from iron deficiency. Aside from the recon~rendations for genetic counselling, this is a low risk group.

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Society of Perinatai O0stetrlclans Annual Meeting


CARDIAC OUTPUT AND PLACENTAL BLOOD FLOW IN THE UNANESTHETIZED GUINEA PIG

Stephen A. Myers, D.O., John Sparks, M.D., Edgar L. Makowski, M.D., Giacomo Meschia, M.D. and Frederick C. Battaglia, M.D. (Division of Perinatal Medicine, University of Colorado Health Sciences Center, Denver)

Previous studies attempting to look at metabolic and hemodynamic alterations in the pregnant guinea pig have utilized acute preparations. However, Sparks et al (abstract, SGI, 1980) studying chronic preparations have documented that metabolic recovery of the pregnant guinea pig requires 3-4 days. In order to see if there were similar hemodynamic changes, studies were performed both acutely and chronically to determine the effects of surgery. Pregnant albino guinea pigs, 25-63 days gestation, under ketamine, xyalazine and atropine anesthesia have catheters placed in the femoral artery and through the carotid artery into the left ven: tricle using microsurgical techniques. The animals are then studied either immediately or on the fourth to sixth postoperative day. The metabolic work of Sparks et al was confirmed. Blood flow studies were performed using radioactive microspheres. Preliminary measurements of cardiac output and organ flows performed using 15, 25 and 42 micron spheres suggest that some shunting of smaller spheres occurs through the heart, uterus (not including the placenta) and skin. However, the magnitude of this shunt is less than 1% of the total cardiac output. As seen in figure i, placental blood flow is reduced from 40 ml/min - 4 ml/min, 10% of its chronic value, when studied acutely. This reduction in placental flow is due not only to an absolute reduction in cardiac output from 270 - 120 ml/min, but to a redistribution of cardiac output from 19% - 4%, as well. From these studies we conclude that: (i) 25 micron spheres yield optimum balance between shunting and hemodynamic alterations; (2) that acute metabolic and hemodynamic studies performed on pregnant guinea pigs do not accurately reflect the unstressed conditions under which fetal growth normally takes place; and (3) that redistribution of blood flow that occurs acutely in the pregnant guinea pig is assymetrical and may be particularly misleading with respect to utero-placental flows. Currently, studies in our laboratory are looking at intra-litter comparisons of chronic placental blood flows and its relation to growth.

ACUTE D CHRONIC

300

200

100

HEART RATE

300

200

lOO

CARDIAC OUTPUT

(ml/min)

2O

15

10

5

PLACENTAL FLOW

(%of C.O.)

40

30

2O

I0

PL~.CENTAL FLOW

(mL/min)

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I Society of Perinatal Obstetricians

Annual Meeting San Antonio, Texas January--1981

THE DEHYDROEPIANDROSTERONE LOADING TEST -

EVALUATION OF CLINICAL UTILITY

David A. Nagey, M.D., Ph.D. Marcos J. Pupkin, M.D.

Lisa K. Mandeville, R.N., B.S.N. David W. Schomberg, Ph.D.

Carlyle Crenshaw, Jr., M.D.

(Department of Obstetrics and Gynecology Duke University Medical Center, Durham, North Carolina)

The dehydroepiandrosterone (DHEA) loading test (DLT) is a biochemical measure of placental function that involves the maternal intravenous injection of 25 mg of DHEA with subsequent measurement of maternal serum estrogen response. A simple mathematical model of the DHEA to estrogen conversion system is utilized to analyze the data resulting in a DHEA to estrogen conversion rate constant. This conversion rate constant is capable of discriminating with significance, within a high risk population, between mothers who will later deliver infants with intrauterine growth retardation or fetal distress in labor or both and those mothers who will deliver normal, undistressed infants. Of those patients with suspected or clinical intrauterine growth retardation (n=31) a conversion rate constant less than 3.0xi0-3 min-I was predictive of a birthweight below the tenth percentile sixty percent of the time. A conversion rate constant greater than this threshold was always predictive of a birthweight above the tenth percentile and fifty percent of the time signified a birthweight above the twenty-fifth percentile. The DHEA to estrogen conversion rate constant is also significantly related to the percentile birthweight.

The DLT is too cumbersome to permit replacement of the daily serum estriol and too expensive to permit replacement of the weekly non stress test or contraction stress test, in the management of high risk obstetric patients. How- ever, the DHEA to estrogen conversion rate constant yields fewer false positive results than other techniques used to predict intrauterine growth retardation and has produced fewer false positive and fewer false negative results than a clinical appraisal of pregnancy progression at test time, when intrauterine growth retardation was either diagnosed or suspected. The DLT is a reliable test of placental function that may prove useful in judging the efficacy of clinical pregnancy interventions in dealing with situations where prematurity and intrauterine growth retardation are confused.



THE EFFECT OF FETAL ASPHYXIA ON LIDOCAINE TOXICI’~Y

William F. O’Brien, LCDR (MC) USN and Robert C. Cefalo, M.D., Ph.D. (Department of Obstetrics and Gynecology, Uniformed Services University School of Medicine, Bethesda, Maryland and University of North Carolina, Chapel Hill, North Carolina)

Local anesthetics have become an important part of modern obstetrical care. Although reasonably safe, these agents have been shown to have detrimental effects in some fetuses. In the present study we examined the ~nfluence of fetal asphyxia on the distribution and cerebral uptake of maternally infused lidocaine. Results demonstrate that asphyxia is associated with higher concentrations of lidocaine in fetal arterial plasma, increased presentation of the drug to cerebral tissue, and increased cerebral lidocaine uptake. These findings underscore the importance of evaluation of fetal status when considering the risks and benefits of maternal druq use,

Cerebral lidocaine flow (ug/min)

normal (n=8)

245 ± 46

asphyxic (n=9)

4!7 ± 83

Sianificance*

p<O.Ol

Cerebral lidocaine uptake (ug/min/lOOg)

29 ± 13 96 ± 12 p<O.Ol

o! /o lidocaine uptake 0.12 ± 0.05 0.29 ± 0.06 p<O.05

* Student’s unpaired t-test

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,USE OF THE ~MNIOTIC FLUID FO~M STABILITY INDEX (FSI) - TEST IN DISCRIMINATING

BETWEEN ~HE SEVERELY GROWTH RETARDED FETUS AND THE APPROPRIATELY GROWN, BUT VERY

SMALL, PRETE~M FETUS

G. Sher, M.D., B. E. Statland, M.D., Ph.D., V. K. Knutzen, M.D.(Department of Ob- stetrics and Gynecology, University of Nevada, School of Medicine, Reno, Nevada and Department of Pathology, University of California, Davis Medical Center, Sacramento, California)

We recently introduced the Foam Stability Index (FSI) - Test, a functional assay which expresses the overall surface tension lowering ability of amniotic fluid surfactant in terms of the highest ethanol volume frsction (EVF,) which per- mits a stable ring of foam to persist after graded volumes of ethanol are shaken with fixed volumes of amniotic fluid supernatant. The highest EVF capable of producing a stable ring of foam is expressed as the Foam Stability Index. An FSI of 0.47 or greater is indicative of fetal pulmonary maturity.

