Combined Hepatitis B Virus and Hepatocellular Carcinoma Screening Using Point-of-Care Testing and Ultrasound in a Tanzanian Emergency Department

The WHO aims to detect 90% of global cases of hepatitis B virus (HBV) by 2030. Sub-Saharan Africa carries a disproportionate burden of HBV and hepatocellular carcinoma (HCC). In this study, we sought to assess the utility of a combined HBV and HCC screening program in Tanzania. We conducted a prospective, serial cross-sectional study of patients who participated in a combined HBV and HCC screening program at a regional referral hospital emergency department (ED) in Arusha, Tanzania, between April 19, 2022 and June 3, 2022. All patients completed a study questionnaire and were tested for HBV surface antigen. Patients who were HBV positive were screened for HCC via point-of-care ultrasound (POCUS). The primary outcome was the number of new HBV diagnoses. Data were analyzed with descriptive statistics. A total of 846 patients were tested for HBV (primary ED: 761, clinic referral: 85). The median age of patients was 44 ± 15 years, and 66% were female. Only 15% of patients reported having a primary care doctor. Thirteen percent of patients had been previously vaccinated for HBV. There were 17 new HBV diagnoses (primary ED: 16, clinic referral: 1), which corresponds to a seroprevalence of 2.0% (95% CI: 1.2%, 3.2%). No patients had liver masses detected on POCUS. An ED-based, combined HBV and HCC screening protocol can be feasibly implemented. This study could serve as a model for HBV/HCC screening in regions with high HBV endemicity and low rates of community screening.

Effectiveness of progestogens to improve perinatal outcome in twin pregnancies: an individual participant data meta-analysis

BACKGROUND

In twin pregnancies, the rates of adverse perinatal outcome and subsequent long-term morbidity are substantial, and mainly result from preterm birth (PTB).

OBJECTIVES

To assess the effectiveness of progestogen treatment in the prevention of neonatal morbidity or PTB in twin pregnancies using individual participant data meta-analysis (IPDMA).

SEARCH STRATEGY

We searched international scientific databases, trial registration websites, and references of identified articles.

SELECTION CRITERIA

Randomised clinical trials (RCTs) of 17-hydroxyprogesterone caproate (17Pc) or vaginally administered natural progesterone, compared with placebo or no treatment.

DATA COLLECTION AND ANALYSIS

Investigators of identified RCTs were asked to share their IPD. The primary outcome was a composite of perinatal mortality and severe neonatal morbidity. Prespecified subgroup analyses were performed for chorionicity, cervical length, and prior spontaneous PTB.

MAIN RESULTS

Thirteen trials included 3768 women and their 7536 babies. Neither 17Pc nor vaginal progesterone reduced the incidence of adverse perinatal outcome (17Pc relative risk, RR 1.1; 95% confidence interval, 95% CI 0.97-1.4, vaginal progesterone RR 0.97; 95% CI 0.77-1.2). In a subgroup of women with a cervical length of ≤25 mm, vaginal progesterone reduced adverse perinatal outcome when cervical length was measured at randomisation (15/56 versus 22/60; RR 0.57; 95% CI 0.47-0.70) or before 24 weeks of gestation (14/52 versus 21/56; RR 0.56; 95% CI 0.42-0.75).

AUTHOR'S CONCLUSIONS

In unselected women with an uncomplicated twin gestation, treatment with progestogens (intramuscular 17Pc or vaginal natural progesterone) does not improve perinatal outcome. Vaginal progesterone may be effective in the reduction of adverse perinatal outcome in women with a cervical length of ≤25 mm; however, further research is warranted to confirm this finding.

Light microscopy of the exfoliation syndrome

The exfoliation syndrome affects all structures of the ocular anterior segment, as well as the conjunctiva and occasionally, nonocular structures. The exfoliative material has been shown by a series of light microscopic and gross anatomic studies to be only loosely adherent to the anterior lens capsule, zonules and anterior vitreous face, and firmly adherent to the equatorial lens capsule and posterior epithelium of the iris and the nonpigmented ciliary epithelium. Electron microscopy demonstrates that, in these latter regions, exfoliation material consisting of characteristic, cross-banded fibrils embedded in an amorphous matrix, is present both within the epithelial cells and associated with a disorganized, reduplicated basement membrane. These findings suggest that the material arises from the epithelium of the lens, iris and ciliary body, possibly the result of an underlying metabolic disorder. From these areas, the material enters the aqueous humor and later deposits on the anterior lens capsule, zonules, vitreous face, anterior surface of the iris, and trabecular meshwork. Histochemical studies demonstrate the presence of glycosaminoglycans, which may comprise the interfibrillar portion of the exfoliative material. Other studies demonstrate histochemical similarities between exfoliative material and zonules and are supported by recent work suggesting that the exfoliative fibrils are related to the microfibrillar portion of elastin. Although some reports suggest similarities between exfoliative material and amyloid, a majority of histochemical studies do not support this possibility.

Fetal macrocrania: diagnosis, delivery and outcomes

OBJECTIVE

To describe fetal macrocrania including prenatal diagnosis, delivery considerations and clinical outcomes.

STUDY DESIGN

A retrospective case series was developed by reviewing 26 885 ultrasounds performed between 1 March 2003 and 30 June 2007 for the prenatal diagnosis of macrocrania. Medical records of each mother/infant pair were reviewed for demographic information, ultrasound findings, obstetric management and outcomes.

RESULT

Twenty-three fetuses were diagnosed with macrocrania. Median gestational age at diagnosis was 31.1 weeks (range 18.3-38.1) and at delivery was 36.9 weeks (range 30.7-39.9). Fifteen patients (65%) underwent amniocentesis for karyotype; none were aneuploid but one had a duplication on chromosome 7. All the 23 infants were liveborn. Twenty-one deliveries were by Cesarean (91%), with thirteen of these by classical incision (62%). Of the infants, 5 (22%) died shortly after birth, 16 (70%) were stabilized in the neonatal intensive care unit and were discharged alive and 2 (8%) were transferred to another center and subsequently died. Eighteen babies required ventriculoperitoneal shunting (78%).

CONCLUSION

Macrocrania is a diagnosis usually made in children but can also be made prenatally. Fetal macrocrania is usually a result of ventriculomegaly due to an obstructive process to cerebrospinal fluid flow. Abdominal delivery is usually required, often necessitating a classical uterine incision. Targeted ultrasonography, extensive counseling of parents and delivery at a tertiary care center with availability of neurosurgery is recommended.

Association between small for gestational age and paternally inherited 5' insulin haplotypes

OBJECTIVE

To test the association between small for gestational age and polymorphisms in the insulin gene in newborns and their mothers, as well as the effect of the parental transmission of haplotypes.

