Role of patient education level in predicting macrosomia among women with gestational diabetes mellitus

OBJECTIVE

To evaluate the role of education level in predicting the risk of macrosomia among women with gestational diabetes mellitus.

STUDY DESIGN

Women with gestational diabetes, who were referred to the California Diabetes and Pregnancy Sweet Success Program between June 2001 and December 2002, were included in the study. Multiple logistic regression was used estimate the risk of macrosomia, defined as a birth weight >4000 g.

RESULTS

Compared to college-educated women, high school- and middle school-educated women were 21% (relative risk (RR), 1.21; 95% confidence intervals (CI), 1.01-1.44) and 35% (RR, 1.35; 95% CI, 1.09-1.70) more likely to deliver a macrosomic infant, respectively.

CONCLUSION

Gestational diabetics with a lower level of educational attainment appear to have an increased risk of macrosomia. Future studies are necessary to determine whether this finding reflects a variation in adherence to recommended treatments by education/literacy level, or if it is a surrogate marker for intrinsic, biological differences or differences in lifestyle.

Controversial and special situations in the management of preterm premature rupture of membranes

The management of preterm premature rupture of membranes is one of the many controversial areas of medicine. Many of the protocols used to manage preterm premature rupture of membranes are not based on solid data. Other situations are rarely encountered, making it very difficult to arrive at a management scheme on which all can agree. This article presents five such areas along with available literature and discusses treatment options involving these controversial or special topics.

Accuracy of self-monitoring of blood glucose: impact on diabetes management decisions during pregnancy

PURPOSE

This study tested the hypothesis that the accuracy of self-monitoring of blood glucose (SMBG) values of patients with diabetes during pregnancy deviates substantially from reference values.

METHODS

The patients' glucose values were measured on 6 different SMBG meters; reference values were from the HemoCue B Glucose Analyzer. Over a 5-year period, 1973 comparisons between SMBG values and reference values were recorded during clinic visits and used for this study. Data were analyzed for percent of values that varied more than +/- 10.5% and +/- 15.5% from the reference value. Out-of-range data at each variance level were analyzed to determine the impact on medical management if decisions were based solely on SMBG values.

RESULTS

One third of SMBG readings deviated significantly, which could adversely affect treatment for half of these patients if diabetes management was based on SMBG values. At the 10.5% deviation level, 34% of SMBG meter readings were out of range; 54% of these would have implied erroneous treatment. At the 15.5% deviation level, 18% were out of range; 63% of these would have implied erroneous management.

CONCLUSIONS

The accuracy of home meters should be verified at regular intervals, and SMBG values should not be the sole criterion for diabetes management during pregnancy.

A comparison of echocardiography and pulmonary artery catheterization for evaluation of pulmonary artery pressures in pregnant patients with suspected pulmonary hypertension

OBJECTIVE

This study was undertaken to compare the accuracy of echocardiography versus pulmonary artery catheterization to estimate pulmonary artery pressures in pregnant women with suspected pulmonary hypertension.

STUDY DESIGN

A retrospective chart review was performed between January 1990 and February 2000 for all pregnant patients with cardiac disease. Patients with pulmonary artery pressure values estimated by cardiac catheterization and echocardiography during pregnancy were included. Pulmonary hypertension is defined as pulmonary artery systolic pressure >30 mm Hg.

RESULTS

Twenty-seven patients were included in the study. There was a significant overestimation of the mean pulmonary artery pressure with echocardiography compared with catheterization (55.4 vs 51.1 mm Hg; P <.005). Of the 20 patients, pulmonary artery pressure was significantly greater when estimated by echocardiography than when measured by catheterization (59.6 vs 54.8 mm Hg; P <.004). Thirty-two percent (8/25) of the patients had pulmonary hypertension when estimated by echocardiography but had normal pulmonary artery pressures on subsequent catheterization.

CONCLUSION

Echocardiography significantly overestimated pulmonary artery pressures compared with catheterization in pregnant patients with suspected pulmonary hypertension. Patients with structural cardiac defects appear to have a significantly greater difference in pulmonary artery pressures. Thirty-two percent of pregnant patients with normal pulmonary artery pressures may be misclassified as having pulmonary artery hypertension when measured by echocardiography alone.

Recurrence of gestational diabetes: who is at risk?

OBJECTIVE

The object was to determine the recurrence rate of gestational diabetes mellitus and to find various risk factors that might increase this rate.