It has been suggested that chronic placental insufficiency results in ac- celerated fetal pulmonary maturity. We decided to investigate whether the measurement of this parameter in pregnancies associated with a very small fetus could assist in differentiating between the very small growth retarded fetus, and the very small appropriately grown preterm fetus. Fetal pulmonary maturity was measured using the Lecithin/Sphingomyelin (L/S) ratio assay, and the FSI-Tes~

Twenty-seven pregnancies associated with very small fetuses were evaluated. Zriteria for inclusion in the study required: (I) That the height of fundus neasure 34 cm. or less, and (2) that clinical findings and/or special investiga- tions rendered delivery imminent. All patients who had previously received phar- nacologic agents with the potential of enhancing fetal lung maturity, as well as those patients with premature rupture of the membranes, were excluded from the study.

In twenty-seven such pregnancies, both L/S ratio assays and FSI - Tests were performed on amniotic fluid specimens~collected within 72 hours of delivery. Of the twenty-seven low birth weight (LBW) neonates, we noted 15 cases of intrauterine growth retardation (IUGR), none of which suffered from hyaline membrane disease, and 12 cases of appropriately grown (AGA) neonates, 8 of which had hyaline-m~nbrane disease. The 15 cases of IUGR were characterized by FSI values varying from 0.47 to 0.55, while the 12 cases of AGA had values varying from 0.42 to 0.48. Thus, the FSI showed an excellent discrimination between these two entities. The L/S ratio, on the other hand, varied from i.I to 3.4 in IUGR and ranged from 1.0 to 2.4 in AGA, showing a great degree of overlap. The combinatio~ of an L/S ratio of 1.5, and an FSI value of less than 0.46, consistently identified the fetus with future hyaline m~nbrane disease. The results of this study strongly suggest the following: (i) That the detection of a mature FSI value (greater than 0.46) in pregnancies associated with a very small fetus enables discrimination between IUGR and AGA fetuses. (2) In pregnancies complicated by IUGR, the functional FSI - Test is far more reliable than the LiS ratio assay which is often "falsely" immature.

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RISKS PRECEDING INCREASED PRIMARY CESAREAN BIRTH RATES

Robert J. Sokol, M.D., Mortimer G. Rosen, M.D. and Sidney F. Bottoms, M.D. (Peri- natal Clinical Research Center and Department of Obstetrics and Gynecology, Cleveland Metropolitan General Hospital (CMGH)/Case Western Reserve University)

Studies of cesarean birth rates, in general, have been focused on indications for abdominal delivery, often described in terms of broad categories, such as repeat cesarean, dystocia, fetal distress and breech presentation. Our purpose in the present study was to approach the problem differently, by evaluating maternal risks which were recorded in a computer based uniform perinatal record system prior to making the decision for delivery. Among 2744 consecutively delivered mothers who received antenatal care at CMGH, the total cesarean birth rate was 13.91%, with a primary rate of 9.3% and repeat rate of 4.6%. Excluding repeat cesareans, relative risks for primary cesarean birth and risk specific primary cesarean birth rates were calculated for each of approximately i00 pregnancy risk factors detectable prior to delivery. To minimize statistical problems with multiple comparisons, a p<.O005 was c~n~sidered significant.

Maternal age, race and education were found to be unrelated to primary cesarean birth. Primigravid patients and those with 6 or more pregnancies were 1.5 fold more likely than average to be delivered abdominally. Of those risks which can be detected early, during the course of antenatal care, only i small clinical pelvimetry, 2 diabetes mellitus and 3 Rh sensitization were associated with significantly increased relative risks for primary cesarean birth. Of those problems typically detectable by the time of labor onset, I) preeclampsia, 2)premature rupture of the menbranes,3) low placentation, including placenta previa &) moderate or severe abruptio placenta and 5 abnormal fetal presentations were found to be significant risks for cesarean birth. Of problems which may arise during the course of labor, those reflecting "dystocia" were associated with increased risk for primary cesarean birth, e.g., prolonged labor (>20 hours) was associated with a 1.7 fold and secondary arrest of dilatation with a 2.,5 fold increase. For the risk category "fetal distress," the relative risks in the presence of specific problems were--prolapsed cord--6.4X, presence of meconium--l.4X, abnormal fetal heart rate (bradycardia > five minutes and/or severe decelerations > 30 minutes) --2.7X and fetal scalp blood pH < 7.25--5.4X.

Based on these data, it appeared that about 60% of primary cesareans might be accounted for by single pregnancy risks. Thus, abnormal fetal presentation, which was associated with a sixfold increase in risk and a cesarean birth rate of 60%, could alone account for nearly 30% of the primary cesareans which were performed. Similarly, antenatal problems could account for 5%, abnot-mal labor for 10% and fetal distress for 15%. This leaves a minimum of 40% which may be accounted for by combinations of preceding risks. From another perspective, approximately 20% of the primary cesareans were performed for small pregnancies, related to prematurity and/or intrauterine growth retardation, but about 80% were performed for normal size pregnancies.

The results of this study suggest that for the large majority of patients, the need for primary cesarean birth cannot be accurately predicted prior to the onset of labor. Although the small fetus, with its associated increased risks for malpreseetation and fetal distress, can be detected at labor onset and clearly contributes significantly to the primary cesarean birth rate, most abdominal deliveries can be expected to be performed for normal birthweight pregnancies, often for "dystocia." This suggests that the normal birthweight category is that area in which critical evaluation and study of obstetrical management may be most fruitful in responding to the questionof rising cesarean birth rates.

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FETAL ELECTROCARDIOGRAM (FECG) CONFIGUP_ATION OBTAINED DURING LABOR USING A WIDE BAND TELEHETRY SYSTEM VERSUS A DIRECT CABLE

Hilo B. Sampson, M.D., Jessics L. Thomason, M.D., and Bruce A. Work, Jr., M.D. (division of Perinatology, University of Illinois School of Medicine, Chicago, Ill.)

