I I I I I PROCEEDINGS i OF THE SECOND ANNUAL SCIENTIFIC MEETING OF THE I i SOCIETY OF PERINATAL OBSTETRICIANS I I

I 4--7 FEBRUARY 1982 SAN ANTONIO, TEXAS I HILTON PALACIO DEL RIO I ! I I

I Publication of these Proceedings has been made possible through the support of Beckman Instruments, Inc. We gratefully acknowledge I their contribution to the success of this meeting. I I ACKNOWLEDGEMENTS

I The Society would like to express ~s deepest appre~ation to the following organizatio~ (as listed a~phabetically) for their support of this toeing:

I ADR ULTRASOUND V~iting Professor I BECKMAN INSTRUMENTS, INC. Proceedings MERRELL DOW, INCo Prize Paper cash award and I two Award Paper cash awards PERINATAL RESOURCES Prize Paper cash award for best I p.~per by fellow I would like to thank several individuaZs witho~whose work t~ meeting I co~d not have been h~d. Dr. Roy Petrie, our Secretary-Treasurer, for a~ the phone cat~s, ma~ng~, checking, re-checking and moral support

I The Prog~ Committee~Drs. Tom Barden, Stan G~.~l, Dick Paul, Bruce W.~rk and Bruce Young~as we~l as their junior faculty and fe~ows for reviewing the more than 100 abstract~ sub- I mitred ~nd for recruiting appropriate d~scas~ants

Dr. John Morrison for working out and organizing an exciting I "theme session," as well as for reviewing ab~tract~

Dro Bob Hayashi for organizing the local arrangements

I M~. Norma Brown, my secretary, for managing a~ correspondence and for preparing the P~ceedings for pri~ing

I Roberta, my wife, for bookkeeping the sc~ ring and ranking of the abstracts and for organizing the P~oceedings I

Robert J. Sokol, M.D. Chairman, Program Committee, SPO 8 January 1982 ! PROGP4~M SOCIETY OF PERINATAL OBSTETRICIANS I PALACIO HILTON San Antonio, Texas I 4--7 February 1982 I THURSDAY, 4 February 1982 I 2:00 p.m. Annual Board of Directors Meeting

5:00--8:00 p.m. Registration Social Hour (cash bar) I

~RIDAY, 5 February 1982 I 7:00--8:00 a.m. Continental Breakfast I 7:30 a.m.--12:30 p.m. Registration

8:00--8:10 a.m. Welcome--Robert J. Sokol, M.D.

8:10 a.m.--12:00 noon PREMATURITY: WHERE WE STAND HOW Moderator: John C. Morrison, M.D.

8:10--8:40 a.m. j CORRELATES OF PREMATURITY: DETECTING HISTORY, PHYSICAL AND LABORATORY ASSESSmeNT Richard Berkowitz, M.D. I 8:40--8:50 a.m. Questions and Answers

8:50--9:20 a.m. THERAPEUTIC MEASURES FOR PREVENTION OF I PREMATURE LABOR John W. C. Johnson, M.D. I 9:20--9:30 a.m. Questions and Answers 9:30--9:50 a.m. Coffee Break I 9:50--10:20 a.m. THE MATERNAL ADMINISTRATION OF STEROIDS IN PATIENTS AT RISK FOR PREMATURITY John Co Morrison, M.D. I 10:20--10:30 a.m. Questions and Answers I 10:30--11:00 a.m. ADVERSE EFFECTS OF TOCOLYTIC AGENTS: MATERNAL, FETAL AND NEONATAL Thomas L. Gross, M.D. I ll:O0~ll:lO a.m. Questions and Answers I 11:10--11:40 a.m. RISKS OTHER THAN RDS FOR THE PREMATURE NEONATE I Mildred L. Stahma~, M.D. 11:40 a.m.--12:00 noon Questions and Answers I 12:00 noon--l:O0 p.m. FIRST SCIENTIFIC SESSION Moderator: Robert J. Sokol, M.D.

I 12:00--12:20 p.m. A SIMPLE ESTIMATED FETAL WEIGHT (EFW) FORMULA, BASED ON RF~L-T[ME ULTRASOUND MEASUREMENTS OF FETUSES LESS THAN 34 WEEKS’ GESTATION I Gary R. Thurnau, M.D., Ralph Tamura, M.D., Rudy Sabbagha, M.D., O. Richard Depp, III, M.D. I Discussant: Peter Grannum, M.D.

12:20--12:40 p.m. DIAGNOSIS OF INTRACEREBRAL HEMORRHAGES BY I ULTRASOUND IN UTERO I. Lustig, M.D., F. Silverman, M.D., I B. K. Young, M.D. Discussant: Mortimer G. Rosen, M.D. I 12:40--1:00 p.m. *** Merrell Dow Award Pa.pe~: FETAL ECHOCARDIOGRAPHY: THE DIAGNOSIS AND SIGNIFICANCE OF A PERICARDIAL EFFUSION USING REAL-TIME DIRECTED M-MODE ECHO- I CARDIOGRAPHY (RTD~) . G. R. DeVore, M.D., R. L. Donnerstein, M.D., C. S. Kleinman, M.D., L. D. Platt, M.D., I J. C. Hobbins, M.D.

Discussant: Bruce A. Harris, Jr., M.D. I 1 : 00 p.m. Adjourn I 6:30 p.m. Reception 7:30 p.m. Annual Banquet | SATURDAY, 6 February 1982 I 7:00--8:00 a.m. Continental Breakfast 7:30 a.m.--12:30 p.m. Registration

I 8:00--10:00 a.m. SECOND SCIENTIFIC SESSION Moderator: Donald M. Sherline, M.D. I 8:00--8:20 a.m. THE USE OF AMNIOCENTESIS IN THE PRETERM GESTATION WITH RUPTURED MEMBRANES I David B. Cotton, M.D., Howard T. Strassner, M.D. Discussant: Ronald Gibbs, M.D.