STUDY DESIGN

Seventy-eight patients with gestational diabetes mellitus in their index pregnancies were evaluated in subsequent pregnancies. Medical records for the index and subsequent pregnancies were abstracted for age, parity, body mass index, birth weight, gestational age of gestational diabetes mellitus diagnosis, insulin requirement, weight gain, and interval between pregnancies. These variables were then compared between patients with and without gestational diabetes mellitus in their subsequent pregnancies.

RESULTS

Fifty-four of 78 patients (69%) had gestational diabetes mellitus in a subsequent pregnancy. The recurrence of gestational diabetes mellitus was more common when the following variables were present in the index pregnancy: parity > or = 1 (P < .004; odds ratio 3.0, 95% confidence interval 1.4-4.8), body mass index > or = 30 kg/m2 (P < .04; odds ratio 3.6, 95% confidence interval 1.1-25.9), gestational diabetes mellitus diagnosis at < or = 24 gestational weeks (P < .0003; odds ratio 20.4, 95% confidence interval 2.5-444), and insulin requirement (P < .0002; odds ratio 2.3, 95% confidence interval 1.3-3.4). A weight gain of > or = 15 pounds (P < .003; odds ratio 2.9, 95% confidence interval 1.0-5.3) and an interval between pregnancies < or = 24 months (P < .03; odds ratio 1.6, 95% confidence interval 1.1-2.2) were also associated with a recurrence of gestational diabetes mellitus. A multiple logistic regression analysis revealed that an interval of < or = 24 months and a weight gain of > or = 15 pounds between pregnancies were most strongly correlated with a recurrence of gestational diabetes mellitus.

CONCLUSIONS

Gestational diabetes mellitus is more likely to recur in parous, obese women who had an early gestational diabetes mellitus diagnosis and required insulin in the index pregnancy. In addition, a shorter interval (< or = 24 months) and a larger weight gain (> or = 15 pounds) between pregnancies appear to be the most significant risk factors for a recurrence of gestational diabetes mellitus.

Papillary thyroid carcinoma manifesting as thyroid storm of pregnancy: case report

A patient with known hyperthyroidism was seen at 25 weeks' gestation with a rapidly growing neck mass. She was initially in thyroid storm and received aggressive medical therapy. Two subsequent episodes of thyrotoxicosis occurred during pregnancy in spite of large doses of propylthiouracil. Post partum the patient was diagnosed with a locally advanced thyroid malignancy.

Assessment of costs and benefits of management of gestational diabetes mellitus

The purpose of this pilot study was to perform a cost-identification analysis of care for gestational diabetes mellitus (GDM) by determining the direct costs of the diagnostic procedures and treatment used for the outpatient management of GDM (program input costs) and the direct costs of maternal hospitalization after diagnosis of GDM, delivery of the baby, and newborn care (outcome costs). Reimbursed average charges in the Northern California (NoCal) managed care market in 1996 were used to establish the direct costs, and the direct costs were then applied to the elements of care and pregnancy outcomes of three GDM management programs in NoCal, Southern California (SoCal), and New England (NewEng), using prospectively collected data. Reimbursed amounts for the detailed elements of GDM management (program input costs) are presented in the categories of diagnosis of GDM, diabetes treatment supplies, doctor's office visits, office visits to ancillary providers, and fetal surveillance. Program input costs per patient were $817 for diet-treated and $1,838 for insulin-treated women in NoCal, and were estimated to be $882 for diet-treated and $1,425 for insulin-treated women in NewEng. Program input costs for women requiring insulin treatment who were randomized to premeal or postprandial blood glucose testing (N Engl J Med 333:1237, 1995) in SoCal were estimated to be $3,596 per patient for the premeal group and $3,770 per patient for the postprandial group. Reimbursed amounts for health care expenditures related to pregnancy outcomes are detailed in the categories of hospital and physician charges for maternal antepartum hospitalization ($1,864 for 2 days), vaginal delivery with 50% use of epidural anesthesia ($4,050), cesarean section ($5,932), and neonatal intensive care ($9,130 for 4 days). Outcome costs per patient were $5,792 for diet-treated and $6,462 for insulin-treated women in NoCal. Outcome costs per patient were estimated to be $6,096 for diet-treated and $11,216 for insulin-treated women in NewEng, and $8,013 for the premeal blood glucose group and $7,495 for the postprandial blood glucose group in SoCal (both groups required insulin treatment). Incremental cost-effectiveness of postprandial monitoring in the SoCal controlled trial was $35 per patient in input costs per cesarean section averted and $25 per patient in input costs per neonatal intensive care unit day prevented. The benefit-to-cost ratio of the difference in input and outcome costs was 2.98 in favor of postprandial monitoring in the SoCal study. Cost analysis should be included in clinical trials of the management of GDM.