SUBJECTS

Pairs of healthy African-American full-term newborns (N=207) and mothers were recruited from Memphis TN and Jackson MS with birth weights ranging from 2210 to 4735 g.

METHODS

Six single nucleotide polymorphisms (SNPs) located in the insulin (INS) and insulin-like growth factor 2 (IGF2) genes were genotyped in mothers and newborns. Haplotypes composed of three SNPs in the 5' region of the INS-IGF2 locus were computationally inferred. Odds ratios for risk of small for gestational age (SGA) birth were calculated for individual SNPs and inferred haplotypes in the newborns and in the mothers using logistic regression. For 162 mother--newborn pairs the parental transmission of the haplotypes could be inferred, and the risks for SGA birth were calculated for the three common haplotypes in this sample.

RESULTS

Three INS SNPs exhibited significant association with risk for SGA birth. The SNP alleles associated with increased risk for SGA were opposite in the maternal and newborn genomes, implying opposing influences on the rate of fetal growth. Consistent with these results, haplotypes composed of complementary nucleotide sequences (CAC at rs3842738, rs689 and rs3842748, respectively, in the newborn versus GTG in the mother) were significantly associated with risk for SGA birth. In analyses of haplotypes according to parental transmission, the same trend in risk for SGA was observed for both maternally and paternally transmitted haplotypes, although a significant difference in risk was observed only for paternally transmitted haplotypes.

CONCLUSION

Polymorphisms near the 5' end of the INS-IGF2 locus are significantly associated with risk for SGA birth with a major effect due to the paternally transmitted haplotype, which is preferentially expressed due to imprinting.

Second trimester placental location as a predictor of an adverse pregnancy outcome

OBJECTIVE

To determine if the second trimester placental location is associated with perinatal outcomes.

MATERIALS AND METHODS

Observational study of placental location and the subsequent risk of an adverse pregnancy outcome. Placental location was divided into three categories, low, high lateral and high fundal.

RESULTS

There were 3336 pregnancies analyzed in this study. Low implantation sites had a greater risk of preterm labor (odds ratio (OR) 1.70, 95% confidence interval (CI) 1.38 to 2.90, P<0.001), preterm delivery (OR 1.86, 95% CI 1.36 to 2.54, P<0.001), fewer fetuses with macrosomia (OR 0.56, 95% CI 0.38 to 0.83, P=0.010) and reduced risk of postpartum hemorrhage (OR 0.56, 95% CI 0.46 to 0.95, P=0.026). High lateral implantations had a greater risk of low 1-min (OR 1.80, 95% CI 1.11 to 2.93, P=0.017) and 5-min (OR 3.49, 95% CI 1.46 to 8.36, P=0.005) Apgar scores.

CONCLUSIONS

Low placental implantation was associated with an increased risk of preterm labor, preterm delivery and a reduced risk of postpartum hemorrhage, and of a macrosomic fetus. High lateral implantation was associated with low Apgar scores.

Pre-pregnancy body mass index and pregnancy outcomes

OBJECTIVE

To determine the effect of maternal pre-pregnancy BMI on pregnancy outcomes.

METHODS

Pregnancy cohort recruited pregnancies between 16 and 18 weeks. BMI evaluated underweight, BMI<18.5, normal, BMI 18.5-25, overweight BMI 25-30, and obese BMI>30 women.

RESULTS

Pre-pregnancy BMI classified 331 women as underweight (11.7%), 1982 normal (69.9%), 326 overweight (11.5%), and 188 as obese (6.6%). Obese women were more likely to develop gestational diabetes (p<0.001), hypertension (p<0.001), preeclampsia (p<0.001), need labor induction (p<0.001), cesarean delivery for fetal distress (p<0.001), postpartum hemorrhage (p=0.003), need neonatal resuscitation (p=0.001) and deliver hypoglycemic infants (p=0.007). Being underweight is correlated with fetal growth restriction (p=0.001).

CONCLUSION

Pre-pregnancy obesity is a risk factor for gestational diabetes, preeclampsia, labor induction, cesarean for fetal distress, postpartum hemorrhage and neonatal hypoglycemic and need for resuscitation. Being underweight is risk factor for fetal growth restriction.

Acute tocolysis for suspected intrapartum fetal distress: maternal effects of terbutaline versus magnesium sulfate

This study was undertaken to determine the maternal hemodynamic impact of terbutaline versus magnesium sulfate in the acute treatment of fetal distress prior to cesarean delivery. Forty-six women were prospectively randomized to receive 0.25 mg subcutaneous terbutaline or 4.0 g intravenous magnesium sulfate for in utero fetal resuscitation before cesarean delivery. There were no significant differences between groups in baseline mean arterial pressure, arterial pressure before and after induction of anesthesia, maternal heart rate, maternal oxygen saturation, estimated blood loss, and pre- and postoperative hematocrits. Magnesium sulfate-treated women received significantly more intraoperative intravenous fluids (2365 +/- 877 ml) than the terbutaline group (1624 +/- 564 ml; P < 0.001). However, mean urine output was significantly greater in the terbutaline group (88 +/- 42 ml/h) than in those treated with magnesium sulfate (61 +/- 26 ml/h; P < 0.03). Terbutaline, the superior agent for acute tocolysis, is not associated with an increase in maternal cardiovascular side effects during anesthesia.

Frequency of nursing, physician and hospital interventions in women at risk for preterm delivery

OBJECTIVE

To determine the frequency of nursing intervention, physician treatment and hospital evaluation for women receiving outpatient management services for preterm labor.

METHODS

Outpatient services included: patient education; daily and as-needed nursing assessment of monitored uterine activity (MUA) and patient symptoms; treatment compliance; and physician notification for values exceeding established limits. We analyzed service data from women with singleton gestations at 20.0-34.9 weeks.

RESULTS

Overall, 307 249 days of data from 10 660 women were reviewed, and 634 983 hours of MUA was assessed. On 53 665 (17.5%) of monitored days, patients exhibited increased MUA and/or symptoms of preterm labor with nursing intervention and reassessment. Physician notification/intervention was required 7316 (13.6%) times, and hospital admission was needed for 3163 (43.2%) of these patients. In the hospital 1400 (44.3%) patients received tocolysis. The mean ( +/- standard deviation) length of hospital stay was 3.2 +/- 7.2 days, and 428 (13.5%) of women remained hospitalized until delivery, with 324 (10.2%) delivering within 48 h.