3 I 8:20--8:40 a.m. *** Perinatal Resources Prize Paper: RAPID DIAGNOSIS OF AMNIOTIC ’FLUID INFECTION BY GAS-LIQUID CHROMA- TOGRAPHY I Michael G. Gravett, M.D., David A. Eschenbach, M.D., Carol Spiegel, Ph.D., King K. Holmes, M.D., Ph.D. I Discussant: Stanley A. Gall, M.D. I 8:40--9:00 a.m. THE USE OF BREAST STIMULATION TO RIPEN THE CERVIX IN TERM PREGNANCIES John P. Elliott, M.D., LTC, MC, USA, James I F. Flaherty, D.O., CPT, MC USA Discussant: Bruce A. Work, Jr., M.D. I

9:00--9:20 a.m. A CLOSER LOOK AT THE USE OF LAMINARIA DIGITATA FOR PREINDUCTION RIPENING OF THE CERVIX: ITS I EFFICACY AND SAFETY George M. Kazzi, M.D., Sidney F. Bottoms, M.D., Mortimer G. Rosen, M.D. I Discussant: David Baker, M.D. I 9:20--9:40 a.m. THE EFFECTS OF EPIDURAL ANALGESIA ON THE COURSE OF LABOR AND MODE OF DELIVERY M. Diro, M.D., S. N. Beydoun, M.D. I Discussant: Justin P. Lavin, Jr., M.D. I 9:40--10:00 a.m. DYSTOCIA: A "DISAPPEARING" RISK FOR THE NEONATE Sidney F. Bottoms, M.D., Victor J. Hirsch, I B.A., Robert J. Sokol, M.D. Discussant: Robert Co Cefalo, M.D. I

10:00--10:30 a.m. Coffee Break

10:30 a.m.--12:10 p.m. THIRD SCIENTIFIC SESSION Moderator: Jacques Roux, M.D.

i0:30--I0:50 a.m. FHR RESPONSE TO SCALP SAMPLING S. L. Clark, M. L. Gimovsky, F. C. Miller

Discussant: Richard Depp, M.D.

i0:50--ii:i0 a.m. SHOCK INDICATION BY TRANSCUTANEOUS PO2 MEASUREMENTS IN THE SHEEP FETUS A~ CATECHOLAMINE RELEASE A. Jensen, W. Konzel, K. Kastendieck

Discussant: Bruce K. Young I 8:20--8:40 a.m. *** Perinatal Resources Prize Paper: RAPID DIAGNOSIS OF AMNIOTIC FLUID INFECTION BY GAS-LIQUID CHROMA- TOGRAPHY I Michael G. Gravett, M.D., David A. Eschenbach, M.D., Carol Spiegel, Ph.D., King K. Holmes, M.D., Ph.D. I Discussant: Stanley A. Gall, M.D. I 8:40--9:00 a.m. THE USE OF BREAST STIMULATION TO RIPEN THE CERVIX IN TERM PREGNANCIES John P. Elliott, M.D., LTC, MC, USA, James I F. Flaherty, D.O., CPT, MC USA Discussant: Bruce A. Work, Jr., M.D. I

9:00--9:20 a.m. A CLOSER LOOK AT THE USE OF LAMINARIA DIGITATA FOR PREINDUCTION RIPENING OF THE CERVIX: ITS I EFFICACY AND SAFETY George M. Kazzi, M.D., Sidney F. Bottoms,M.D., Mortimer G. Rosen, M.D. I Discussant: David Baker, M.D. I 9:20--9:40 a.m. THE EFFECTS OF EPIDURAL ANALGESIA ON THE COURSE OF LABOR AND MODE OF DELIVERY M. Diro, M.D., S. N. Beydoun, M.D. I Discussant: Justin P. Lavin, Jr., M.D. I 9:40--I0:00 a.m,~ DYSTOCIA: A "DISAPPEARING" RISK FOR THE NEONATE Sidney F. Bottoms, M.D., Victor J. Hirsch, B.A., Robert J. SokOl, M.D. I Discussant: Robert C. Cefalo, M.D. I

10:00--10:30 a.m. Coffee Break

10:30 a.m.--12:iO p.m. THIRD SCIENTIFIC SESSION Moderator: Jacques Roux, M.D.

10~30--10:50 aomo FHR RESPONSE TO SCALP SAMPLING S. L. Clark, M. L. Gimovsky, F. C. Miller

Discussant: Richard Depp, M.D.

10:50--11:10 arm. SHOCK INDICATION BY TRANSCUTANEOUS PO2 MEASUREMENTS IN THE SHEEP FETUS AND CATECHOLAMINE RELEASE A. Jensen, W. Konzel, K. Kastendieck

Discussant: Bruce K. Young 4 I 11:10--11:30 a.m. EFFECTS OF OXYGEN ADMINISTRATION ON FETAL-MATERNAL PHYSIOLOGY IN LABOR F. Silverman, M.D., C. Antoine, M.D., I. Lustig, I M.D., B. K. Young, M.D. I Discussant: Thomas J. Benedetti, M.D. 11:30--11:50 a.m. PERINATAL MORTALITY IN ASSOCIATION WITH ELECTRO’qIC FETAL HEART RATE MONITORING (EFM) OF VERY LOW I BIRTH WEIGHT INFANTS: A POPULATION-BASED STUDY IN KING COUNTY K. K. Shy, M.D., M.P.H., D. E. Hickok, M.D., I M.P.H., A. Olshan, B.A., Do A. Luthy, M.D. I Discussant: Richard Paul, M.D. 11:50 a.m.--12:10 p.m. FOLLOWUP OF LOW BIRTHWEIGHT INFANTS: RELATIONSHIP BETWEEN MODE OF DELIVERY, FETAL PRESENTATION, FETAL I DISTRESS AND EARLY DEVELOPMENTAL OUTCOME N. Hardt, M.D., M. Ogburn, M.H.A., M. Resnick, I Ed.D., A. Cruz, M.D. Discussant: Franklin C. Miller, M.D.

I 12:10--1:00 p.m. Business Meeting (members only)

I i:i0 p.m. Adjourn

I SUNDAY, 7 February 1982 7:00--8:00 a.m. Continental Breakfast

-I 8:00--10:00 a.m. FOURTH SCIENTIFIC SESSION Moderator: Bruce K. Young, M.D. I 8:00--8:20 a.m. *** Merrell Dow Prize PaFer: PLASMA VOLUME DETERMINA- TION IN PREGNANCIES (0~LICATED BY CHRONIC I HYPERTENSION Baha M. Sibai, M.D., Thomas N. Abdella, M.D., Garland D. Anderson, M.D., Jack H. McCubbin, M.D.

I Discussant: Thomas J. Benedetti, M.D.

I 8:20--8:40 a.m. ANTEPARTUM PREDICTION OF THE POSTMATURE INFANT William Rayburn, M.D., Mary E. Motley, L.P.N., Laurence Ste1~pel, M.D., R. Michael Gendreau, M.D.