The effects of carbohydrate restriction in patients with diet-controlled gestational diabetes

OBJECTIVE

To determine the effect of carbohydrate restriction on perinatal outcome in patients with diet-controlled gestational diabetes mellitus (GDM).

METHODS

Women with diet-controlled GDM were divided non-randomly into two groups based on their dietary carbohydrate content: those with low dietary carbohydrate content (below 42%) and those with high dietary carbohydrate content (exceeding 45%). Subjects kept dietary accounts and were followed with daily fasting and postprandial glucose assessments. Subjects also were tested daily for urinary ketones. Glycosylated hemoglobin, mean fasting and postprandial glucose values, incidence of macrosomia and large for gestational age (LGA) infants, cesarean deliveries for cephalopelvic disproportion and macrosomia, and need for insulin therapy were compared between the groups.

RESULTS

The two groups were identical in terms of demographic characteristics. Significant reductions in the postprandial glucose values were seen among subjects in the low-carbohydrate group (P < .04). Fewer subjects in the low-carbohydrate group required the addition of insulin for glucose control (P < .047; relative risk [RR] 0.14; 95% confidence interval [CI] 0.02, 1.00). The incidence of LGA infants was significantly lower in the low-carbohydrate group (P < .035; RR 0.22; 95% CI 0.05, 0.91). Subjects in the low carbohydrate group also had a lower rate of cesarean deliveries for cephalopelvic disproportion and macrosomia (P < .037; RR 0.15; 95% CI 0.04, 0.94).

CONCLUSION

Carbohydrate restriction in patients with diet-controlled GDM results in improved glycemic control, less need for insulin therapy, a decrease in the incidence LGA infants, and a decrease in cesarean deliveries for cephalopelvic disproportion and macrosomia.

Postprandial versus preprandial blood glucose monitoring in women with gestational diabetes mellitus requiring insulin therapy

BACKGROUND

The fetuses of women with gestational diabetes mellitus are at risk for macrosomia and its attendant complications. The best method of achieving euglycemia in these women and reducing morbidity in their infants is not known. We compared the efficacy of postprandial and preprandial monitoring in achieving glycemic control in women with gestational diabetes.

METHODS

We studied 66 women with gestational diabetes mellitus who required insulin therapy at 30 weeks of gestation or earlier. The women were randomly assigned to have their diabetes managed according to the results of preprandial monitoring or postprandial monitoring (one hour after meals) of blood glucose concentrations. Both groups were also monitored with fasting blood glucose measurements. The goal of insulin therapy was a preprandial value of 60 to 105 mg per deciliter (3.3 to 5.9 mmol per liter) or a postprandial value of less than 140 mg per deciliter (7.8 mmol per liter). Obstetrical data and information on neonatal outcomes were collected.

RESULTS

The prepregnancy weight, weight gain during pregnancy, gestational age at the diagnosis of diabetes and at delivery, degree of compliance with therapy, and degree of achievement of target blood glucose concentrations were similar in the two groups. The mean (+/- SD) change in the glycosylated hemoglobin value was greater in the group in which postprandial measurements were used (-3.0 +/- 2.2 percent vs. 0.6 +/- 1.6 percent, P < 0.001) and the infants' birth weight was lower (3469 +/- 668 vs. 3848 +/- 434 g, P = 0.01). Similarly, the infants born to the women in the postprandial-monitoring group had a lower rate of neonatal hypoglycemia (3 percent vs. 21 percent, P = 0.05), were less often large for gestational age (12 percent vs. 42 percent, P = 0.01) and were less often delivered by cesarean section because of cephalopelvic disproportion (12 percent vs. 36 percent, P = 0.04) than those in the preprandial-monitoring group.

CONCLUSIONS

Adjustment of insulin therapy in women with gestational diabetes according to the results of postprandial, rather than preprandial, blood glucose values improves glycemic control and decreases the risk of neonatal hypoglycemia, macrosomia, and cesarean delivery.