A compact single channel telemetry unit was used to monitor feta! heart rate (FHR) during labor in 23 patients. The transmitter, which measured ll.7x6.3x2.5 cm and weighed 10.4 oz, was attached securely to the patient’s gown to allow freedom of movement. The two fetal scald electrode wires were connected to a modified leg plate whose reverse side was grounded to the patient. Parallel 25 cm wires connected the plate to the transmitter. The receiver module was incorporated into a conventional monitor with both oscilloscope display and 25 mm/sec paper readout of the FECG. Overall telemetry bandwidth was 0.5-100 Hz. 23 patients were initially monitored by direct ECG for 30 minutes after membranes had ruptured spontaneously and switched to telemetry monitoring for an average time between 40 minutes and one hour. Patients were successfully monitored to a distance of 20 meters or until they passed through an~ metal lined barrier. Direct and telemetry transmitted FHR’s were identical.

KlapholtzI has suggested that 60 Hz noise should be decreased in telemetry systems which are D.C. powered. No noise was noted with either system in this study. FECG’s were obtained with no decelerations, during mild, moderate and severe decelerations and for one fetus who had a sinus arrhythmia. No differences between direct and telemetry FECG’s were found and comparision of the complexes revealed no configuration changes. This suggests that no observable FECG configuration information is lost when telemetry is used to monitor the human re,as during labor. Uterine pressures were not monitored in this study, but a multiplexed system and a two channel system have been used to transmit intrauterine pressure data.2,3

i. Klapholtz H. and Kotaro S: Evaluation of the model 78100A adult telemetry unit for use in fetal heart rate monitoring. J Reprod Med 18:79,1977 2. Flynn A, Kelly J, Hollings G, et.al: Continuous fetal monitoring in th ambulant patient patient in labor. Brit Med J 2:842,1976. 3. Neuman MR, Roux JF, Patrick JE, et. al: Evaluation of fetal monitoring by telemetry. Obstet Gyneco! 54:49, 1979



PARENTERAL NUTRITION SUSTAINING FETAL GROWTH IN TWINS DURING MATERNAL STARVATION.

Luis R. Saldana, M.D., C. Allen Stringer, M.D. and Berel Held, M.D. (Department of Obstetrics and Gynecology of the University of Texas Medical School at Houston)

A 33 year old white female, P I-0-5-I, was transferred at 29 weeks of gestation with twin pregnancy and status post-intestinal bypass. Workup at 27 weeks had revealed twins with BPD of 62mm and 68mm, urinary tract infection, and hemoglobin of 8.1 grams %.

Physical exam revealed normal vital signs. Fetal heart rates at 152 bpm and 140 bpm were recorded. Lower extremities had massive edema. Iron and vitamin B-12 deficiency anemia, ulcerative colitis in remission, and flat OGTT were found. BUN, uric acid, and creatinine were normal. Urinary tract infection responded to antibotics. Anemia responded to parenteral iron and B-12. Repeat ultrasound on 8/23/79 revealed BPD of 74mm in both fetuses. Elevated liver function tests (bilirubin = 1.2 mg/dL SGOT = III U/L, alkaline phosphatatase 157 U/L) were noted but patient demanded discharge for social problems.

She was re-admitted a week later with anorexia and vomiting, mild icterus, and ketotic breath. Laboratory data showed urinalysis with ketonuria and coarse granular casts. Serum bilirubin = l.gmg/dL, SGPT : 558 U/L, SGOT = 287 U/L, K = 2.5mEq/L and CO2 = 19mEq/L. Serum creatinine = 2.4ra!!alL, ~]ric acid = 15.2rag/alL and BUN = 58mg/dL. Creatinine clearance = 42ml/min. Fetuses had normal heart tones and BPD of 78mm.

Parenteral nutrition was instituted for 26 days. Oral nutritional intake was supplemented by 500cc’s dextrose 10%, 500cc’s travasol 8.5%, multivitamins and trace metals and albumin 12.5 grams. Every third day 500mL of intralipid was added~ Electrolytes, glucose and trace metals were monitored and normal. Liver function returned to normal in 5 days. Creatinine clearance doubled in 5 days and returned to normal (llOml/min) within I0 days.

Ultrasound at 33 weeks showed one fetus with BPD = 84mm and the other at 81mm. Amniocentesis revealed L/S ratio of 1,6. Ten days later the larger fetus had BPD = 87mm and the smaller fetus a BPD : 85mm. Amniocentesis five days later revealed L/S ratio of 4.4. Primary cesarean section was performed at 35 weeks with infants in good condition, weighing 2040 and 2050 grams; a 160 gram deficit for gestational age.

This case demonstrates the feasibility of manipulation of fetal growth by i ntravenous al iment ati on. Par ent er al nutri ti on corrected hepato-ren al dysfunction and allowed us to await fetal lung maturity with minimal birth weight deficit.

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~ocle~y o~ ~erlnata~ O~s~e~rlc~ans Annual Meeting

San Antonio, Texas January--J981

CYTOPATHOLOGIC STUDIES OF AMNIOTIC FLUID AND ITS CORRELATION TO FETAL MATURITY AND FETAL DISTRESS.

Luis R. Saldana, M.D., Juan W. Arias, M.D. and Carlos Bedrossian, M.D. with the technical assistance of Cherie Koch (Departments of Obstetrics and G~n~ecology and Pathology of the University of Texas Medical School at Houston)

64 samples of amniotic fluid were examined cytologically after being stained with the Papanicolaou method. This method revealed large polygonal cells which could be grouped as anucleated, superficial, and intermediate types. These cells stained eosinophilic or cyanophilic and appeared to originate from fetal epidermis. In addition, small round cells presumed to be of fetal internal visceral origin were sometimes present and stained universally cyanophilic. These cells are presumed to be representative of fetal distress by others. An effort was made to verify this hypothesis by comparing the prevalence of visceral cells with clinical parameters of intrauterine fetal stress.

Cells of amniotic membrane origin were intermediate in size and uniformly cyanophilic. These cells appear to have a significant relationship to fetal maturity by gestational age and lecithin/sphingomyelin (L/S) ratio. There was no correlation between three commonly used cytologic hormonal indices (maturation index, eosinophilic index and anucleate count) applied to fetal epidermal cells and three clinical indicators of fetal maturity (gestational age of 37 weeks or more, L/S over 2.0 and birth weight over 2500 grams). However, amniotic cells were present in large numbers in 88% of all mature infants.

