Sinusoidal fetal heart rate pattern

The etiology of sinusoidal fetal heart rate (FHR) patterns is diverse and consequently they ave been associated with poor as well as normal fetal outcome. Four patients who demonstrated sinusoidal FHR patterns are reported, and the factors associated with these patterns and their effect on fetal outcome are discussed. Three of the babies were delivered by emergency cesarean section and were markedly depressed at birth. Two of the infants died and the third required prolong hospitalization. The fourth baby was delivered vaginally and had a normal outcome. The possible pathophysiology is discussed and recommendations are made for the management of this FHR pattern.

Pregnancy complicating ambulatory patient management of diabetes

Two groups of patients are summarized. The first group demonstrates contemporary perinatal outcome using a predominantly outpatient management plan. The second group demonstrates extension of the outpatient management using a reflectance meter for in-the-home blood glucose assessments. The financial savings of outpatient management is emphasized.

The late postpartum eclampsia controversy

The diagnosis of late postpartum eclampsia remains controversial. Six cases thought to represent eclampsia occurring 3 or more days post partum are reported, as is a review of the pertinent literature.

Effect of diabetes mellitus on amniotic fluid lecithin/sphingomyelin ratio and respiratory distress syndrome

Ninety-eight insulin-dependent diabetic patients were cared for during 108 pregnancies following an ambulatory program aimed at close control of blood sugar levels. The incidence of respiratory distress syndrome (RDS) in these patients was not different from that in nondiabetic patients. Fetal pulmonary maturity seemed to progress at a normal rate as evidenced by an equal incidence of mature lecithin/sphingomyelin (L/S) ratios at various stages of gestation in diabetic and nondiabetic patients. There was no evidence that Class B and C diabetic patients have delayed fetal lung maturation or that Class E, F, and R patients have accelerated maturation. It is concluded that careful metabolic control of the pregnant diabetic patient results in a normal process of fetal pulmonary maturation without increased risk of RDS.

Screening for fetal and neonatal risk in the postdate pregnancy

One hundred four postdate pregnancies were managed according to a well-defined protocol calling for weekly oxytocin challenge tests and urinary estriols three times per week. Although the perinatal mortality rate in these patients was not increased there was a significant increase in the incidence of neonatal morbidity and complications. The clinical syndrome of dysmaturity was seen in 20 per cent of the neonates. When meconium was present in the amniotic fluid the incidence of neonatal and fetal complications was higher. The cesarean section rate was twice the normal rate, with nonprogression of labor being the commonest indication. It is recommended that: (1) pregnancies carried beyond 42 weeks do not require termination simply because they are post dates; (2) all postdate patients should be monitored during labor; (3) trained personnel to initiate neonatal resuscitation should be present at each postdate delivery.

Injection of corticosteroids into mother to prevent neonatal respiratory distress syndrome

In this study, 500 mg. of hydrocortisone were injected intravenously into 126 women every 12 hours for four doses in a double-blind, randomized fashion. These 126 subjects were at risk for delivery of a premature infant because of premature labor of fetomaternal disease necessitating intervention. There were 67 patients in the treatment group and 59 in the placebo group. All patients had immature lecithin/sphingomyelin ratios and/or were at less than 34 weeks' gestation. From these data, it appeared that there was a significant decrease in respiratory distress syndrome when the treatment group was compared to the placebo group. The neonatal survival rates also were improved significantly by steroid treatment. There was no demonstrable adverse steroid effect in mothers of fetuses in the long-term or short-term follow-up period, although a significant number of patients were lost to follow-up and the methodology of infant evaluation was imprecise. It would appear from these data that the injection of steroids is beneficial in mothers at risk of being delivered of premature infants. However, many questions remain to be answered before this method can be relied upon as therapy for women with premature labor.

Effect of surgical stress on the distribution of placental blood flows

The distribution of the uterine and umbilical blood flows over the surface of the placenta was measured in 9 near-term sheep in an effort to assess the effects of surgical stress. The blood flows were observed to be relatively evenly distributed over the surface of the placenta. It was determined that the heterogeneity of distributions observed in the study could have caused the transplacental clearance of a very diffusible molecule to decrease by no more than 2 0/0. It is concluded that at the macroscopic level, in both the acute and chronic conditions, the uterine and umbilical blood flows of the near-term sheep are relatively evenly distributed over the surface of the placenta and that this distribution per se does not significantly contribute to transplacental concentration gradients.

The use of amniotic fluid bubble stability, L/S ratio, and creatinine concentration in the assessment of fetal maturity

Amniotic fluid bubble stability and creatinine concentration are analyzed in relation to the L/S ratio and clinical outcome. Bubble stability by the standard method showed 20.5 per cent (31/151) initial disagreement between two laboratories, 53.6 per cent (81/151) correlation with L/S ratio, and did not correlate well with patient outcome. However, a "foamy" test, i.e., foam noticeable at a distance, in both 1:1 and 1:2 dilutions, indicated an elevated L/S ratio and mature pulmonary outcome. Amniotic fluid creatinine levels showed an estimated 5 to 6 per cent risk for RDS at levels we formerly thought to be safe (greater than or equal to 2.0 mg. per 100 ml. with maternal serum less than or equal to 0.9 mg. per 100 ml.), and has many false-negative values. Fetal maturity can be estimated with clinical data and amniotic fluid analysis. Amniotic fluid sampling is necessary in all instances where the clinical data leave a reasonable doubt of actual gestational age and in all cases for elective preterm delivery. We recommend a sequential approach to amniotic fluid analysis. First a bubble stability test (a "foamy" at both 1:1 and 1:2 dilutions indicates pulmonary maturity). If the bubble stability test is not "foamy", an L/S ratio. The risk of RDS associated with creatinine concentration makes this test unacceptable in any case of elective delivery; however, it may be useful as a weighing factor in emergency situations where phospholipid analysis is unavailable.