I Discussa~t: Sze-Ya Yeh, M.D. I 8:40--9:00 a.m. MYO-INOSITOL HOMEOSTASIS IN FETAL RABBIT LUNG ¯ J. G. Quirk, M.D., Ph.D., J. E. Bleasdale, Ph.D.

Discussant: Steven Golde, M.D. ! 9:00--9:20 a.m. ACCELERATED PULMONARY MATURITY AS MEASURED BY THE BECKMAN FSI CASETTE: A RELIABLE DISCRIMINATOR BETWEEN THE SGA AND AGA VERY PRETERM FETUS J. Lipshltz, W. D. Whybrew, Go D. Anderson, ! B. Sibai, T. Abdella, J. Dacus

Discussant: Thomas L. Gross, M.D. !

9:20--9:40 a.m. THE USE OF AMNIOTIC FLUID 3-METHYLHISTIDINE TO I CREATININE MOLAR RATIO FOR THE DIAGNOSIS OF INTRAUTERINE GROWTH RETARDATION M. Miodovnik, M.D., J. P. Lavin, M.D., I Z. Gimmon, M.D., L. L. Edwards, B.A., J. Hill, R.N., J. E. Fischer, M.D., T. P. Barden, M.D.

Discussant: Amelia Cruz, M.D. I

9:40--10:00 a.m. MATERNAL DIETARY RESTRICTION AND REPLETION: I EFFECTS ON CARDIAC OUTPUT AND PLACENTAL BLOOD FLOW IN THE RAT R. Ao Ahokas,-Ph.D., G. D. Anderson, M.D., J. Lipshitz, M.D., K. Broyles~ B.S. I Discussant: Robert Johnson, M.D. I 10:00--10:20 a.m. Coffee Break I 10:20 a.m.--12:00 noon FIFTH SCIENTIFIC SESSION Moderator: Stanley A, Gall, M.D. I

10:20--10:40 a.m. NORMAL PREGNANCY IS A STATE OF PHYSIOLOGIC ABSORPTIVE HYPERCALCIURIA I D. R° Coustan, M.D., N. D. Ravin, M.D., J. Mo Gertner, M.D., A. S. Kliger, M.D. A. E. Broadus, M.D. I Discussant: Dwight P. Cruikshank, M.D. I 10:40--11:00 a.m. EFFECT OF CALCIUM SUPPLEMENTATION ON BLOOD PRESSURE IN NORMAL PREGNANT WOMEN J. M. Belizan, M.D., Ph.D., Jose Villar, M.D., I M.P.H., M.Sc. Discussant: Dwight P. Cruikshank, M.D. I i] :00~Ii:20 a.m. *** Merrell Dow Award Pap.e~: A~IOTIC FLUID ERYTHRO- CYTES. A TECHNIQUE FOR ISOLATION AND POSSIBLE UTILIZATION IN ANTENATAL DIAGNOSIS D. M. Doran, Ph.D., H. E. Fadel, M.D., F. A. Garver, Ph.D.

Discussant: George Ho Nolan, M.D.

iI:20~iI:40 a.m. FETAL ACTIVITY PERIODS IN DIABETIC AND NON-DIABETIC PREGNANCIES L. J. Dierker, M.D., S. K. Pillay, Ph.D., Y. Sorokin, M.D., M. G. Rosen, M.D.

Discusr, ant: Maurice Druzin, M.D.

11:40 a.m.ml2:00 noon MATERNAL GLUCOSE VARIABILITY AND NEONATAL OUTCO~ IN THE PREGNANT DIABETIC R. Artal, M.D., S. H. Golde, M.D., J. Gratacos, M.D., S. N. McClellan, M.D., M. Montoro, M.D., J. Mestman, M.D.

Discussant: Stanley J. Stys, M.D.

12:00 noon Adjourn I I I I I I

I ABSTRACTS I TO BE PRESENTED I TO THE .I SOCIETY I I

I (in order of presentation) I I I I I I Society of Perinatal Obstetricians Annual Meeting ! San Antonio, Texas February, 1982 ! A SIMPLE ESTIMATED FETAL WEIGHT (EFW) FORMULA, BASED ON REAL-TIME ! ULTRASOUND MEASUREMENTS OF FETUSES LESS THAN 34 WEEKS GESTATION Gary R. Thurnau, M.D. (Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Utah Medical Center, Salt Lake City, Utah), ! Ralph Tamura, ~.].D., Rudy Sabbagha, M.D., and O. Richard Depp, i11, M.D. (Department of Obstetrics and Gynecology, Division of Maternal Fetal ~,~edicine, Northwestern University, Chicago, Illinois),. Alan Dyer, Ph.D. (Department of ! Biostatistics, Northwestern University, Chicago, Ilinois).

When a Dreterm or low birth weight neonate is anticipated, accurate antenatal assessment of fetal weight is an important factor in reducing perinatal morbidity ! and mortality. Previous formulas have proved to be somewhat reliable in pre- dicting fetal weight; however, many of them are mathematically cumbersome and I inaccurate when applied to the preterm and low weight fetus (< 2,000 grams). The purpose of this study was to devise, a simple formula for estimatin.q weights of preterm fetuses without the need of a calculator, weight charts or I complex mathematical computations. Real-time ultrasound measurements of fetal biparietal diameters (BPD) and abdominal circumferences (AC) were obtained in 70 gravidas within or~e week of I delivery. Of the 70 cases, 62 had birth weights within the range of 500 to 2,000 grams with a mean birth weight of 1,135 grams. With the aid of computer I analysis, two simple arithmetic formulas were derived: 1. For deliveries which occur between four and seven days after having I obtained the ultrasound measurements: EFW = (BPD X AC X 9.337) - 300

2. For deliveries which occur within three days of the ultrasound I measurements : I EFW = (BPD X AC X 9.0) - 300 Multiple regression analysis of the above data demonstrated a correlation coefficient (R) of 0.957 and a standard deviation of 100 grams (88 grams Der I kilo.oram of fetal weight).