In utero fetal stress was defined clinically by antepartum (abnormal non-stress test), intrapartum (fetal heart rate deceleration or acidosis), and neonatal (low birth weight and congenital anomalies) criteria. The stressed immature infants had an incidence of visceral cells approaching I0(~/~. However, the stressed mature infants had a prevalence of only 62% visceral cells. We found visceral cells in 15 of 18 high-risk pregnancies with positive criteria for fetal stress. However, many of the controls near term also had visceral cells in amniotic fluid. This has implications regarding the management of premature labor and premature rupture membranes in the premature fetus. The presence of visceral cells in amniotic fluid of premature fetuses may indicate that such fetuses may be chronically stressed and therefore should be delivered. However, it should be noted that the prevalence of visceral cells (58%) was identical for those fetuses having mature and immature L/S ratios and therefore bore no relationship to fetal lung maturity. Further studies into the cytologic indices of fetal distress are indicated.

J:~nuary--1981

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?~ATE~NAL AND FETAL PROSTGLANDINS DURING ACUTE FETAL ACIDOSIS

William F. O’Brien, M.D., Robert Co Cefalo, M.D., Ph.D., and Peter W. Ramwell, Ph.D. (Departments of Obstetrics amd Gynecology, Uniformed Services University School of Medicine, Bethesda, ~,(aryland and University of North Carolina, Chapel Hill, North Carolina)

Prostaglandins F2~and E have been detected in high~entrations in the fetal circulation. These substances have been shown to cause marked changes in fetal amd uterine blood flow when injected into preg-nant animals or fetuses. In the present study fetal lambs were subjected to acute~asphyxia via ligation of

multiple intercotyledonary vessels. Fetal and m~ternal Pg F2~ levels were ~ elevated when mild or marked fetal acidosis was produced. No correlation between Pg E with fetal status was noted. Maternal status was not correlated with maternal or fetal Pg levels.

Group Fet pH

Normal 7.34 + .01

Fet PO~ Fet i ?g F~ ~at i Pg Fo ~

23 _+ 3 205 _+ 17’ 187 + 22*

~Id Acidosis 7.24 + .02 18 + 2 388 + 103 ~ 300 ± 44

~rked Acidosis 7.10 ± .01 15 ± 3 561 ± 108 561 ± II0"

* p<O.01 (Student’s t test

Although the exac% source of significance of the increase in prostaglandins noted in asphyxic fetuses is unknown, these results indicate that prostaglandins may play a role in the pathogenesis of acute fetal distress.

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~oc~ety o~ Per~nata± Obstetr~clans- Annual Meeting


Remarks and Comments on the evaluation of obstetrical regionalization and care in Michigan. J.F. Roux, M.D., Jackson, Wyoming.

In 1973, the Michigan legislature enacted a program of regionalization of perinatal care. The state was divided into eight Health Service Areas (HSA) having level I, II, and III hospitals. With the purpose to evaluate the state of regionalization in Michigan, the Michigan Subcommittee in Obstetrical and Neonatal Plan- ning visited 30 level I, II, and III hospitals. A qugstionnaire was sent to the various hospitals three months before each visit and each group made of task force members met with the Director of the Hospital, the Director of Nursing, the Chief of Obstetrics and Neonatology, the head nurse of the labor/delivery floor and postpartum area. The hospital facilities, and perinatal statistics were assessed. The percent of television sets, telephone and cars in the state were also computed to determine whether or not communications influence the pattern of referral to level II and III centers. The questionnaire was subjective and objective and permitted an overall appraisal of high risk care.

The data indicated that there is no formally organized regional perinatal net- work in Michigan. High risk evaluation processes are rarely used. By contrast, the neonatologists have regionalized newborn care. Fetal maternal physicians are located in University Centers and their influence on the medical community is very limited. They take care mainly of indigent patients. Transfer of pregnancy patients from one hospital to another ~ake place, but there is no written recommenda-

tions or regulations. There is no state-wide prenatal and labor record. This makes patient transfer and data gathering difficult. In most level I and II hospitals there is no active prenatal high risk screening and because of that the patients are diagnosed as being at risk too late to alter their clinical management Most hospitals ignore their perinatal statistics. From the obstetrician point of view, neonatologists meddle aggressively with obstetrical care whereas from the neonatal point of view the obstetricians are not very knowledgeable in high risk ?regnancies and do not use the talents of the pediatricians. An@sthesia is the least available service on a regular 24 hour basis in level III centers. With a

few exceptions level III centers have not actively promoted high risk care. There is, often, no high risk team and clinics in leve! II and III hospitals. The prac- ticing obstetrician in level I and II centers feel that they are capable to deal with any complications of pregnancy and labor. The administrators of level I and II center~ are afraid to lose patients and beds to regionalization and they have t~ deal often with unreasonable physician demands for equipments and facilities. Fro~ these subjective and objective data it is concluded that the decrease in perinatal mortality in Michigan in the last i0 years was not due to high risk obstetrical regionalization but rather to the availability of neonata! centers with active neonatal transfer. It is also evident from this survey that the talents of the fetal maternal physicians are under utilized. The fetologist is ignored, feared and occasionally respected. It is, from this survey, possible to make some recommendations to implement high risk obstetrics in Michigan¯ This will be discussed.

This work was supported partly by the Department of Obstetrics and Gynecology, Michigan State University, Lansing Michigan and by the Michigan Department of Public Health, Lansing, Michigan.


San Antonio, Texas Januar y-- 1981

SERUM AND ERYTHROCYTE FOLATE IN MOTHERS OF CHILDREN WiTH CLEFT LIP ± CLEFT PALATE

Jennifer R. Niebyl, M.D., David A. Blake, Ph.D., Laura Eo Rocco, R.N., M.S., E. David Mellits, SC.D.(Departments of Obstetrics and Gynecology and Pharmacology, Johns Hopkins University School of Medicine, Baltimore, Maryland)

Maternal vitamin deficiency has been implicated as a possible etiologic factor in the production of birth defects. In one study, early vitamin supplementation in the subsequent pregnancy of mothers who had a previous child with cleft lip±cleft palate was associated with a reduction of the incidence of the defect from 5.5% to 1.9%I After per±conceptional multiple vitamin supplementation, 0.6% of mothers who had a previous child with a neural tube defect had another affected child, compared with 5.0% of unsupplemented mothers2.

We studied 9 mothers of children affected with cleft lip±cleft palate (affecteds) and 15 control mothers with unaffected children when they were not pregnant, and during the early first trimester of pregnancy. There was no significant difference between the two groups with respect to a number of demo- graphic variables, including age and weight. However, the affected patients had more living children compared to the controls (p<.05).

In the non-pregnant state, the mean serum and erythrocyte folate levels were both significantly lower in the affected group compared to the control group.