Tocolysis in advanced preterm labor: impact on neonatal outcome

Chart review of 73 patients with 3.5 cm or more dilation, intact membranes, and regular contractions at less than 36 weeks. Forty-four (group A) received tocolysis with magnesium sulfate, and 13 of the 44 also received indomethacin. Twenty-nine (group B) received no tocolysis. Obstetric and neonatal outcomes were compared. Demographic factors and admission gestational age, cervical dilation, effacement, and uterine activity were similar. Twenty-one of the 44 in group A versus 3 of 29 in group B had delivery delayed by more than 48 hours (p = 0.002). Group A had a lower incidence of severe respiratory distress syndrome; 4 of 48 babies in group A versus 9 of 32 in group B (p = 0.04; RR = 0.47; confidence interval [CI], 0.2, 1.0). Tocolysis in advanced preterm labor delays delivery by more than 48 hours in 50% of patients. The neonatal benefits of aggressive tocolysis in cases with advanced cervical dilation may outweigh the potential maternal risks of tocolysis, particularly in the setting of extreme prematurity. Delay in delivery enabling steroid enhancement of pulmonary maturity reduces the severity of respiratory distress syndrome.

Preterm premature rupture of membranes and abruptio placentae: is there an association between these pregnancy complications?

OBJECTIVE

Our purpose was to determine whether the incidence of abruptio placentae is increased in pregnancies with preterm premature rupture of membranes and to assess whether certain clinical risk factors in this group predispose them to have abruptio placentae.

STUDY DESIGN

A retrospective cohort study over a 2.5-year period was performed. The study group consisted of 756 singleton pregnancies between 20 and 36 weeks' gestation complicated by preterm premature rupture of membranes and managed expectantly. The control group consisted of 11,240 pregnancies not complicated by preterm premature rupture of membranes and delivered during the same time period. The incidence of abruptio placentae was compared between the two groups. The study group of patients with preterm premature rupture of membranes was further subdivided into cases with (n = 38) and without abruptio placentae (n = 718) and compared. Clinical factors such as admission amniotic fluid index, history of bleeding before or after rupture of membranes, incidence of intrapartum fetal distress, and low 5-minute Apgar scores (< 6), latency-to-delivery interval, gestational age and weight at delivery, and incidence of amnionitis and endometritis were compared.

RESULTS

The incidence of abruptio placentae in the study group (38/756, 5%) was significantly higher than that in the control group (97/11, 240, 0.9%) (p < 0.001, odds ratio = confidence interval). Comparison of cases with preterm premature rupture of membranes with and without abruptio placentae demonstrated both groups to have a similar gestational age at delivery, birth weight, latency-to-delivery interval, amniotic fluid index, and infectious morbidity. The group with abruptio placentae had a significantly higher incidence of bleeding before rupture of membranes (six of 38, 15% vs eight of 718, 1%; p < 0.005) and of intrapartum fetal distress (18/38, 46% vs 49/718, 7%; p < 0.0009).

CONCLUSIONS

Pregnancies complicated by preterm premature rupture of membranes that are managed expectantly are at significant risk for abruptio placentae. Preterm premature rupture of membranes in such cases is more often preceded by bleeding. These abruptions may predispose the patient to intrapartum fetal distress.

Pulmonary injury associated with appendicitis in pregnancy: who is at risk?

OBJECTIVE

Our purpose was to determine risk factors for pulmonary injury in women with antepartum appendicitis.

STUDY DESIGN

This case-control study included 49 patients with appendicitis during pregnancy. Patients who had pulmonary injury composed the study group (n = 9); the control subjects had no injury (n = 40). Records were abstracted for gestational age at surgery, type of anesthesia, presenting symptoms, findings on physical examination, vital signs, laboratory test results, use of tocolytics or antibiotics, and fluid management. Pulmonary injury was characterized by dyspnea, tachypnea, PaO2 < or = 70 mm Hg, and an abnormality on chest radiography.