CONCLUSION

In this population of women receiving outpatient preterm-labor management services, 95.1% of excessive MUA or patient-reported symptoms of preterm labor were managed on an outpatient basis. Outpatient management allowed for appropriate identification and triage of women requiring hospital admission.

Adjunctive antibiotic treatment of women with preterm rupture of membranes or preterm labor

Subclinical infection is associated with preterm rupture of the membranes (PROM) and preterm labor (PTL) in many cases. It was hypothesized that antibiotic treatment might delay delivery and/or decrease infectious morbidity in those with PROM or PTL. Patients from 19 to 34 weeks with PROM and no labor or PTL with intact membranes (but not both) were separately randomized to receive ampicillin versus placebo in addition to usual therapy. There were 36 women with PTL (21 ampicillin/15 placebo) and 84 with preterm PROM (41 ampicillin/43 placebo). Demographically, the treatment and placebo groups were similar. Outcome variables analyzed included delivery delay after treatment, maternal chorioamnionitis/endometritis, Apgar score, neonatal infection, or respiratory distress, and hospital stay. There were no significant differences between the ampicillin and placebo groups in those with PTL or preterm PROM as it concerned outcome parameters. Adjunctive ampicillin used for treatment of idiopathic PTL or preterm PROM was not beneficial in this study.

Application of learning theory to obstetric maloccurrence

The average fellow of the American College of Obstetricians and Gynecologists performs approximately 140 deliveries per year. Based on this estimation and the established prevalence of three commonly litigated maloccurrences, we calculated the number of years of clinical experience required to encounter one case. Permanent brachial plexus palsy complicates only 1 per 4553 deliveries so a clinician would encounter such a case in 33 years of practice. For every 6667 deliveries, there is a case of cerebral palsy attributable to intrapartum hypoxia, so a practioner would see only one case every 48 years. Since the rate of asphyxia with uterine rupture is 1 per 2819 vaginal births after Cesarean section and the average provider performs seven vaginal births after Cesarean deliveries per year, a clinician would have a case in 403 years of practice. Adverse outcomes expressed as an absolute percentage or as the number of cases per number of deliveries are statistically accurate. Expression of these maloccurrences in terms of the number of years of clinical experience permits the generation of a clinically relevant data point and also allows insight into why their prevalence has not decreased.

Ultrasound estimation of amniotic fluid volume using the largest vertical pocket containing umbilical cord: measure to or through the cord?

OBJECTIVES

The purpose of this investigation was to determine the preferable method, either measuring to the umbilical cord or through the umbilical cord to the base of the pocket, of ultrasonically estimating amniotic fluid volume.

SUBJECT AND METHODS

This was a prospective study carried out in singleton pregnancies undergoing a third-trimester amniocentesis. The amniotic fluid index (AFI) and single deepest pocket (SDP) were measured prior to amniocentesis. If measured spaces contained umbilical cord, measurements were made to and through the cord. Actual amniotic fluid volume was determined by the dye-dilution technique.

RESULTS

One-hundred pregnancies were evaluated. Low dye-determined volume was identified in a significantly greater number of pregnancies using the AFI to the cord (7/28, 25%) compared to through the cord (2/28, 7%) (P = 0.025). The SDP technique to the cord was superior in low volumes (2/28, 7%) vs. (0/28, 0%) through the cord (although statistical significance could not be determined because there were no low through-the-cord measurements).

CONCLUSIONS

For the detection of low amniotic fluid volumes, the AFI to the cord is better than through the cord. Measurement to the cord and through the cord had similar accuracy for both the AFI and SDP techniques in normal and high dye-determined amniotic fluid volumes.

Dye-dilution techniques using aminohippurate sodium: do they accurately reflect amniotic fluid volume?

OBJECTIVE

To determine whether the dye-dilution technique using aminohippurate sodium accurately measures amniotic fluid volume.

METHODS

Singleton pregnancies with intact membranes undergoing a Cesarean delivery had their amniotic fluid volume assessed by the dye-dilution technique and direct measurement.

RESULTS

Fifteen women were prospectively assessed. Six patients had their amniocentesis on the delivery table and nine patients at 4-24 h prior to the Cesarean delivery. The six women undergoing an amniocentesis just before delivery had good concordance between the dye-determined and direct measurement of amniotic fluid volume (r = 0.99, p = < 0.001). Among the nine women with varying times from amniocentesis to direct measurement, the correlation was not significant (r = 0.36, p = 0.08). The percentage difference between the dye-determined and directly measured amniotic fluid volume was significantly smaller in the women undergoing amniocentesis just prior to delivery (7%) than in the women with varying times from amniocentesis to delivery (37%, P < 0.001).

CONCLUSION

Dye-determined amniotic fluid volume accurately reflects actual amniotic fluid volume but the dye-determined concentrations, in vivo, may undergo rapid changes.

Outpatient cervical ripening with prostaglandin E2 and estradiol

OBJECTIVE

To determine whether weekly outpatient administration of prostaglandin gel or estrogen cream initiated labor in women with an unfavorable cervix.

METHODS

All uncomplicated pregnancies at term gestation who were candidates for a vaginal delivery with a Bishop score of < or = 6 were randomly assigned to receive on a weekly basis: prostaglandin E2 gel (n = 41); estrogen cream (n = 44); or inert lubricant jelly (n = 43).

RESULTS

In the three groups no differences were observed among 128 subjects in the weekly Bishop scores, cervical dilatation or gestational age upon admission to the labor and delivery suite, the percentage of patients presenting with spontaneous labor or ruptured membranes, the number of post-date inductions or neonatal outcome.

CONCLUSIONS

Weekly out-patient cervical ripening using either prostaglandin gel or estrogen in women with an unfavorable cervix at 37 weeks' gestation was no more effective than a placebo in Bishop score improvement or in preventing post-date inductions.

Does uterine wiping influence the rate of post-Cesarean endometritis?

OBJECTIVE

To compare two methods of uterine cleansing to remove residual amnion-chorion at the time of Cesarean delivery.

METHODS

All consenting uninfected parturients undergoing a non-emergency Cesarean delivery at the university were enrolled. All patients received antibiotic prophylaxis of a 1-g intravenous bolus of a first-generation cephalosporin immediately after cord clamping. Postpartum endometritis was defined as a temperature of > or = 100.4 degrees F (38 degrees C) on two occasions 6 h apart after the first 24 h with uterine tenderness and/or foul-smelling lochia.