Current prospective utilization of the above formulas in twenty cases has I demonstrated this to be an accurate and simple means of estimating weight of preterm fetuses less than 34 weeks gestation. I I I

Ii ! February, 1982 I I DIAGNOSIS OF INTRACEREBRAL HEMORRHAGES BY ULTRASOUND IN UTERO I. Lustig, M.D., F. Silverman, M.D., and B. K. Young, M.D. (Department of Obstetrics and Gynecology, Division of Maternal- I Fetal Medicine, New York University Medical Center and School of Medicine, New York, N.Y.) Fetal intracranial anatomy can be identified in utero I utilizing real time ultrasonography. The cerebral vasculature and nuclei are used as landmarks for locating the various anatomical structures. Presently we are using linear array I and sector scanning to evaluate the fetal brain at different gestational ages followed by intrapartum and postpartum scanning. Anatomical correlation was done by scanning the I fixed neonatal brain followed by cutting serial sections. A case of fetal intraventricular hemorrhage was diagnosed by real time ultrasound in utero. The baby was delivered and succumbed with the findings confirmed clinically and at autopsy. I The diagnostic criteria for fetal IVH were compared with those of the neonate and contrasted with other ultrasound diagnoses in the fetus. Fetal and neonatal intracranial hemorrhage I appear essentially the same sonographically. Ultrasound may be used to diagnose cerebral edema, intracranial hemorrhage, symmetrical and asymmetrical hydrocephalus. Measurements of I ve~tricular length, width, volume, and ratio of the ventricular width to one half the biparietal diameter were studied. This is particularly useful in differentiating asymmetrical hydro- cephalus from IVH in the fetus. IVH and subependymal ! hemorrhages have not been described previously in the fetus, however, they are a common finding in prematures. Most hemorrhages are diagnosed in the first 15 minutes to three days I of life. Intrauterine intracranial bleeding may present a pivotal observation, demonstrating a final common pathyway for I the mechanism of fetal demise. I ! I I I 13 Society of Perinatal Obstetricians Annual Meeting I San Antonio, Texas February, 1982

I FETAL ~CH~CARDIOGRAPHY: THE DIAGNOSIS AND SIGNIFICANCE OF A PERICARDIAL EFFUSION USING REAL-TIME DIRECTED M-MODE ECHOCARDIOGRAPHY (RTDME). G.R.DeVore, M.D~, R.L.Don- nerstein, M.D., C.S. Kleinman, M.D., L.D.Platt, M.D. and J.C. Hobbins, M.D. (From I the Departments of Obstetrics and Gynecology and Pediatric Cardiology,Yale Universi- ty School of Medicine,New Haven, CT and the University of Southern California School of Medicine, Los Angeles, CA).(* This research funded by THE THRASHER RESEARCH FUND)

I Hydrops fetalis, an endstage manifestation of massive fluid accumulation, us- ually presents at autopsy with gross ascites,pericardial and pleural effusions, and soft tissue edema.Although fluid within the abdomen, chest and integument is readily I detected with conventional ultrasound, its presence requires a significant quantity to be present before becoming apparent ultrasonically. However the pericardial sac, a potential space in which abnormal fluid accumulation separates the normally appos- ! ed epicardial and pericardial membranes, has the potential of being an early indicat. or of fluid accumulation within the fetus because of the minimal amount required for ~istension. The following is a report of our findings from the evaluation of the fetal heart using RTDME in normal and high-risk pregnancies. Our observations I suggest that the pericardial space is a sensitive indicator of early fluid accumula- tion occurring within the fetus destined to develop gross hydrops (ascites, pleural effusions and soft tissue edema). I Using RTDME (Advanced Technology Laboratories, Bellevue, WA), the four-chamber view of the heart from 200 examinations was imaged in real-time,and the M-mode cursor subsequently directed to the cardiac structures of interest. The diagnosis I of a pericardial effusion was made if there were (1)separation of the epicardial and )ericardial membranes, (2)loss of motion of the pericardium with ventricular systole (3) paradoxical motion of the ventricular walls and the interventricular septum, and (4) evidence of fluid accumulation beginning at the atrioventricular junct3on I and increasing in quantity towards the ventricular apex. Of the 200 examinations, ~pericardial effusions were observed in the following clinical situations: IRHESUS HEMOLYTIC ANEMIA. Five fetuses with Rh disease demonstrated a pericardial ! effusion. Two fetuses at 20 and 21 weeks of gestation had an obvious pericardial effusion with concomitant ascites. Both ~ied within 7 days of the diagnosis. Two fetuses at 22 and 24 weeks of gestation were noted to have a pericardial effusion, WITHOUT evidence of ascites, pleural effusions or soft tissue edema. Both concomitan. I tly underwent intrauterine transfusions because of an elevation of the amniotic flui delta optical density. In both cases, following the second of five intrauterine transfusions, the pericardial effusions resolved. The fifth fetus,at 31 weeks of I gestaton,was noted to have a pericardial effusion just prior to delivery. The effus- ion was confirmed at birth and resolved four days later when the serum albumin re- turned to normal. I STRUCTURAL DEFECTS. Three fetuses with cardiac structural defects (hypoplastic left ventricle, hypoplastic right ventricle, and an intracardiac rhabdomyoma) demonstrat- ed pericardial effusions which resulted from obstruction of intracardiac blood flow. ARRHYTHMIA. A fetus at 27 weeks of gestation was diagnosed with RTDME as having I intermittent atrial tachycardia (265/minute) and a pericardial effusion. There was no other evidence of congestive heart failure. The fetus was treated by administer- ing digoxin to the mother. Ten days following the initiation of treatment, the fetal I heart rate was 130/minute and there was no longer evidence of a pericardial effusion From OUr study of the fetal heart using RTDME, it appears that the insult re- sulting in fluid accumulation within the fetus, although occurring simultaneously I throu~outthe various organ systems, can be diagnosed in its earliest phase by imaging the fetal heart and looking for evidence of a pericardial effusion. This sen sitive diagnostic capability allows the physician to institute earlier therapy I (i.e. intrauterine transfusion, digoxin), depending upon the etiology.