The patients were also studied early in the first trimester at approximately 7 weeks from their last menstrual period. At this time mean serum folate was significantly lower in the affected group than in the control group, but there was no significant difference in erythrocyte folate at this time. However, 3 patients in the affected group and 3 in the control group were already taking vitamins at the time they were studied early in pregnancy.

Affecteds Controls [ n 9 15 age,yrs. 28.1 ± 2.5 28.0 ± 2.7 NS weight,lb. 126 ± 7 132 125 NS living children 1.6 i i.i 0.6 ± 0.6 <.05 Non-pregnant serum folate ~g/ml 4.1 ± 1.6 9.4 ± 4.9 <.01 erythrocyte folate ~g/ml 116.8 138.1 186.3 ±75.6 <.05 Pregnant days from LMP 45 i 8 51 ± 8 NS serum folate ~g/ml 3.7 ± i.I 8.7 ± 4.9 <.01 erythrocyte folate ~g/ml 117.3 ±30.2 162.2 ±84.0 NS

i. Briggs RM: Vitamin supplementation as a possible factor in the incidence of cleft lip/palate deformities in humans. C!in. Plas. Surg. 3: 647, 1976.

2. Smithells RW, Sheppard S, Schorah CJ, et al.: Possible prevention of neural- tube defects by per±conceptional vitamin supplementation. Lancet I: 339, 1980.

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Society of Perinatal ~bstetricians Annual Meeting

San Antonio, Texas

January--1981

TEMPERATURE _RESPONSE OF CUTANEOUS p0 IN THE RABBIT 2

Frank Silverman, M.D., Miriam Katz, M.D., and Bruce K. Young, M.D. (Department of Obstetrics and Gynecology, Division of Maternal- Fetal Medicine, New York University School of Medicine, New York, New York)

Continuous transcutaneous measurement of p02 (Cp02) has been adapted to fetal and neonatal use, utilizing a noninvasive miniaturized modified Clark p02 electrode attached to the skin by adhesive. The unprepared ear of the rabbit female Giant Flemish rabbit was used for attachment, of the electrode, and blood for arterial p02 (Ap02) was taken from the auricular artery of the same ear. The rabbits were gently restrained and unanesthetized. Cp02 and Ap02 were compared at 21°C (room temperature), 45°C, and 60°C, with 20 experiments in each group. The data demonstrated that Cp02 is not the same as Ap02. It is most closely related to !ocal blood flow. Cp09 only indirectly reflects Ap02, when peripheral flow is comparaDle to central. Proper use of Cp02 in the fetus and neonate requires cognizance of blood flow conditions for correct interpretation. Cp02 data are not indicative of Ap02 when reduced peripheral circulation is present.

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San Antonio, Texas January--i 981

FETAL HEART RATE PATTERNS AND FETAL MOVEMENTS IN PREGN.~N~CIES OF 20-30 WEEKS GESTATION

Y. Sorokin, M.D., L. J. Dierker, Jr., M.D., I. Zador, Ph.D., S. Pillay, Ph.D. M. L. Schreiner, R.N., M. G. Rosen, M.D., Department of Obstetrics and Gynecology and the Perinatal Clinical Research Center, Cleveland Metropolitan General Hospital/Case Western Reserve University

Fetal heart rate (FHR) and fetal movements (FM) are used clinically to evaluate fetal well-being. However, there is relatively little information on FHR changes and FM in the very premature human fetus and, hence, no established criteria for nonstress monitoring in the premature fetus below 30 weeks’ gestation

Normal low risk pregnant women were monitored at 20-30 weeks’ gestation (12 ~patients at 20-22 weeks and i0 at 28-30 weeks). Baseline FH~ was considered to be ithe average during the 20 seconds prior to change. FHR change, monitored with an iabdominal ECG or Doppler ultrasound, was categorized as I) acceleration, an

increase of at least i0 BPM above baseline, 2) deceleration, a decrease of at least i0 BPM below baseiine,3) acceleration/deceleration. FM were identified if detected by at least one of the three techniques used - i) patientperception, 12) observer or 3) two tocodynamometers. Tocodynamometric findings were confirmed by either patient or observer. Each patient was monitored for approximately 2 hours° The tracings were displayed on a 4 channel recorder, with a paper speed of 5 mm/sec. Each minute of recording was interpreted separately for FHR change, FM and association between the two. The findings are displayed in the table.

Gestational Age

(weeks)

20-22

28-30

...... FHR change, rela[ive f}eq~ency~n %

Accelerations Decelerations Acceli (n) (n) Decel (n)

1.8 (13)~ 96.7 (700) 1.5 (Ii)

36.0(242) 33.8(227) 30.2(203)

Associations in % (n) FHR changes FM with

.with FM .FH.R.’ change

68.4(495) 68.0(495)

81.3(546) 90.0(546)

A total of 1302 minutes of recordings at 20-22 weeks were analyzed. Of 724 FHR changes, 1.8% were accelerations, 96.7% were decelerations and 1.5% were accel eration/decelerations. Of the FHR changes, 68.4% were associated with FM; of the F~[, 68.0% were associated with FH~ chan~es, indicating that 32.0% of FM did not link with any FHR change.

For the second maturational period (28-30 weeks), 1106 minutes of recordings were analyzed. Of 672 FHR changes, 36.0% were accelerations, 33.8% were decelerations, and 30.2% were acceleration/decelerations. Of the FHR changes, 81.3% were associated with FM; 90% of FM were associated with FHR changes and 10% did not ilink with any FHR change.

The findings of this study suggest that in normal pregnancy FHR deceleration

is common from 20 to 30 weeks’ gestation. With advancing gestational age, FHR decelerations are less common and the frequency of FHR acceleration and acceleration/deceleration patterns increases. Our data also indicate that the association~ between FHR change and FM becomes stronger with advancing gestational duration, suggesting the s~eculation of fetal central nervous system maturation and coord- ination of physiologic response. Further research in normal and abnormal preg- ancies will be necessary to further define the association between FM and FHR change in the premature fetus and to establish criteria for nonstress monitoring.

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FETAL ELECTROENCEPHALOGRAPHY AND FETAL BEH~VIORAL STATES

Y. Sorokin, M.D.,JFACOG, Assistant Professor of Obstetrics and Gynecology, L. J. Dierker,Jr.,M.D., S. Pillay,Ph.D., Roger H. Hertz,M.D., M. G. Rosen, M.D.