RESULTS

Between January 1998 and February 2000 there were 1400 patients enrolled in this investigation. A total of 153 women were determined to have chorioamnionitis present at surgery and 17 women refused participation, leaving 614 women in the uterine wipe group and 616 in the no wipe group. Maternal demographics were similar between patient groups (NS). Intrapartum factors including gestational age at time of Cesarean section, type of anesthesia used for the operative delivery, hours of amnion rupture prior to delivery, use of internal monitoring devices, type of skin incision, method of placental removal, total operative time and estimated blood loss were similar between patient groups (NS). An almost identical number of patients in each arm of the study developed post-Cesarean endometritis (65 out of 614, 10.5%, in the uterine wipe group vs. 66 out of 616, 10.7%, in the no wipe group; p = 1).

CONCLUSIONS

Both methods of removing residual amnion-chorion membrane tissue and associated debris at surgery were comparably effective, but neither produced a dramatic reduction in the incidence of postoperative endometritis.

A Canadian faculty of medicine and dentistry's survey of career development needs

INTRODUCTION

Career development efforts for adult learners are more likely to succeed if they are responsive to the learners' needs, offered at convenient times, and provided in a variety of forms.

METHODS

The Faculty of Medicine and Dentistry at the University of Alberta conducted a self-administered career development needs survey of full-time academic faculty. Faculty members were asked to identify how useful each of 35 career development skills would be to them and at which stage in an academic career it would be most useful. Preferred educational modes and times of delivery were also assessed. The mean rankings of skill needs were examined overall as well as by gender, academic rank, departmental category (clinician versus basic scientist), marital status, and the presence of school-aged children at home.

RESULTS

185 of 446 (41%) mailings were returned, of which 181 were evaluated. The number one perceived career development need across all subgroups was 'Effective writing of grants and publications'. Six of the top 10 needs were identified as useful at all career stages. Significant differences in rankings of needs were noted between subgroups. Half days were preferred to full days for career development efforts and short courses to other educational modes.

DISCUSSION

Several career development skills were identified as priorities independently of gender, academic rank, and clinical versus basic science career tracks. Differences suggest that within a basic global programme, a variety of career development modules may need to be developed for subgroups.

Changes in Thy1 gene expression associated with damaged retinal ganglion cells

PURPOSE

The temporal series of molecular events that occur in dying retinal ganglion cells is poorly understood. We have examined the change in expression of a normally-expressed ganglion cell marker gene, Thy1, relative to the kinetics of cell loss caused by acute and chronic damaging stimuli.

METHODS

For acute experiments, mice were subjected to optic nerve crush or intravitreal injections of N-methyl-D-aspartate (NMDA) to induce ganglion cell death. RNase protection analysis was used to quantify Thy1 mRNA levels from total retina RNA and in situ hybridization was used to monitor the pattern of Thy1 positive cells. Changes in Thy1 expression were compared to the time course of cell loss induced by each treatment. To induce elevated intraocular pressure (IOP), the episcleral veins of rats were injected with hypertonic saline, which scleroses Schlemm's Canal and the trabecular meshwork. Elevated IOP was monitored every day for 35 days after which the animals were sacrificed and the retinas harvested for quantitative RT-PCR or fixed for in situ hybridization studies. Evaluation of glaucomatous damage caused by elevated IOP was determined from histological sections of the optic nerves of all rat eyes.

RESULTS

After optic nerve crush, Thy1 mRNA levels decreased within 24 h, although the number of expressing cells did not decline until 7 days. Both measures showed a loss of Thy1 well in advance of cell loss, which was detected by 2 weeks after surgery. This change in expression was not dependent on execution of the cell death program since a similar decrease was detected in Bax-/- ganglion cells, which are resistant to cell death induced by optic nerve crush. Thy1 mRNA levels and the number of expressing cells also decreased within 6 h after NMDA injection, in advance of cell loss, which was detected by 24 h. Similarly, elevated intraocular pressure was associated with a decrease in mRNA and expressing cells in a pressure-dependent manner. In moderately hypertensive rat eyes, the number of cells expressing Thy1 decreased before significant cell loss in the retina. Virtually no Thy1-expressing cells were detected in eyes with severe disease.

CONCLUSIONS

Thy1 mRNA abundance and expressing cells, decreased in advance of detectable ganglion cell loss caused by three different modalities of damage. This change is independent of the committed step of cell death.

Labor and membrane rupture in twin gestation. Can they affect the ability to estimate fetal weight?

OBJECTIVE

To determine whether labor or fetal membrane rupture adversely affects the ability of ultrasound to accurately estimate fetal weight (EFW) in a twin gestation.

STUDY DESIGN

A medical record audit was performed of the two-year experience of women delivering live born twins and undergoing a complete ultrasound examination within 72 hours of delivery. Those patients experiencing labor or membrane rupture at the time of the previous ultrasound examination were compared to those without these factors to determine if there was any detrimental impact on the accuracy of ultrasound to EFW.

RESULTS

The overall ability of ultrasound to accurately EFW was in the range of 64-76%. This was not significantly different from the accuracy in women experiencing labor (62-80%) or in women with membrane rupture (63-81%). The ability of ultrasound to detect fetal discordance is this series ranged from 78% to 100%, with specificity that ranged from 84% to 89%.

CONCLUSION

The ability of sonography to accurately EFW as well as detect discordant twin gestation is not altered by the presence of labor or membrane rupture.

Maternal morbidity and mortality associated with intrauterine fetal demise: five-year experience in a tertiary referral hospital

BACKGROUND

Risk factors for and management of intrauterine fetal demise (IUFD) have been investigated, but the maternal morbidity has not been evaluated.

METHODS

Over a 60-month interval, all cases of IUFD after 20 weeks' gestation were reviewed for maternal trauma and maternal postpartum complications.

RESULTS

In this retrospective analysis, 498 singleton and 24 twin pregnancies with an IUFD were identified. A cervical or perineal laceration requiring surgical repair complicated 9.4% of pregnancies. One uterine dehiscence and one uterine rupture occurred. Endometritis, the most common postpartum complication, occurred in 63 of 522 patients (12%). One maternal death occurred. Total mean hospital stay was 4.9 +/- 5.7 days.

CONCLUSION

Maternal morbidity and rarely mortality can follow IUFD, but this morbidity is similar to that observed without IUFD.

Pregnancy outcome in women with preterm labor symptoms without cervical change

OBJECTIVE

This study was undertaken to determine pregnancy outcome in women who have preterm labor symptoms without cervical change according to fetal fibronectin status.

STUDY DESIGN

Patients who were examined at the obstetric emergency department with symptoms of preterm labor but without cervical change underwent fetal fibronectin collection. Pregnancy outcome and fetal fibronectin results were analyzed after delivery.