RESULTS

Pulmonary injury developed in nine study patients (18%) (adult respiratory distress syndrome, n = 2; pulmonary edema or infiltrates, n = 7) as a complication of appendicitis during pregnancy. All study group patients were at > 20 weeks' gestation compared with 27 of 40 (67%) control subjects (p = 0.05). Univariate analysis showed that fluid overload > or = 4 L, maximum respiratory rate > 24 breaths/min, maximum heart rate > 110 beats/min, maximum temperature > or = 100.4 degrees F, general anesthesia, and tocolytic use were significant (p < 0.005). By multivariate analysis with the use of stepwise logistic regression a model of fluid overload > or = 4 L, respiratory rate > 24 breaths/min, maximum temperature > or = 100.4 degrees F, and tocolytic usage would predict 99% of injury cases.

CONCLUSIONS

Iatrogenic factors such as injudicious fluid management and tocolytic use can greatly increase the risk for pulmonary injury with antepartum appendicitis.

Gestational diabetes: does the presence of risk factors influence perinatal outcome?

OBJECTIVE

Our purpose was to determine whether gestational diabetics with risk factors for gestational diabetes have worse glucose tolerance and poorer birth outcomes than those without risk factors.

STUDY DESIGN

We conducted a nonconcurrent cohort study of gestational diabetics identified by universal screening and delivered from Jan. 1, 1990, to Dec. 31, 1992. Multiple gestations and patients with chronic medical conditions were excluded. The following risk factors for gestational diabetes mellitus were abstracted: obesity (> 80 kg), family history of diabetes, previous gestational diabetes mellitus, and previous macrosomic, stillborn, or anomalous fetus. Patients with one or more risk factors were compared with those without risk factors. A group of low-risk nondiabetic patients served as controls. The incidences of A2 diabetes mellitus, cesarean section, neonatal macrosomia, and shoulder dystocia were the outcome variables of interest.

RESULTS

Selective screening would have failed to detect 43% of gestational diabetics. Twenty-eight percent of the missed gestational diabetics would have required insulin (class A2). When compared with controls, patients with gestational diabetes mellitus were at increased risk for macrosomia (26% vs 11%, p < 0.01), cesarean section (37% vs 15%, p < 0.01), and shoulder dystocia (9% vs 2%, p < 0.05). Patients with and without risk factors did not differ in mean maternal age, gestational age at delivery, birth weight, incidence of requiring insulin, macrosomia, or cesarean delivery. The similarities between those with and without risk factors remained after stratification by maternal age (> or = 30 years).

CONCLUSION

Gestational diabetics are at increased risk for adverse birth outcomes compared with low-risk controls. Class A2 diabetes mellitus and fetal macrosomia with its attendant risks are equally prevalent among patients with and without risk factors for gestational diabetes mellitus. Because > 40% of cases will be missed with selective screening, universal screening should be favored for detection of gestational diabetes mellitus.

Prediction of an abnormal karyotype in fetuses with omphalocele

The aim of this study was to assess the value of ultrasonographic evaluation in predicting abnormal karyotypes in fetuses with omphalocele. Forty fetuses with antenatally diagnosed omphalocele and available karyotype results were reviewed. Ultrasound evaluation included herniation contents and size, and the detection of other anomalies. Nine of 40 consecutive fetuses had abnormal karyotypes: trisomy 18 (n = 5), trisomy 13 (n = 3), 47,XXX (n = 1). Only 1/25 with an extracorporeal liver versus 8/15 with an intracorporeal liver had abnormal chromosomes [P = 0.0006, RR = 0.14 (0.02 < RR < 0.9)]. Small defects (< 3 cm) were associated with abnormal karyotypes [P = 0.01, RR = 4.7 (1.4 < RR < 15.6)]. Finding concurrent malformations was highly associated with chromosomal anomalies [P = 0.00004, RR = 4.4 (2.3 < RR < 8.5)]. The presence of associated malformations, an intracorporeal liver, and a small herniation size are highly suggestive of an associated abnormal karyotype.

Tocolysis with indomethacin increases the incidence of necrotizing enterocolitis in the low-birth-weight neonate

OBJECTIVE

The null hypothesis states that prolonged antenatal indomethacin exposure within 24 hours of delivery does not increase the incidence of necrotizing enterocolitis in the low-birth-weight neonate.

STUDY DESIGN

The neonates of patients receiving indomethacin tocolysis admitted in preterm labor (N = 56) were compared with the neonates of preterm labor patients who received no indomethacin tocolysis (N = 703). These neonatal groups were then compared with regard to gestational age at delivery, birth weight, mode of delivery, antenatal magnesium and steroid exposure, incidence of respiratory distress syndrome, perinatal depression, sepsis, umbilical catheterization, and feeding rates and volumes. The overall incidence of necrotizing enterocolitis, mortality secondary to necrotizing enterocolitis, and the intervals from delivery and feeding to necrotizing enterocolitis diagnosis were also compared. The association between necrotizing enterocolitis and the duration of indomethacin exposure and the interval from exposure to delivery for both the indomethacin and control groups was determined.