The concept of behavioral state implies a clustering of physiological variables that occur repeatedly in an individual person or in a fetus. A behavioral state is stable over a described period of time, and it is seen in similar form in other individuals. The early classification of behavioral states used observational criteria. Subsequent observations made electroencephalography (EEG) a useful tool for differentiation between the various sleep states and wakefulness

As in the adult, observations of human neonatal behaviour include body movements, respiration, heart beat, electromyogram (EMG), electroencephalogram and eye movements. For definitions of state recent work suggested that in the human newborn analysis of FHR variability may be sufficient to identify neonatal active and quiet sleep.

Some of the physiologic variables used in the definition of neoDatal state are available for measurement in the fetus at the present time. For example, recent observations of fetal heart rate (FHR) variability and fetal movements demonstrated cycles of active and quiet periods during the antenatal period. Fetal electroencephalography (FEEG) cannot be used prior to rupture of the membranes during early labor. In these studies intraparnum~FEEG has documented ~the exist- ence of the four EEG patterns.

In this study human fetal activity states were studied during normal labor using FEEG and FHR variability. Twenty normal human fetuses at term gestation were studied following rupture of the amnio=ic membranes. Direct FHR and FEEG recordings were obtained using two suction electrodes placed on the parietal areas

of the fetal scalp. The analog data was recorded both on a paper record as well as on magnetic tape. The FEEG recordings were interpreted with visual pattern identification on each ten second page. The interpretation of FEEG data follows the established neonatal EEG criteria for coding of sleep states. The FEEG was coded according to the pattern occupying more than one half of each one minute epoch. _The basic four FEEG patterns of trace alternant (T/A), high voltagle slow (HVS), low voltage irregular (LVI), and mixed activity (MIX) were seen.

The FHR recording was used independent of the fetal EEG state recordings.

As in earlier antepartum studies from this laboratory FHR beat to beat variabilit’ of less than ten beats during one minute epochs indicated a quiet epoch. The correlation between these intervals and the EEG recordings of quiet sleep (T/A) was made. The results demonstrate the ability of the FHR data to be correlated with fetal behavioral state and its potential usefulness in the antenatal period.

As noted in exurauterine studies of th~ preterm infant, there is a shift in the p~oportion of active aud quiet sleep as maturation progresses. This shift is characterized by an increase in quiet sleep. Quiet sleep is triggered by the higher brain centers including the cortex and indicates more complex processes.

Under certain circumstances abnormalities of behavioral state organization

and characteristics were described in the neonate (diabetic mothers, SGA infants, fetal alcohol syndrome). With the use of the antenatal study model there is a

potential for documentation of similar events in the fetus. This study during the intrapartum period links fetal state observation witi~

a parameter useful in the antepartum period.

Annual Meeting San Antonio, T~xas

January--1981

EISENMENGER’ SYNDROME IN PRE~ Management by Elective Cesarean Section with Epidural Anesthesia

Joseph A Spinnato, M.D., B.J. Kraynack, M.W. Cooper, M.D., Departments of Obstetrics, Anesthesiology, and Cardiology, Texas Tech University School of ~dicine, Lubbock, Texas

The occurence of Eisenmenger’s Syndrome (ES) in pregnancy is associated with. a maternal mortality rate of 30%. In the case of 15 of the reported 23 deaths, the cardiac d~agnosis was not known until post-mortem examination, limiting conclusions that can be drawn. Eight reported instances of Cesarean Section have resulted in maternal mortality in five patients (62.5%). Cesarean Section has been reserved for the most dire of maternal circumstances and its safety cannot be assessed accurately by literature review. We report the successful management of a patient at term with Eisenmenger’s Syndrome by elective cesarean section with epidural anesthesia. The circumstances of this patient including obstetrics, anesthetic, and cardiovascular considerations are discussed.

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MONOAMNIOTIC TWINS" ULTRASOUND, AMNIOGRAPHY, CESAREAN SECTION

Joseph A. Spinnato II, M.D., D. Eric Blackwell, M.D., M. Wayne

Heine, M.D., Harlan R. Giles, M.D.

Monoamniotic twin gestation results in marked fetal wastage mo~t oomm~n]y ~s~i~ted with umbJlica! cord ~ccidents0 Attempts to decrease fetal wastage have been hampered by an inavailability to identify routinely a twin gestation as monoamniotic. The use of ultrasound to establish the diagnosis of monoamniotic twin gestation and recommendations regarding the management of such gestations are discussed.

~ocme=y oz =er~naCa~ oos=e=rmczans Annual Meeting

San Antonio, Texas January-- 1981

HLA TYPING IN ASSOCIATION WITH GESTATIONAL DIABETES AND PREGNANCY INDUCED HYPERTENSION

Jessica L. Thomason, M.D., William N. Spellacy, M.D., Bruce A. Work, M.D., and Milo B. Sampson, M.D. (Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Abraham Lincoln School of Medicine).

In the past decade HLA typing has become prevalent and various diseases have been found ~- associated with the presence or absence of certain HLA antigens. More specifically some HLA types have been associated with patients having insulin dependent diabetes mellitus. Human leukocyte antigens at two loci (A and B) of pregnant patients who developed gestational diabetes were compared to pregnant patients without abnormal carbohydrate metabolism during their pregnancy. Also a second group of patients who developed pregnancy induced hypertension had typing and were compared to patients without evidence of this disease. Statistical analysis of this data showed the absence of HLA BW-40 to be significant when comparing gestational diabetics to control pregnant patients. Pre- liminary analysis of hypertensive disorders of pregnancy reveals neither the presence nor the absence of various HLA antigens associated with the disease.

Antenatal screening of pregnant patients with a strong family history for diabetes may show that patients with the absence of HLA BW 40 must be watched closely for the development of abnormal carbohydrate metabolism during their pregnancy. While noting that no HLA antigen is found in association in patients with gestational induced hypertension it is important to continue to probe

_this group of high risk problem patients since the mechanisms of onset, early recognization and management remain an obstetrical problem.


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ANTEPARTUM FETAL HEART RATE TESTING AND THE POST-TERM GESTATION

Yvonne S. Thornton, M.D., Sze-Ya Yeh, M.D. and Roy Ho Petrie, M.D.(Sloane Hospit~

for Women and the Section of Perinatal Obstetrics of the Division of Perinatal Medicine of the College of Physicians and Surgeons, Columbia-Presbyterian Medical Center, New York, New York)

This study has examined the role of antepartum fetal heart rate testing (APFHRT) in the management and outcome of the post-term gestation. It spanned a ten year period from 1969 to 1979 and was conducted at the Sloane Hospital for Women at the Columbia-Presbyterian Medical Center in Ne~ York.