15 Society of Perinatal O~stetricians I Annual Meeting San Antonio, Texas I February, 1982

THE USE OF AI~NIOCENTESIS IN THE PRETERM GESTATION WITH I RUPTURED MEMBR~ES David B. Cotton, M.D., and Howard T. Strassner, M.D. (Department of Obstetrics and Gynecology, University of Southern California~ School of Medicine and I Women’s Hospital, Los Angeles County/University of Southern California Medical Center, Los Angeles, California snd AIrs Bates Hospital, Berkeley, California I The use of amniocentesls in patients with premature rupture of membranes between 22 and 36 weeks gestation was studied. All patients had membrane rupture documented by sterile speculum examination using pooled fluid, ferning and alkallne pH (nitrazlne paper) criteria. Ultrasound was performed to I obtain fetal biparletal diameter, placental localization and the optimum site for amniocentesls. If an adequate "pocket" of amniotic fluid was identified a transabdominal amniocentesis was aseptically performed and the amniotic fluid I sent for lecithin-sphingomyelin (L/S) ratio, phosphatidylglycerol (PG), gram stain, anaerobic and aerobic culturing. Clinical management of the patients was based on the amniotic fluid findings with delivery of any patient showing I evidence of fetal pulmonary maturity or bacteria on gram stain. In the presence of labor with documented pulmonary immaturity and no evidence for infection labor inhibition was accomplished with either ritodrine or i terbutaline and cortlcosteroid therapy initiated. Forty-six patients with premature rupture of-membranes (PROM) underwent ultrasound examination in an attempt to obtain amnlotic fluid for analysis. Twenty-five patients underwent real-tlme ultrasound examination and amnlotic fluid was successfully obtained i by transabdomina] amnlocentesis in 6 of the 25 (24%). Twenty-one patients underwent static ultrasound examination and amniotic fluid was successfully obtained in 16 of 21 patients (76Z). Successful amniocentesls overall was performed in 22 of the 46 patients or 48Z. Among the 22 patients in whom I successful amniocentesis was performed I0 patients (45Z) had an L/S ratio of 1.8 or greater. Fifty percent of those infants in whom pulmonary maturity was documented and pregnancy terminated required 3 or more weeks of I hospltalization. Gram stain and culturing of amniotic fluid was accomplished in 21 cases. Six or 29Z of patients had bacteria identified with subsequent amniotic fluid culture growth in 4, no growth in I and 1 culture was lost. i Ali patients with bacteria on gram stain or a positive amniotic fluid culture developed clinical amnionitis or endometritls. Among the 6 pregnancies with bacteria on gram stain there was 1 case of neonatal sepsis and 1 fetal demise. Three out of the 15 patients in whom there were no bacteria on gram I stain and negative araniotic fluid cultures subsequently developed amnionltis or endometritis. There were no cases of neonatal sepsis or death in this group. No neonatal deaths occurred in the group of patients in whom fetal ! pulmonary maturity was identified and pregnancy terminated. However, the fact that 50Z of these infants required 3 or more weeks of hospitalization suggests that the practice of terminating a preterm gestation on the basis of fetal I pulmonary maturity alone requires further scrutiny. Additionally, it would appear that bacteria on amniotic fluid gram stain identifies a group at high risk for infectious morbidity and serious consideration should be given to termination of pregnancy in these cases. Finally, the absence of bacteria on I !amniotic fluid gram stain especially when coupled with fetal pulmonary immaturity selects the most suitable candidate for non-intervention in the l preterm gestation with ruptured membranes. I 1 I 17 I Snn Anto’~i~,, ’[exas February, 1982

I RAPID DIAGNOSIS OF AMNIOTIC FLUID INFECTION BY GAS-LIQUID CHROMATOGRAPHY

Michael G. Gravett, M.D., David A. Eschenbach, M.D., Carol Spiegel, Ph.D., I and King K. Holmes, M.D., Ph.D. (Departments of Obstetrics and Gynecology, and Medicien, University of Washington, Seattle, Washington.) Sponsored I by David A. Luthy, M.D. Amniotic fluid infection (AFI) is an important cause of perinatal morbidity. The diagnosis of AFI is usually based upon clinical signs which may not be present until late in the course of the infection. Results of traditional I tests used to diagnose AFI, including amniotic fluid WBC count, Gram stain, and culture are either insensitive, nonspecific or not immediately avail- able. Gas-liquid chromatography (GLC) has been used to detect bacterial I organic acid metabolites in a variety of body fluids. In this study, we found that GLC was useful in the rapid diagnosis of AFI. I Amniotic fluid samples from 16 patients with a clinical diagnosis of AFI and from 22 non-infected comparison patients were examined for the presence of organic acids by using GLC. Lactate was present in all samples. Other organic acids including acetate, succinate, butyrate, oxaloacetate, and I isobutyrate were present in more than trace amounts in 15 of 16 patients with and l of 22 patients without AFI (p < 0.0005). GLC had a sensitivity of 94% and a specificity of 95% in the diagnosis of AFI. The detection I of organic acids other than lactate in more than trace amounts probably results from bacterial metabolism within amniotic fluid and was used to define an abnormal GLC. The one patient with a normal GLC and clinical I AFI had a sterile amniotic fluid culture, no histologic evidence of chorio- amnionitis, and primary genital herpes.

An abdormal GLC was also correlated with the quantitative recovery of bac- i teria from amniotic fluid. Growth of bacteria in > 2+ concentration was seen in 14 of 16 patients with an abnormal GLC and in l of 22 patients in I which only lactate was found (p < 0.0005). When compared to the amniotic fluid WBC count aPd the amniotic fluid Gram stain, GLC was both more sensitive and specific. GLC can be completed within one hour on as little as one milliliter of amniotic fluid and may I be a useful adjunct in the rapid diagnosis of AFI.

I Abno rma I No rma l Clinical Group No. % No. % AFI (n=16) l I 15 (94%) (5%) p 2+ Growth 14 (87.5%) l ( 5% I

19 Society of Perinatal Obstetricians Annual Meeting I San Antonio, Texas February, 1982 I THE USE OF BREAST STIMULATION TO RIPEN THE CERVIX IN TERM PREGNANCIES I John P. Elliott, M.D., LTC, MC, USA and James F. Flaherty, D.O., CPT, MC, USA (Dept of Obstetrics and Gynecology, Letterman Army Medical Center, Presidio of San Francisco, CA 94129). I Induction of labor may be a matter of medical or obstetrical necessity. Patients with worsening maternal or fetal problems often have an unfavorable cervix which may preclude successful I induction. A preliminary report of our experience with breast stimulation to change a cervix unfavorable for induction into one more favorable I is presented. Patients at greater than 39 weeks gestation were studied. Pelvic examinations were performed initially and 3 days later by the same obstetrician. Each treatment group was blinded I to the examiner and patients were assigned randomly to each group. A Bishop score (Obsteto and Gynecol. 24:266, 1964) was calculated at each examination. Patients in the treatment group massaged their breasts for one hour three times a day for three days. The I control group avoided breast stimulation. Patients in both groups were asked not to have intercourse during the study period. I Nineteen patients were randomized to the control group and 22 to the treatment group. Three patients in the control group failed to return for the second examination and were dropped from the I study, leaving 16 patients in the control group. Gestational age for the stimulated group was 40 2/7 wks ~ 0.6 wks (mean ~ S.D.) compared to the control group 40 1/7 wks ± 0.4 wks (mean ~ S.D.) I Initial Bishop score for the stimulated group was 5.5 ~ 2.3 (mean ~ S.D.) and that for the control group was 4.6 ± 1.8 (mean ± S.D.). These groups were not significantly different. The I mean change in Bishop score was 2.8 ± 1.9 (mean ~ S.D.) in the trea%~ent group compared to 0.7 ± 0.9 (mean ~ S.D.) .for the contr,! group (Sig. p < .01 by t test). In addition one patient went into I labor in the contr~l group as compared to ii in the treatment group [Sig. p < .05 by X=). There were no maternal or neonatal compli- cations in either group. I Breast stimulation appears to be an effective method for "ripening" a patient’s cervix at term. Successful induction appears to be related to a high Bishop score and breast stimulation changes the I cervix toward a higher Bishop score. Another benefit of the stimulation lies in the higher incidence of labor in the trial I period. I I