RESULTS

Of the 235 patients sampled, 20% (n = 48) had positive fetal fibronectin results. The mean +/- SD gestational age at delivery was lower in women with positive fetal fibronectin results (34.2 +/- 4.1 vs 37.7 +/- 2.3 weeks; P <.001); these women were more likely to deliver preterm as a result of preterm labor than women with other obstetric indications (46% vs 19%; P <.001). Infants born to these women demonstrated lower birth weight (2317 +/- 895 g vs 2877 +/- 557 g; P =.003), were more likely to be admitted to the neonatal intensive care unit (42% vs 14%; P <.001), and were more likely to die in the neonatal period (11% vs 0%; P <.001).

CONCLUSION

Patients with symptoms of preterm labor but without cervical change who have negative fetal fibronectin results are less likely to deliver preterm. Therefore in women with symptoms but without cervical change fetal fibronectin should be considered for risk assessment.

A program of uterine activity monitoring and its effect on neonatal morbidity

In a recent study 34 patients at high risk for preterm delivery who received uterine activity monitoring were compared with 33 similar patients who attempted to detect contractions by palpation. The incidence of preterm delivery was significantly reduced among those using the uterine activity detection device, although all patients in both groups had the same prenatal care and educational intervention. When short-term neonatal morbidity associated with preterm delivery was compared between the two groups, adverse effects decreased significantly among those in the monitored group (p = 0.001). The majority of short-term morbidity in both groups was noted in those delivering preterm and thus was gestational age related. No significant difference was found in neonatal morbidity between the groups when the infants were delivered at less than 37 weeks' gestation. Uterine activity monitoring, which is effective in preventing preterm birth, is also efficacious in decreasing short-term neonatal morbidity.

Subjective versus objective evaluation of amniotic fluid volume of pregnancies of less than 24 weeks' gestation: how can we be accurate?

This study was undertaken to compare subjective versus objective ultrasonic evaluation of amniotic fluid volume in pregnancies of less than 24 weeks' gestation. Amniotic fluid volume was subjectively (visualization without ultrasonic measurements) and objectively (visual interpretation with ultrasonic measurements) evaluated in 42 singleton pregnancies undergoing termination. The actual amniotic fluid volume was then determined using a dye-dilution technique. The women evaluated were in their mid-20s, primarily African American, and between 15 and 23 weeks' gestation. There was no significant difference in the total number of correct estimates of amniotic fluid volume when the data were stratified by level of operator experience (P = .34), ultrasonic technique (P = .33), or the combined correct subjective versus combined correct objective estimates (P = .68). We have concluded that the accuracy of amniotic fluid volume assessment in pregnancies of less than 24 weeks is not influenced by the level of operator experience or the type of ultrasonic measurement.

Effect of general anesthetics on IOP in rats with experimental aqueous outflow obstruction

PURPOSE

To determine the effect of several common general anesthetics on intraocular pressure (IOP) after experimental aqueous outflow obstruction in the rat.

METHODS

A single episcleral vein injection of hypertonic saline was used to sclerose aqueous humor outflow pathways and produce elevated IOP in Brown Norway rats. Animals were housed in either standard lighting or a constant low-level light environment. Awake IOPs were determined using a TonoPen (Mentor, Norwell, MA) immediately before induction of anesthesia by either isoflurane, ketamine, or a mixture of injectable anesthetics (xylazine, ketamine, and acepromazine). For each anesthetic, IOPs were measured immediately after adequate sedation (time 0) and at 5-minute intervals, up to 20 minutes. RESULTS; Awake IOPs ranged from 18 to 52 mm Hg. All anesthetics resulted in a statistically significant (P: < 0.01) reduction in measured IOP at every duration of anesthesia when compared with the corresponding awake IOP. With increasing duration of anesthesia, measured IOP decreased approximately linearly for both the anesthetic mixture and isoflurane. However, with ketamine, IOP declined to 48% +/- 11% (standard lighting) and 60% +/- 7% (constant light) of awake levels at 5 minutes of anesthesia, where it remained stable. In fellow eyes, the SD of the mean IOP in animals under anesthesia was always greater than the corresponding SD of the awake mean. Anesthesia's effects in normal eyes and eyes with elevated IOP were indistinguishable.

CONCLUSIONS

All anesthetics resulted in rapid and substantial decreases in IOP in all eyes and increased the interanimal variability in IOPs. Measurement of IOP in awake animals provides the most accurate documentation of pressure histories for rat glaucoma model studies.

A prospective, randomized, controlled trial of high and low maintenance doses of magnesium sulfate for acute tocolysis

OBJECTIVE

This study was undertaken to compare a high-dose protocol for magnesium sulfate tocolytic therapy with a low-dose regimen with respect to time needed to achieve tocolysis.

STUDY DESIGN

Patients between 24 and 34 weeks' gestation with preterm labor were included. Patients with ruptured membranes or nonreassuring fetal assessments were excluded. Gravid women received a 4-g loading dose of magnesium sulfate and were prospectively randomly assigned to receive a maintenance dose of 2 or 5 g/h.

RESULTS

The median times to tocolysis were 120 minutes (semi-interquartile range, 30 minutes) in the low-dose group and 90 minutes (semi-interquartile range, 28 minutes) in the high-dose group (P <.001).

CONCLUSION

Patients treated with a higher maintenance dose of magnesium sulfate had a higher frequency of side effects; however, tocolysis was achieved more rapidly and they required shorter admissions to the labor and delivery unit without increased maternal or neonatal morbidity.

Determination of amniotic fluid volume in twin pregnancies: ultrasonographic evaluation versus operator estimation

OBJECTIVE

We sought to determine the accuracy of amniotic fluid volume estimation (visually) in diamniotic twin pregnancy versus ultrasonography techniques.

STUDY DESIGN

In this prospective study the volume of each sac in 23 sets of diamniotic twin pregnancies was subjectively and objectively estimated by a second-year obstetric resident, nurse sonographer, maternal-fetal medicine fellow, and maternal-fetal medicine staff. The actual volume was confirmed by amniocentesis and a dye-dilution technique.

RESULTS

There was no difference in the total number of correct estimates of volume by level of operator experience (P =.98), ultrasonography technique (P =.87), or combined subjective versus objective correct estimates (P =.87). Identification of low volume was not different among the four evaluators (P =.48), but the percentage of correct estimates was poor (7%-29%). The 2-diameter pocket was a better predictor of oligohydramnios (57%) than the amniotic fluid index or the largest vertical pocket (12.5%; P =.002).

CONCLUSION

The extremes of volume (low or high) are poorly identified by the subjective or objective assessment of volume.

The effects of physical abuse on pregnancy outcomes in a low-risk obstetric population

OBJECTIVE

This study was undertaken to evaluate the impact of physical abuse on pregnancy outcomes.