RESULTS

The incidence of necrotizing enterocolitis in neonates who were delivered within 24 hours of maternal indomethacin therapy was 20% compared with 9% in the control group (p = 0.005). The incidence of necrotizing enterocolitis in neonates with > 48 hours of antenatal indomethacin exposure was 26.4% compared with 4.1% in those with < 48 hours exposure (p = 0.042). The interval from first feeding to necrotizing enterocolitis development was significantly shorter in the indomethacin group versus the control group (2.1 +/- 3.0 vs 6.8 +/- 6.3 days) (p = 0.001), as was the mean interval from delivery to development of necrotizing enterocolitis (10.2 +/- 3.7 vs 15.2 +/- 3.8 days) (p = 0.019).

CONCLUSIONS

Antenatal indomethacin exposure occurring within < or = 24 hours of delivery and of at least 48 hours' duration is associated with a significant increase in the incidence of necrotizing enterocolitis in the low-birth-weight neonate.

Use of Amniostat-FLM in detecting the presence of phosphatidylglycerol in vaginal pool samples in preterm premature rupture of membranes

OBJECTIVE

The presence of phosphatidylglycerol in amniotic fluid from the vaginal pool has been established as a reliable marker of pulmonary maturity in pregnancies complicated by preterm premature rupture of membranes because its presence is not affected by contaminants. This study was undertaken to determine the distribution of positive phosphatidylglycerol relative to gestational age from vaginal pool amniotic fluid samples and to assess the efficacy and accuracy of the Amniostat-FLM (Hana Biologics; Irvine Scientific after Sept. 14, 1989), an antibody agglutination method for rapidly detecting phosphatidylglycerol.

STUDY DESIGN

All singleton nondiabetic pregnancies between 26 and 36 weeks with premature rupture of membranes from whom a vaginal pool sample was obtained were studied. The percent positive by gestational age was analyzed. The neonates that were delivered with a positive phosphatidylglycerol were evaluated for the presence of hyaline membrane disease and other immediate sequelae of prematurity.

RESULTS

Of the 201 vaginal pool amniotic fluid samples assayed for phosphatidylglycerol with the Amniostat-FLM procedure, 18% (36/201) were positive for phosphatidylglycerol and none of the delivered infants developed hyaline membrane disease.

CONCLUSION

The Amniostat-FLM seems to be accurate in predicting pulmonary maturity from vaginal pool samples.

Effects of digital vaginal examinations on latency period in preterm premature rupture of membranes

OBJECTIVE

To compare the clinical outcome in patients with preterm premature rupture of membranes (PROM) who had a sterile speculum examination with those having a digital vaginal examination.

METHODS

We studied 271 singleton pregnancies complicated by preterm PROM from the Memorial Medical Center of Long Beach Perinatal Outreach program that met the criteria for expectant treatment from January 1986 to April 1990. Patients were not included in the study if they had multiple gestations, cerclage, advanced labor, or any indication for delivery on admission (eg, mature lung profile, chorioamnionitis). All subjects were maternal transports to our tertiary care facility and were managed similarly by our perinatal group. The women were questioned as to whether a digital vaginal examination had been performed before transport. Latency period and other obstetric characteristics were then compared. The latency period, defined as days from rupture of membranes until active intervention was initiated or labor began spontaneously, was also stratified by gestational age.

RESULTS

One hundred twenty-seven subjects had a digital vaginal examination and 144 had a sterile speculum examination. A significantly (P less than .0001) shorter mean latency period (2.1 +/- 4.0 versus 11.3 +/- 13.4 days) was found in those who had a digital vaginal examination. In addition, a shorter latency period was noted for each gestational age. No difference in uterine activity or cervical dilatation and effacement was noted between the groups on admission.

CONCLUSION

Digital vaginal examinations performed on patients whose pregnancies are complicated by preterm PROM appear to shorten significantly the latency period.

Does amniotic fluid index affect the accuracy of estimated fetal weight in preterm premature rupture of membranes?