21 Society of Perinatal Obstetricians I Annual Meeting San Antonio, Texas I February, 1982 ~ CLOSER LOOK AT THE USE OF LAMINARIA DIGITATA FOR PREINDUCTION RIPENING OF THE CERVIX: ITS EFFICACY AND SAFETY I George M~. Kazzi, M.D., Sidney F. Bottoms, M.D. and ~ortimer G. Rosen, M.D. (Depart- ment of Obstetrics and Gynecology and the Perinatal Clinical Research Center, Cleve- land Metropolitan General Hospital/Case Western Reserve University) I Induction of labor, in the presence of the unripe cervix has been associated with a high incidence of failure. When the need for delivery is critical, a cesar- ean birth often may be the only alternative. Many methods have been used to ripen I the cervix before induction, including manually stripping the membranes, insertion of an extraovular Foley catheter or laminaria and the use of systemic drugs such as prostaglandins, relaxin and estrogens. Recently several studies were reported on I the use of laminaria for preinduction cervical ripening in term pregnancies when delivery was indicated for medical reasons. All studies showed significant short- ening of induction delivery time, more successful inductions and decreased need for oxytocin. In no studies were side effects, specifically due to laminaria, such as ! ’major cervical trauma or infectious morbidity reported. The purpose of this study was to assess the safety and efficacy of laminaria used for the pre-induction ripening of the cervix. Twenty-five study patients in ! which laminaria tents had been used were compared with 28 control patients in a matched retrospective study. Both groups had comparable indications for induction parity, mean maternal age, mean birth weights and gestational ages. I With respect to facilitating labor with the use of laminaria we found that there were no significant differences between the duration of labor-delivery time, ’induction-delivery time and duration of ruptured membranes when all patients in both groups were compared. However, when patients with modified cervical Bishop I scores < 3 were compared, there was significant shortening of the induction-deli- very time and labor-delivery time in the laminaria group. There were no differ- !ences in the incidence of cesarean birth between the laminaria and non-laminaria I igroups. ! Wit~ respect to complications following the use of laminaria, we found that maternal endometritis was present in 15 out of 25 mothers in the ~aminaria group I(60%), as compared with 3 out of 28 in the control population (11%). One hundred I percent of those mother~ who had cesarean births in the study ~rouD had endometri- tis as compared with 27% in the control grouD (p < 0.005). Six of the 16 vaginal births (38%) in the study group had endometritis, while there were no infections ! in the control vaginally delivered patients (p < 0.01). Five neonates (20%) had sepsis in the study group, compared with no documented evidence of sepsis in the control group (p < 0.05). Four (50%) of the 8 preterm babies (less than 36 weeks) ! had sepsis. The blood cultures grew group B beta-hemolytic streptococcus in three infsnts and enterobacter in the fourth. Three of the preterm septic neonates succumbed. The birthweights of the neonatal deaths were 1100 grams, 1670 grams I and 1770 grams with gestational ages by modified Dubowitz of 28 weeks, 32 weeks and 35 weeks respectively. Our conclusion is that while laminaria may decrease the duration of labor in patients with very low modified Bishop scores, their use is associated with a I significant increase in maternal morbidity and neonatal morbidity and mortality and should not be used in preterm pregnancies. I I

i 23 Society of Perinatal ODstetrlcians Annual Meeting I San Antonio, Texas February, 1982 I I|IE EFI:EC~S OF EPII)UtUM, ANALGESIA ON THE COURSE OF LABOR AND MODE OF DELIVERY. I M. 1)ir~,, M.I)., and S.N. Beydoun, M.D. (Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Ut~iversity of Miami School of Medicine, .lacks,m Memorial ttospital, Miami, Florida.

I ’lhe effectiveness of epidural anesthesia and its safety in obstetric practice is ~,ell established. Currently it is wideJy used for operative deliveries as ~ell a~s for the relief of labor pains. However, its effects on the course of I labor and mode of delivery are still controversial. This controversy is based tm the existing reports(that lacked matched controls)and most of which were in fact primarily designed to study other parameters of this proced,,,,,~; while i {he conclusions drawn as to its effects on labor and delivery were the result o~" incidental observations. A matched contro!led study was carried out during a 12 ~,~onths period at the University of Miami School of Medicine, laekson Mem¢~rial ttosp[tal. The criteria used in the selection of the study patients I were: spontaneous onset of labor, sing]eton gestation in the vertex presen- tat ion, no known medical or obstetric complications, and those patients were ep~dural was given soJely for the relkef of labor pa~ns. Controls were matched I strictly for race, age within 2 years, same parity, gestational age within 2 ~ .eks .and baby’s birth weight within 200 gms. The first patien{ fullfilling the c~mtro! criteria who delivered after a study one, became her matched control. I It is important to note that no anesthesia or obstetric personnel knew about the conduct of the study while in progress, except the two authors who, on the other hand, were not personally involved in any direct management of the patients. This we believe has eliminated any potential bias that could have I occurred. 43 patients with matched controls were available for the final analysis which fncluded duration of labor, incidence of oxytocin augmentation, incidence of Forceps and cesarean section deliveries as well as the immediate I outoome of the neonate as .judged by apgar scores. Pa~red t test and chi2 were used For analysis. I I.,\BOR ()XYTOCIN FORCEPS CESAREAN MEAN APCAR SCORES MF,,jN !tRS. AUC. (%) DEL. (%) I)EL. (%). 1 rain. 5 min. I 16.50 32(74.4) 11 (25.6) 7 (16.3) 7.9 9.0 11.t)4 13(30.2) 4 (9.3) 0 (0) 8.5 9.1 I P40.O01 P~O.001 [email protected] P(O. Ol t~.). 05 NS /\’~ .~,u~[’~,~rized in the table the results showed that the epidural group ~,ad si>,~,if !(’ant lv prol~mged duration of labor and a higher incidence ot both forceps I trcan section deliveries. (Only patients secti,med for failure of progress t,’~’r,, i~?cluded in the study.) A larger number of patients in t-lie epidural group rleetted oxvtocin angmentation which was also found to be required for a longer I period of time than in controls(mean 6.5 hr. v/s 4.2 hrs.) The significant difference in the one minute mean apgar scores may be exp]ained by the prolonged secured stage and mere instrumental deliveries in the study group. The sign-iii- I canoe disappears at five min,~tes. I