STUDY DESIGN

This prospective investigation identified all women seen in the outpatient obstetric clinic with a history of physical abuse and matched each with the next 2 women seen without a history of physical abuse (case/control ratio, 1:2).

RESULTS

Twenty-eight abused women were matched with 56 control subjects. The frequencies of preterm birth, mode of delivery, Apgar scores <7 at 5 minutes, umbilical artery pH <7.10 at birth, and unhappy or ambivalent feelings about the pregnancy were not statistically different between the 2 groups. Admission to the neonatal intensive care unit was more common among infants of the abused women (n = 4 [14.2%] vs n = 2 [3.6%]), despite heavier birth weights in the abused group (3501 +/- 581 g vs 3200 +/- 549 g; P =. 023), but this trend did not reach significance.

CONCLUSION

A history of physical abuse did not result in adverse pregnancy outcomes, although neonatal intensive care unit admission was more likely.

Patterns of intraocular pressure elevation after aqueous humor outflow obstruction in rats

PURPOSE

To determine the diural intraocular pressure (IOP) response of Brown Norway rat eyes after sclerosis of the aqueous humor outflow pathways and its relationship to optic nerve damage.

METHODS

Hypertonic saline was injected into a single episcleral vein in 17 animals and awake IOP measured in both the light and dark phases of the circadian cycle for 34 days. Mean IOP for light and dark phases during the experimental period were compared with the respective pressures of the uninjected fellow eyes. Optic nerve cross sections from each nerve were graded for injury by five independent masked observers.

RESULTS

For fellow eyes, mean light- and dark-phase IOP was 21 +/- 1 and 31 +/- 1 mm Hg, respectively. For four experimental eyes, mean IOPs for both phases were not altered. Six eyes demonstrated significant mean IOP elevations only during the dark phase. Of these, five showed persistent, large circadian oscillations, and four had partial optic nerve lesions. The remaining seven eyes experienced significant IOP elevations during both phases, and all had extensive optic nerve damage.

CONCLUSIONS

Episcleral vein injection of hypertonic saline is more likely to increase IOP during the dark phase than the light. This is consistent with aqueous outflow obstruction superimposed on a circadian rhythm of aqueous humor production. Because these periodic IOP elevations produced optic nerve lesions, both light- and dark-phase IOP determinations are necessary for accurate correlation of IOP history to optic nerve damage in animals housed in a light- dark environment.

Sonographic measurements of fetal parts to predict pulmonary maturity among twins and singletons

To determine if sonographic examination of fetus can be readily utilized to predict a mature lecithin/sphingomyelin (L/S) ratio among twins and singletons. Twins (n = 36) undergoing amniocentesis for assessment of pulmonary maturity were matched with singleton (1:2) for maternal demographics, gestational age (GA), and indications for procedure. At the time of amniocentesis, twins and singletons with mature L/S ratios differed significantly in mean GA (33.2 +/- 2.7 vs 34.5 +/- 4.6 wks, p = 0.01), biparietal diameter (BPD), abdominal circumference (AC), femur length (FL) and estimate of birth weight (EFW). Based on ten receiver operating characteristics curves constructed, the following diagnostic thresholds predicted a mature L/S ratio with a true positive rate of 100% among twins and singletons, respectively: 1) BPD $84 and $92 mm; 2) head circumference $315 and $320 mm; 3) AC $295 and $350 mm; or 4) FL $64 and $72 mm; or 5) EFW $2400 and $3200 g. Using any one of these five criteria correctly identified pulmonary maturity among 59% of twins and 28% of singletons (p = 0.001). Sonographic measurement of fetal parts or EFW may be a noninvasive method to predict a mature L/S ration among twins as well as singletons.

Chronology of optic nerve head and retinal responses to elevated intraocular pressure

PURPOSE

To determine the chronology of optic nerve head and retinal responses to elevated intraocular pressure (IOP).

METHODS

After 1 to 39 days of unilaterally elevated IOP, experimental and fellow rat eyes were examined for morphology and immunohistochemical labeling alterations and for ganglion cell DNA fragmentation.

RESULTS

Mean IOP for the experimental eyes was 36 +/- 8 mm Hg, an approximately 15-mm Hg elevation above normal values. By 7 days of pressure elevation above 40 mm Hg, endogenous immunostaining for brain-derived neurotrophic factor and neurotrophin 4/5 was absent from the nerve head and superior retina, whereas normal labeling was present in the inferior retina and distal optic nerve of these same eyes. These changes were preceded by a loss of gap junctional connexin43 labeling and astrocytic proliferation in the nerve head and by increased retinal ganglion cell layer apoptosis in the retina. Nerve head depletion of neurotrophins coincided with evidence of axonal degeneration, loss of astrocytic glial fibrillary acidic protein staining, and spread of collagen VI vascular immunolabeling. After longer durations at these same pressures, neurotrophin labeling returned to nerve head glia and scattered retinal ganglion cells.

CONCLUSIONS

Optic nerve head and retinal responses, including the depletion of endogenous neurotrophins, are readily identified in the rat eye after experimental IOP elevation. However, the apparent chronology of these responses suggests that the withdrawal of neurotrophic support was not the only determinant of retinal ganglion cell apoptosis and axonal degeneration in response to pressure.

Sterilization and its consequences

The purpose of this review is to analyze critically the two techniques of sterilization (bilateral tubal ligation [BTL] and vasectomy) so that a physician may provide informed consent about methods of sterilization. A MEDLINE search and extensive review of published literature dating back to 1966 was undertaken to compare preoperative counseling, operative procedures, postoperative complications, procedure-related costs, psychosocial consequences, and feasibility of reversal between BTL and a vasectomy. Compared with a vasectomy, BTL is 20 times more likely to have major complications, 10 to 37 times more likely to fail, and cost three times as much. Moreover, the procedure-related mortality, although rare, is 12 times higher with sterilization of the woman than of the man. Despite these advantages, 300,000 more BTLs were done in 1987 than vasectomies. In 1987, there were 976,000 sterilizations (65 percent BTLs and 35 percent vasectomies) with an overall cost of $1.8 billion. Over $260 million could have been saved if equal numbers of vasectomies and BTLs had been performed, or more than $800 million if 80 percent had been vasectomies, as was the case in 1971. The safest, most efficacious, and least expensive method of sterilization is vasectomy. For these reasons, physicians should recommend vasectomy when providing counseling on sterilization, despite the popularity of BTL.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians

LEARNING OBJECTIVES

After completion of this article, the reader will be able to predict the failure rates and likelihood of successful reversal of tubal ligation and vasectomy; to recall the difference in cost between the two sterilization procedures, and to describe the short-term and long-term complications associated with each of the two methods of sterilization.