Estimated fetal weights play a critical role in the management scheme of patients with preterm premature rupture of membranes but are often technically difficult to obtain in these patients because of low amniotic fluid volume. Previous studies have had conflicting data as to the accuracy of estimated fetal weights in preterm premature rupture of membranes. This study was undertaken to evaluate the effect of amniotic fluid index on the accuracy of estimated fetal weights in pregnancies complicated by preterm premature rupture of membranes. Over a 2-year period at Long Beach Memorial Medical Center, 98 patients with preterm premature rupture of membranes who had an ultrasonographic examination with estimated fetal weights and amniotic fluid index performed within 48 hours of delivery were identified and compared with a control group of 55 patients in preterm labor with normal amniotic fluid index for gestational age, also obtained within 48 hours of delivery. Shepard and Hadlock formulas were used to estimate fetal weight. Results were measured in percent error from the actual birth weight. All birth weights were less than 2000 gm. No statistical differences were identified. The value of amniotic fluid index did not affect the accuracy of predicted estimated fetal weight in preterm premature rupture of membranes. Predicted estimated fetal weight of patients with preterm premature rupture of membranes appears to be as accurate as predicted estimated fetal weight in pregnancies with normal amniotic fluid volumes.

Rate of recurrence of preterm premature rupture of membranes in consecutive pregnancies

The reported incidence of preterm premature rupture of membranes ranges between 1% and 2% of all pregnancies. The rate of recurrence is poorly defined. The goal of this study was to establish the frequency of recurrence in a high-risk referral practice. Over a 5-year period we identified 121 patients with preterm premature rupture of membranes who had a minimum of two consecutive pregnancies under our care, resulting in a total of 255 pregnancies for analysis. Recurrent preterm premature rupture of membranes occurred in 39 of 121 patients, for a rate of 32.2% (95% confidence interval, 23.9 +/- 40.5). We were unable to demonstrate an association between the estimated gestational age at the time of rupture in the index pregnancy, latency period, interval between pregnancies, and the probability of repeat preterm premature rupture of membranes in the next pregnancy. We conclude that patients with preterm premature rupture of membranes should be counseled regarding the significant risk of recurrence and need to have close follow-up in their subsequent pregnancies.

Correlation of amniotic fluid index and nonstress test in patients with preterm premature rupture of membranes

The amniotic fluid index and the nonstress test are commonly used in the expectant management of preterm premature rupture of membranes. This study was designed to investigate the interrelationship of the nonstress test and the amniotic fluid index during the preterm rupture of membranes latency period. Fifty patients with preterm premature rupture of membranes for greater than 48 hours were prospectively followed with daily 1-hour nonstress tests and blinded, daily amniotic fluid index examinations (totaling 422 evaluations). The overall average daily amniotic fluid index was statistically lower in the earlier gestations and nulliparous patients but was not influenced by the fetal position or nonlaboring uterine activity. An increased incidence of variable decelerations and nonreactive nonstress tests was associated with a significantly lower overall average daily amniotic fluid index, but these differences were beyond the standard precision of the amniotic fluid index examination. The daily nonstress test appears to identify clinically significant lower fluid volumes during the latency period and should remain the mainstay in the management of preterm premature rupture of membranes.

Color flow Doppler--a useful instrument in the diagnosis of vasa previa

Vasa previa is associated with an increased perinatal mortality rate and rarely is diagnosed in the antepartum period. We present a case in which vasa previa was correctly diagnosed by use of color flow Doppler imaging. This modality is a valuable adjunct in the evaluation of patients suspected to have vasa previa.

Fetal gastroschisis and omphalocele: is cesarean section the best mode of delivery?

There has always been controversy regarding the mode of delivery of fetuses with abdominal wall defects. Prior studies may have been biased in this evaluation as a result of the effects of delay in repair, transport of the fetus to level III facilities, and antenatal diagnosis compared with an unsuspected diagnosis. The purpose of this study was to evaluate mode of delivery at level III institutions with access to complete care to determine if cesarean section improved outcome. One hundred eight infants were treated in the study period for abdominal wall defects. Fifty-six infants met all criteria for admission to the study. No difference in neonatal morbidity or mortality was identified. No difference was found in infants who were born by elective cesarean section compared with infants delivered after labor ensued. In conclusion, we found no evidence that cesarean section or avoidance of labor improved outcome in fetuses with uncomplicated abdominal wall defects.