I 25 Society of Perinatal Obstetricians I Annual Meeting San Antonio, Texas I February, 1982 DYSTOCIA: A"DISAPPEARING" RISK FOR THE NEONATE I Sidney F. Bottoms, M.D., Victor J. Hirsch, B.A. and Robert J. Sokol, M.D. (Depart- ment of Obstetrics and Gynecology, Cleveland Metropolitan General Hospital/Case Western Reserve University)

I The association of dystocia with increased neonatal morbidity and mortality was well documented more than i0 years ago. In view of the numerous changes in ob- stetrical practice occurring during the past decade, our purpose in this study was I to evaluate the current risks of dystocia for the neonate.

In order to assess the neonatal risks specifically attributable to dystocia, we studied specific dysfunctional labor patterns (diagnosed prospectiyely by com- i puter), method of delivery, Apgar scores (assigned by labor nurse or pediatrician), and mortality in a group of patients limited to exclude risks clearly not caused by dystocia. This study population consisted of 5831 singleton, vertex, I non-low-birthweight (~ 2500 gm), viable pregnancies with spontaneous labor and no major congenital malformations recognized at birth. The study group included 69% I of all deliveries during a recent 2½ year period at our hospital. The results, according to the most severe type of dysfunctional labor pattern observed in each patient, were as follows:

I Normal Prolonged Latent Protraction Arrest Total Incidence 64.9% 0.7% 23.6% 10.8% 100.0% Midforceps Rate 0.8% (0) 2.0% 4.3% 1.5% Cesarean Rate 5.2% 25.6% 4.1% 13.4% 6.0% I Low Apgar Rate 1.2% (0) 1.3% 1.3% 1.2% Perinatal Mortality (N) 8 0 0 0 8(1.4/1,000)

The frequency of low Apgar scores (~ 6 at 5 minutes) did not vary significantly I according to labor pattern in the overall study population. In contrast, the 5.1% frequency of low Apgar scores with cesarean was 6 times the 0.9% frequency of low Apgar scores with vaginal delivery (p < 0.0001, chi-square). Among patients with I cesareans, patients with arrest dis6rders hac[ a significantly lower frequency of low Apgar scores than other patients (p < 0.05, exact test). Notably, all peri- natal deaths (i intrapartum and 7 neonatal) occurred in association with a normal I labor pattern (p < 0.05, exact test). In this group of patients, neonatal outcomes with dystocia in general and arrest disorders in particular appear to be comparable to or better than neonatal out- I comes with normal labor, giving the appearance that the risks cf dystocia~for the neonate are disappearing. This improvement in neonatal outcomes with dystocia compared to previous studies might be related to changed obstetrical management, I improved neonatal care, better general health and/or other factors. Regardless of the explanation, this improvement occurred with cesarean and midforceps rates for arrest disorders much lower than the rates reported in similar previous studies. Thus, this study suggests that it may be possible to reduce the measur- I able neonatal risks specifically related to dystocia without large increases in the rates of operative delivery. I I

27 Society of Peri~ata~ Obstctricians Annual Meeting San Antonio, Texas February, 1982

I FHR RESPONSE TO SCALP SAMPLING S.L. Clark, M.L. Gimovsky and "F.C. Miller (Department of Obstetrics and Gynecology, University of Southern California School of I.ledicine and I Nomen’s Hospital, Los Angeles County/University of Southern California Medical Center, Los Angeles, California) I Acceleration of fetal heart rate in response to various stimuli has long been considered a reliable sign of fetal well being in both the intra- partum and antepartum periods. However, there has been no correlation I between FHR acceleration and immediate fetal acid-base status. In an effort to define this correlaion, we analyzed 50 FHR tracings in early labor chosen on the basis of intrapartum scalp pH. Fifteen tracings demonstrating I fetal scalp pH < 7.20 and 35 tracings demonstrating fetal scalp pH > 7.20 were reviewed. Data regarding FHR response to endoscope placement, scalp I puncture, and resultant scalp pH were then analyzed. Scalp pH Acceleration No Acceleration > 7.28 21 0 p < .001 I 7.21 - 7.28 i0 4 p < .001 I < 7.20 0 15 p < .001 Total patients: 50

In no case did a fetus with a scalp pH S 7.20 respond to scalp puncture I with an acceleration (defined as an elevation above the baseline of 15 bpm for at least 15 seconds). Among fetuses with a scalp pH > 7.28 all responded to scalp puncture with an acceleration. Fetuses with scalp pH I in the range of 7.21 - 7.28 showed a variable response. Clinical implications are discussed. I I I I I I

29 Society of Perinatal Obstetricians I Annual Meeting San Antonio, Texas I February, 1982 I

SHOCK INDICATION BY TRANSCUTANEOUS PO2 I MEASUREMENTS IN THE SHEEP FETUS AND CATECHOLAMINE RELEASE JENSEN, A*, W.KONZEL*; E. KASTENDIECK**

*DEPT.OB-GYN., GIESSEN UNIVERSITY I **DEPT.OB-GYN., WORZBURG UNIVERSITY

Repetitive hypoxic stress induced by labor is a powerful stimulus for catecholamine release in the fetus. Increasing Epinephrine (E) and Norepinephrine (NE) release in the fetus are supposed to cause peripheral vasoconstriction and hence reduce the transcutaneously measured PO2 (tcPO?). On the basis of these principles the difference between fetal transcutaneous and arterial PO~ in man was previouslv introduced as an indicator for fetal shock condition. (KONZEL~ W; A.JENSEN: SGI, 27~h Annual Meeting; I Denver, Colorado, March 1980; Scient. Abstracts No 230, p. 137.-- JENSEN, A., W. KONZEL: Gynecol Obstet Invest. 11: pp 249-264 (~980~.