Oral nicardipine versus intravenous magnesium sulfate for the treatment of preterm labor

OBJECTIVE

The aim of this study was to compare the efficacy and safety of oral nicardipine in acute therapy for preterm labor with those of parenteral magnesium sulfate.

STUDY DESIGN

Patients between 24 and 34 weeks' gestation with documented preterm labor were randomly assigned to receive oral nicardipine (n = 57) or intravenous magnesium sulfate (n = 65) as initial tocolytic therapy. Patients in the nicardipine group received a 40-mg loading dose and then 20 mg every 2 hours as needed to stop contractions (total 80 mg). Patients in the magnesium sulfate group received a 6-g bolus followed by 2 to 4 g/h to provide uterine quiescence. Patients could be switched to another tocolytic regimen if they continued to have contractions after 6 hours of therapy. The main outcome variables examined were time to uterine quiescence, time gained in utero, recurrence of preterm labor, failure of tocolysis, and pertinent maternal and neonatal outcomes.

RESULTS

There were no significant differences in maternal demographic characteristics between the groups. Among patients who responded with uterine quiescence within 6 hours, there was a significant decrease in the time to uterine quiescence in the nicardipine group (P <.01). Patients in the magnesium sulfate group were more likely to have recurrence of preterm labor necessitating further tocolytic attempts (P =.048). The patients in the magnesium sulfate group had more adverse side effects, mainly nausea and vomiting (P =.004). There were no differences in birth weight, estimated gestational age at delivery, or neonatal complications between the 2 groups.

CONCLUSIONS

Oral nicardipine is an effective, safe, and well-tolerated tocolytic agent. In this prospective clinical trial patients randomly assigned to receive oral nicardipine had arrest of preterm labor more rapidly than did those randomly assigned to receive parenteral magnesium sulfate. Patients who received magnesium sulfate were more likely to have adverse medication effects and recurrent preterm labor.

Secretory component in human amniotic fluid and gestational tissues: a potential endogenous phospholipase A2 inhibitor

OBJECTIVES

Prostaglandins (PGs) are essential mediators of labor during human pregnancy. Phospholipase A2 (PLA2) provides the essential substrate for PG synthesis through the liberation of arachidonic acid from membrane phospholipid stores. Nonlaboring amniotic fluid (NL-AF) contains secretory component (SC)-like protein(s) that suppress in vitro PLA2 activity. This study characterizes the biologic activity, identity, and tissue distribution of these protein(s) in NL-AF and gestational tissues.

METHODS

Third-trimester NL-AF was collected by amniocentesis, fractionated by ammonium sulfate precipitation, and submitted to an in vitro PLA2 assay. Identity of the PLA2 inhibitor in NL-AF was confirmed by Western blot and antibody neutralization studies. Secretory component-immunoreactive proteins were purified by immunoaffinity chromatography and visualized by sodium dodecyl sulfate-gel electrophoresis. Tissue distribution of SC in gestational tissues was determined by immunohistochemistry.

RESULTS

The 100% pellet and supernatant fractions of NL-AF suppressed PLA2 activity, and this activity was neutralized by a polyclonal antibody to SC. Western blot studies revealed an SC-reactive protein in the 70-80-kD range in the 100% pellet fraction of NL-AF. Two SC-reactive proteins were detected in the 60-80-kD range in the eluate from the SC immunoaffinity column, along with minor proteins of 30 and greater than 100 kD. Immunohistochemical studies revealed SC in placental trophoblast, amniotic membranes, and decidual epithelium.

CONCLUSIONS

These results demonstrate that proteins homologous to SC are present in human gestational tissues and possess anti-PLA2 activity. These proteins may contribute to the maintenance of pregnancy by suppressing local PG production.

Accuracy of sonographically estimated fetal weight with and without oligohydramnios. A case-control study

OBJECTIVE

To determine the accuracy of sonographically estimated fetal weight among women with and without oligohydramnios (amniotic fluid index [AFI] < or = 5.0 cm) and to ascertain the ability to detect fetal growth restriction (FGR) (estimated birth weight < 10th percentile for gestational age [GA]) among patients in two groups.

STUDY DESIGN

Assuming that 50% of sonographic predictions are within 10% of the birth weight in the study group, 300 parturients are necessary to show a difference of 15% among controls (alpha = .05, beta = .02). The study group consisted of parturients with a reliable GA of > or = 24, no known anomalies and known AFI of < or = 5.0 cm. The control (1:1) was the next patient with the same GA but AFI between 5.1 and 23.9 cm. The paired t test was used, and the odds ratio (OR) and 95% confidence interval (CI) were calculated. P < .05 was considered significant.

RESULTS

Among the study and control groups (N = 162 each), maternal demographics, mean estimate (P = .078) and actual birth weight (P = .091) were similar. Sonographic estimates within 10% of weight were not significantly different among those with (57%) and without oligohydramnios (59%; OR 0.92; 95% CI 0.59, 1.44). The frequency of FGR was higher among those with inadequate fluid (18%) than controls (9%; OR 2.13; 95% CI 1.10, 4.16). Sensitivity, positive predictive value and likelihood ratio were higher among those with oligohydramnios (76%, 78% and 16) than controls (53%, 42% and 7).

CONCLUSION

The accuracy of sonographic estimates of fetal weight is not influenced by whether the parturient has oligohydramnios. Moreover, the accuracy of identifying FGR is not diminished among those with AFI < or = 5.0 versus > 5.0 cm.

Low amniotic fluid volume is poorly identified in singleton and twin pregnancies using the 2 x 2 cm pocket technique of the biophysical profile

BACKGROUND

This study was done to determine the accuracy of the 2 x 2 cm pocket identifying low amniotic fluid (AF) volume in singleton and twin pregnancies.

METHODS

The AF volume was evaluated by ultrasonography for the presence of a 2 x 2 cm pocket before amniocentesis. The actual AF volume was then determined by a diazo-dye reaction with subsequent spectrophotometric analysis using paraminohippurate.

RESULTS

The AF volume was low in 21 of the 79 singleton pregnancies and normal in 47; hydramnios was present in 11. Among amniotic sacs of the 60 twin pairs, oligohydramnios was found in 33 amniotic sacs. normal AF volume in 80 sacs, and high volume in 7. An AF pocket smaller than 2 x 2 cm was identified in only 3 of the 79 singleton pregnancies and in only 2 of the 120 twin amniotic sacs.

CONCLUSIONS

Judging AF volume on the basis of a 2 x 2 cm pocket misses more than 90% of cases of oligohydramnios in singletons and twins.