A study group was composed of 314 patients at 42+ weeks gestation who were managed with APFHRT. There were two control groups. Control group number one included those post-term patients delivered in the five years preceding our study period (1969-1974). This group did not have the benefit of APFHRT. Control group number two included those post-term patients who did not receive APFHRT during the study period (1974-1979). In addition to the APFHRT, adjunctive testing included 24-hour urinary estriol, ultrasonographic B scan, amnioscopy and amniocentesis, when indicated. Patients were entered into the APFHRT protocol on a voluntary basis.

Statistical analysis demonstrated a significant difference in perinatal morbidity and mortality between the study group and control group number one. There was a statistically significant difference in the perinatal morbidity be-

tween the study group and control group number two. Patients with abnormal APFHRT had a statistically significant increase in the incidence of intrapartum variable decelerations, meconium and the post-term/postmaturity syndrome. Three patients whose pregnancies had progressed to 48-49 weeks, by their last menstrual period, were seen initially at 40 weeks gestation and were followed with APFHRT for 8-9 weeks without any perinatal morbidity or mortality. The physical findings and Dubowitz scores indicated that these three infants were postmature. In

the instances of adjunctive testing of fetal well-being using other systems, these tests either supported the APFHRT findings or were of neutral value. In

no instance were there discrepancies. There were two neonatal deaths in the study group. The first was attributed

to an inadvertent laceration of the umbilical cord during amniocentesis. The

second death was due to a large diaphragmatic hernia of Bochdalek and bilateral pulmonary hypoplasia.

This study also demonstrated a false positive rate for the nonstress test

of 27.4 percent with a false negative rate of 0.6 percent. Despite its high false positive rate, the nonstress test in conjunction with the contraction stress test was a reliable indicator for fetal compromise in the post-term gestation.

Suspected postmaturity continues to be a problem for the clinician. One must either temporize and await the onset of spontaneous labor or intervene and

terminate the pregnancy for fear of increased perinatal morbidity and mortality. With APFHRT, there is an accurate selection of a small group of infants

for whom further prolongation in intrauterine life could be disastrous. The results of this study have shown that APFHRT has a significant impact on decreasing theperinatal morbidity and mortality associated with the post-term gestation.


San Antonio, Texas January~-1981

EFFECTS OF NICOTINE UPON THE ACID-BASE STATUS AND TH~ HEMODYNAMICS OF CHRONICALLY INSTRUMENTED PREGNANT SHEEP. Mitchell Tobias, Jahangir Ayromlooi, Denise Desiderio. Dept. of OB-GYN, Long Island Jewish-Hi!is±de Medical Center, New Hyde

Park, N.Y. 11042. Maternal cigarette smoking has been linked to a variety of neonatal complica-

tions. The effects of nicotine sulphate (15mg over I0 minutes (min) upon maternal (M) and feta! (F) physiology were evaluated in 9 IV infusions to 5 instrumented ewes of 97-117 days of gestation. Experiments were performed at least 2 days postoperatively. M(n=9) and F(n=8) aortic(A) blood samples (0.5cc) were drawn at 0, i0, 30 and 60 min from the start of the infusion. MA pH transiently increased from 7.47±0.01 to 7.5110.01 units (p<0.005) at i0 min. MA base excess also increased from -2.41±1.3 to -0.3 i.i mEq/L (p<0.Ol) at i0 min. M blood pressure (BP) rose during the infusion, from 90.8±3.8 to 118.7±5.6 mm Hg (p<0.O05) at i0 min, remaining high at 30 min. M heart rate (HR) transiently increased from 97±6 to i0716 beats/min (p<0.01) at 1 min, returning to baseline by I0 min. Uterine blood flow (UBF) fell -28.7±9.0% (p<0.02) at i0 min, recovering to only -8.5±2.9% (p<0.025) at 60 min. FBP decreased transiently from 52.6±2.3 to 50.2± 2.0 mm Hg (p<0.05) during the infusion. FA PCO2 also decreased transiently from 41.1±3.1 to 37.212.5 mm Hg (p<0.05) at I0 min. A transient increase in FHR was observed from 197!12 to 215!15 beats/min (p<0.05) at 30 min. No significant

changes were seen in FA PO^, 0~o saturation, or umbilical arterlal blood flow. All F & M values, except U~F, ~eturned to pre-infusion levels by 60 min. The

observed, sustained reduction in UBF may, in part, explain the increased incidence of SGA infants born to smoking mothers.

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Annuhl Meeting San Antonio, Texas

January--1981

ARE B MIMETIC DRUGS THE SOLUTION FOR PREMATURITY?

G. Valenzuela, R. Hayashi

Prematurity is the leading cause of perinatal mortality and long term neurological sequelae. Because B mimetic drugs are able to postpone premature delivery in 80% of the cases, we decided to review the repercussion of this treatment on our population.

A retrospective review of the records of 42,288 patients who delivered over the last i0 years compiled in a computer program as described by Seitchik was performed. The records show a decline in prematurity during the first few years with a plateau for the last ~ive years that superimpose to the years that vasodilan has been used routinely. The spontaneous rupture of membranes, with being delivered within two hours of admission, a higher percentage of breech presentation, less than 40% were nulliparous and higher percentage of birth defects. Also around 50% of the deliveries under 2500 g born over 36 weeks by history as compared to 97% of babies over 2500 g born over 36 weeks. The chance of being discharged alive was increased over the last few years especially for the group 2000-1500 g and over.

Prospectively, during a 12 month period, of 639 patients that presented in premature labor to the labor and delivery suite at the R.B. Green Memorial Hospital$only 72 were eligible for vasodilan treatment. (11.26%)

The present paper shows that for an individual case B mimetic drugs can successfully postpone premature delivery but from a public health care it does not seem to be the solution. From our data it seems that as concern of the possible prematurity, it is necessary to R/O IUGR or small for gestational age. Also a more aggressive management of SROM and increase the awareness of premature labor in the pregnant population so that they may seek health care early enough to allow B mimetic drug a chance to be effective.



EXTERNAL CEPHALIC VERSION UNDER TOCOLYSIS

J.Po VanDorsten, M.D. and B.S. Schifrin, M.D. (Department of Obstetrics and Gynecology, Los Angeles County/University of Southern California, Los Angeles, California)

The increased mortality and morbidity of the term breech is thought to result from the type of delivery (vaginal) rather than the presentation itself. Current management schemes include: i) Cesarean section; 2) Selective vaginal delivery. Both of these strategies result in an exceedingly high Cesarean section rate, but neither attacks the frequency of breech presentation. We studied the feasibility and safety of external cephalic version late in pregnancy on 47 !ow risk patients with breech presentation at 37 to 40 weeks. Normal real time B-scan exam and reactive non-stress test (NST) were also considered prerequisit~ for inclusion. The version group received IV terbutaline (5 mcg/min) for I0 minutes prior to and during the version. The fetal heart rate was monitored during the version and afterwards until a reactive NST was again seen. Transient bradycardia (less than 90 bpm for greater than or equal to i0 seconds) was seen in 60% of the cases, but invariably responded when manipulations ceased. No untoward maternal or fetal complications were encountered at the time of the version.