May-Hegglin anomaly in a pregnancy complicated by intrauterine growth restriction and ambiguous genitalia

OBJECTIVE

Thrombocytopenia as a hematologic disorder complicates up to 4% of all pregnancies. May-Hegglin anomaly is a rare cause of low platelets in pregnancy.

METHODS

A case of May-Hegglin anomaly complicating pregnancy and intrauterine growth restriction in a fetus with ambiguous genitalia is described.

RESULTS

The antepartum and intrapartum diagnosis and management of a patient diagnosed with May-Hegglin anomaly is discussed. The involvement and consultation of a perinatologist, neonatologist, internist, and anesthesiologist is reviewed, with emphasis on the mode of delivery.

CONCLUSION

The potential maternal and fetal complications associated with May-Hegglin anomaly warrant early pregnancy diagnosis and access to a tertiary care facility.

Maternal hypoglycemia: is it associated with adverse perinatal outcome?

OBJECTIVE

To determine if maternal hypoglycemia is associated with adverse perinatal outcome, particularly low birth weight.

STUDY DESIGN

In this prospective study, all patients after 24 weeks' gestation were screened for gestational diabetes using 50 gm of glucola (oral) followed by a 1-hour plasma glucose measurement and hypoglycemia was defined as < or = 88 mg/dl.

RESULTS

In these 426 women the mean (+/- SD) 1-hour plasma glucose value was 99.8 +/- 22.7 mg/dl. Of these, 16 were diagnosed with gestational diabetes and 46 were lost to follow-up leaving 364 patients; 116 with hypoglycemia and 248 with euglycemia. Women with hypoglycemia weighed less at the beginning of pregnancy and at delivery, but total weight gain during pregnancy was similar between both groups. There was no difference between groups in maternal symptomatology, birth weight, or the rate of fetal growth restriction.

CONCLUSION

Hypoglycemia on the 1-hour glucola screen is not predictive of fetal growth restriction or other adverse perinatal consequence.

Microvasculature of the rat optic nerve head

PURPOSE

To describe the arterial blood supply, capillary bed, and venous drainage of the rat optic nerve head.

METHODS

Ocular microvascular castings from 6 Wistar rats were prepared by injection of epoxy resin through the common carotid arteries. After polymerization, tissues were digested with 6 M KOH, and the castings washed, dried, and coated for scanning electron microscopy.

RESULTS

Immediately posterior to the globe, the ophthalmic artery trifurcates into the central retinal artery and two posterior ciliary arteries. The central retinal artery directly provides capillaries to the nerve fiber layer and only contributes to capillary beds in the neck of the nerve head. The remainder is supplied by branches of the posterior ciliary arteries that are analogous to the primate circle of Zinn-Haller. Arterioles arising from these branches supply the capillaries of the transitional, or laminar, region of the optic nerve head. These capillaries are continuous with those of the neck and retrobulbar optic nerve head. All optic nerve head capillaries drain into the central retinal vein and veins of the optic nerve sheath. A flat choroidal sinus communicates with the central retinal vein, the choriocapillaris, and with large veins of the optic nerve sheath.

CONCLUSIONS

The microvasculature of the rat optic nerve head bears several similarities to that of the primate, with a centripetal blood supply from posterior ciliary arteries and drainage into the central retinal and optic nerve sheath veins. Association of nerve sheath veins with the choroid represents an important difference from the primate.

Evaluation of fetal lung maturity in diamniotic twins

OBJECTIVE

This study was undertaken to evaluate the correspondence in fetal lung development between diamniotic twins.

STUDY DESIGN

Lecithin/sphingomyelin ratios were determined for amniotic fluid specimens collected from each sac in 58 diamniotic twin pregnancies.

RESULTS

Overall, the lecithin/sphingomyelin ratios of twin A and twin B and those of the larger and smaller twins of each pair were closely correlated (r >/= 0.83, P <.001). When stratified by gestational age, however, the percentage disparity in lecithin/sphingomyelin ratios between members of twin pairs was significantly greater at </=32 weeks' gestation (25%) than at >32 weeks' gestation (15%, P =.027). An analysis of the lecithin/sphingomyelin ratios of twins with a large lecithin/sphingomyelin ratio disparity (>/=20%) suggested that this disparity was a result of 1 twin having a lecithin/sphingomyelin ratio that was advanced for gestational age with respect to that of the co-twin. Disparities in lecithin/sphingomyelin ratio were not significantly affected by fetal sex or by discordance in size between the twins.

CONCLUSION

At relatively early stages of diamniotic twin gestation (</=32 weeks' gestation), lecithin/sphingomyelin ratios should be obtained for both amniotic sacs to ensure accurate assessment of fetal lung maturity in both twins.

Antenatal testing among 1001 patients at high risk: the role of ultrasonographic estimate of amniotic fluid volume

OBJECTIVE

Our goal was to compare the accuracy of the amniotic fluid index and the 2-diameter pocket technique with respect to accuracy in predicting an adverse pregnancy outcome among patients at high risk undergoing antenatal testing.

STUDY DESIGN

All women with high-risk pregnancies and intact membranes who underwent antenatal testing during an 18-month period were prospectively enrolled. Ultrasonographic estimates of amniotic fluid volume were performed by means of the amniotic fluid index and the 2-diameter pocket technique. Relative risks with 95% confidence intervals and receiver operator characteristic curves were calculated for patients with an ultrasonographic estimate of oligohydramnios (amniotic fluid index of </=5 cm or 2-diameter pocket of </=15 cm2) versus normal fluid level (amniotic fluid index of >5 cm or 2-diameter pocket of >15 cm2). Outcome variables studied were intrapartum and neonatal complications.

RESULTS

Among 1001 patients the mean (+/-SD) amniotic fluid index was 10.5 +/- 5 cm and the mean (+/-SD) 2-diameter pocket was 18.7 +/- 13.6 cm2. Significantly more patients (46%) were considered to have oligohydramnios according to the 2-diameter pocket criteria than according to the amniotic fluid index (21%, P <.0001, relative risk 1.7, 95% confidence interval 1.5-1.8). No significant differences in the incidences of nonreactive nonstress test results, meconium-stained amniotic fluid, cesarean delivery for fetal distress, low Apgar scores, or infants with cord pH of <7.10 were observed between the oligohydramnios and normal amniotic fluid groups (P >.05) when assessed by relative risk with confidence interval and by receiver operator characteristic curves.

CONCLUSIONS

Current ultrasonographic measurements with the amniotic fluid index and the 2-diameter pocket technique are poor diagnostic tests to determine whether a patient is at high risk for an adverse perinatal outcome.