Of the 47 patients, 4 were excluded (oligohydramnios, placenta previa, suspected SGA). Version was attempted on 22 patients; 14 (64%) were successful and all presented in labor with a vertex presentation. The 8 failures all presented as breeches in labor. In reviewing failures, we found that obesity, station, uterine anomaly, and uterine activity prejudiced success.

In the control group (version not attempted), 18 (86%) presented in labor as breeches, and three converted spontaneously to vertex~ There were no untoward intrapartum maternal or fetal/neonatal complications in either group and all babies had Apgar scores greater than or equal to 8 at 5 minutes, Twenty-one of 26 breech presentations in labor were delivered by Cesarean section~ The preliminary data suggest that external cephalic version, in selected patients late in pregnancy, may be useful in reducing the incidence of breech presentation at delivery. Uterine relaxants appear to facilitate the procedure. The maneuver appears safe, but more patients are required to substantiate this point.

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San Antonio, Texas January - 1981

INTRAPARTUM EVALUATION OF THE HUMAN FETUS WITH THE CEREBRAL FUNCTION MONITOR

Uma L. Verma, M.Do and Nergesh A. Tejani, M.D. (The Department of Obstetrics and Gyneco!ogy, Nassau County Medical Center, East Meadow, New York, and the Health Sciences Center, State University of New York at Stony Brook.

Adverse perinata] events .are a major cause of neonata! mortality, morbidity arid eventual neurological deficit. Presently available methods of intrapartum monitoring give only indirect evidence cf cerebra! function. Continuous recording of intra- parLum fetal encephaloaram (FEEG) is difficult from technica! and interpretive aspects. The Cerebral Function Monitor (CFM), a new concept of integrated EEG, overcomes the many short- comings of the conventional EZG. Electrical signals from the bra’~n are amolified by the CFM, but are not written out directly as ]n EEG; i nsteed~ the CFM selects on]’y those fre- quencies between 2 & !5 Hz and after electronic processing ’,.,~r~tes them out as a single compressed bend on a slow speed chart recorder. Upwards or downward movements of the band correspond with increase or decrease in the amount of cerebr~l activity. The width of the band indicates .fluctuations in the electrical activity.

This study is a report of the use of the CFM as a means of eva]uatin~ fecal cerebra! activity during Jabot. Normal ~atterns ~n the fetal and neonatal periods were recognized. !n &ddition the effect of Demero] and Epidura] anesthesia with Mepiv]caine were studied in 30 instances. A quantitiva reducE- ~on j n the cerebral activity was seen with the use of these commonly used agents,

Imtrapsrtum feta! CFM is as yet an experimental tool, end has ~h_ potential for identifyin~ those fetuses who may be dd- pressed in the absence of ominous FHR changes.



"HUMAN FETAL CARDIAC TIME INTERV~L~ KS--AN iNIYfCA~OR OF ~’EIALMATURATION

Robert N. Wolfson, M.D., Ph.D., Ivan Eo Zador, Ph.D., Sasi K. Pillay, Ph.D. and Roger H. Hertz, M.D., (Department of Obstetrics and Gynecology and the Perinatal Clinical Research Center, Cleveland Metropolitan General Hospital (CMGH)~tCase Western ~eserve University, Cleveland, Ohio)

Assessment of fetal maturation is important in the identification and the management of the growth-retarded fetus. Specific fetal cardiac time intervals (FCTI correlate with fetal gestational age, but it is unknown if this reflects maturation of the fetal heart or fetal heart size paralleling fetal growth. The FCTI are subdivisions of the fetal cardiac cycle and reflect the electrical and electro~ mechanical properties of the heart. They have recently received attention as potentially more sensitive indicators of fetal well-being than conventional fetal heart rate monitoring. The purpose of this study was to determine whether theFCrI reflect maturation of the fetal heart and, thus maturation of the fetus.

Fetal heart weight increases progressively with gestational age in both the normal and the growth-retarded fetus. It is known that the growth-retarded fetus has a conistently smaller heart for a given gestational age. However, if fetal heart weight is compared to fetal weight, the growth-retarded fetus and the normal fetus are indistinguishable. This implies that the fetal heart size correlates with fetal weight regardless of gestational age. Therefore, if the FCTI correlate with gestational age but can be demonstrated not to correlate with fetal weight (and thus not correlate with fetal heart size), this would imply that the gestational age dependent FCTI reflect maturation of the fetal heart.

The FCTI divide the fetal cardiac cycle into six parts. Only the electro- mechanical delay time IEDT) and the pre-ejection period (PEP) correlate with gestational age. EDT reflects the conduction p~operties of the heart and is measured as the interval from the onset of the Q~S complex of the fetal electrocardiogram to the closure of the atrioventricular valves. PEP reflects theinono- tropic state of the myocardium and is the interval from the onset of the QRS complex to the opening of the semilunar valves. EDT is a subdivision of PEP. The duration of both EDT and PEP lengthen with gestational age.

Volunteers were recruited from patients receiving obstetrical care at CMGH. Patients were studied between 38 and 40 weeks of gestation and within two weeks of delivery. Fetal gestational age at the time of study was confirmed with the modified Dubowitz assessment of pediatric gestational age after birth. Each infant was classified as small for gestational age or appropriate for gestational age.

In this study, EDT and PEP were obtained from the abdominal fetal electrocardiogram and the Doppler ultrasound measurement of atrioventricular valve closure and semilunar valve opening. Using an interactive offline computer routine, EDT and PEP were calculated as the mean from ten consecutive monitored cardiac cycles. The relationship of EDT and PEP to fetal weight was described by linear regression analysis of EDT and PEP on newborn weight.

Sixteen fetuses were studied: Four small-for-gestational age and twelve ap-

propriate-for-gestational-age newborns. Newborn weight ranged from 2130 to 3969 grams. Linear regression of EDT and PEP showed no correlation to newborn weight, yielding correlation coefficients of 0.]4 and 0.18 respectively. This implies that EDT and PEP do not correlate with fetal heart size and that EDT and PEP may reflect maturation of the fetal heart since they correlate with gestational age without correlating with fetal heart size. The growth-retarded fetus might therefore be identified non-invasively as the one whose values of PEP and EDT increase with gestational age and are inappropriately long compared to estimated fetal weight.

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