MATERIAl AND METHODS: To support these clinically so striking interrelations between I hypoxla, perlphera] vasoconstriction and increasing tc -arterial P02- difference (tc-art-P02-D) 15 respectively 6 experiments were performed, using ~ acutely instru- mented ewes at term and 3 chronic preparations.

After insertion of catheters into maternal and fetal femoral artery and vein, and I application of the tc P02-measuring device on the other hind limb of the fetus, uterine blood flow was interrupted ~I times within 30 minutes for 30,50 and 90 seconds, resp., by occlusion of the maternal descending aorta (MAO). In 15 experiments fetal heart rate (FHR), oxygen saturation (S02), relative local skin perfusion (RLP) and tc PO2 were monitored continuously. At control and at 33 minutes blood samples were I taken to measure pH, P02, SO2, Lacatate, (NE) and (E).

RESULTS: During the 11 hypoxic episodes, each of 60 seconds duration, FHR, S09, RLP ~tc POo all fell and showed almost total recovery after the release of~the I MAO. All chan~es happened in good coordination with the oxygen saturation of the . fetal blood. The prolongation of each hypoxic episode from 60 to 90 seconds led to more pronounced FHR decelerations accompanied by a rapid fall of the tc PO2 to zero, a mmked decrease of the RLP and severe acidosis. In contrast to the MAO o~ 60 seconds the tc PO2 and the RLP did not recover when the MAO was extended to 90 seconds: I Due to hypoxic induced peripheral vasoconstriction a tc-art-P%-D had developed. Tc-art-POo-D and NE exhibited a significant logarithmic relationship (tc-art. P02-D= 9.3 +2.5 %(N~, r = 0,64,2~0.001), whereas E did not correlate. Due to the reduction of uterine blood flow by MAO for 30,60 or 90 sec., respectively,the deceleration area (DA) of FHR increased. DA and catecholamine concentrations corre- I late~ exponent~ally: e ~NA) = 8,41 e0"001 " DA; r = 0,76; 2 0,01; (A)~o = 0,03 O.O02.DA r = 0,6~ 2~3~0 011f the (CA) are correlated with the fetal ~?ood pH, (NE) turns out to be the’mSre sensitive3~arameter INE) = 3.0 ¯ 1024 ~7.7 pH? I r = -0,82, 2~<0.001 ; (A) = 2.7 ¯ 10 7e -12.1 p , r = - 0.84. 2~-. 0.001}. Even minor decrease of pH by hypoxia generated a marked increase of the plasma (NE) whereas pH values below 7.20 were necessary to produce a significant increase of (E). On the strength of anaerobic metabolism of glucose Lactate (L) exhibited ~ comparable I relationship to plasma ICA) concentrations as blood pH values did. CONCLUSIONS: Repetitive hypoxic stress in terms of a reduction of uterine blood flow produces-FHR decelerations an~a considerable increase of plasma catecholamine concentrations in the fetus. Thus tcPO2 readings decline. Increasing catecholamine I concentrations are accompanied by a growing transcutaneous-arterial PO2-difference, decreasing blood DH values ~nd concomitant rising Lactate concentrations. Therefore transcutaneous PO2 measurements are valid for early defection of an impending fetal shock syndrome. FHR monitoring together with tcPO2 monitoring seem to provide I maximum security for the endangered baby during h~gh risk deliveries. I

I 31 Society of Perinatal Obstetricians Annual Meeting San Antonio, Texas February, 1982

EFFECTS OF OXYGEN ADMINISTRATION ON FETAL-MATERNAL PHYSIOLOGY I IN LABOR

F. Silverman, M.D., C. Antoine, M.D., I. Lustig, M.D. and I B. K. Young, M.D. (Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, New York University I Me([ical Center and School of Medicine, New York, N.Y.) Of 47 attempted, 31 patients were evaluated in labor with continuous maternal and fetal monitoring of all parameters. Mothers were monitored continuously for heart rate, electro- I cardiogram, respiratory activity, uterine contractions, and transcutaneous p02. Simultaneously the fetus was evaluated intermittently with scalp blood analysis for pH, P02, pC02, I HC03-, base excess and serum lactate levels, and continuously with a tissue pH electrode and a transcutaneous p02 sensor. Good correlation between maternal arterial p02 and maternal I transcutaneous p02 was found, as well as between fetal trans- cutaneous p02 and.p02 measured in scalp samples. Fetal tissue pH values and pH in intermittent scalp samples showed a weaker correlation. Response of maternal Cp02 to 8-10 i/min of 24% I oxygen by mask was observed. Results demonstrated that fetal intermittent and transcutaneous p02 was affected primarily by changes in maternal p02 with and without additional oxygen I administration. Changes ±n fetal p02 were not always observed in response to maternal p02 alterations, however when present, they followed the same pattern. No constant relationship I between fetal heart rate patterns and fetal p02 were found. There was also no constant relationship between maternal p02 and fetal heart rate pattern. Intermittent and continuous fetal pH measurements were not related to maternal P02, 02 I administrgtion, or fetal oxygen tension. The most consistent finding was the decline of the fetal Cp02 with uterine I contractions. I I I I I I 33 Society of Perinatal Obstetricians I Annual Meeting San Antonio, Texas I February, 1982 FOLLOWUP OF LOW BIRTHWEIGHT INFANTS: RELATIONSHIP BETWEEN MODE OF DELIVERY, FETAL PRESENTATION, FETAL DISTRESS, AND EARLY DEVELOPMENTAL OUTCOME

I N. Hardt, M.D., M. Ogburn, M.H.A., M. Resnick, Ed.D,, A. Cruz, M.D. (Department of Obstetrics and Gynecology and Department of Pediatrics, University of Florida, I College of Medicine, Gainesville, Florida) Dilemmas exist in the obstetric care of low [irthwe~ght infants (less than 1500 g). Current practices reflect concern for both survival and for quality of life. I Limited developmental data is available for this group. Available data supports improved outcome in those infants treated in neonatal intensive care units (NICU). Little is known about the contribution of obstetric factors to development. The study evaluates the relationship between mode of delivery, fetal presentation, I fetal distress, and development at one year of age.

The study group included 140 low birthweight infants (LBWI) enrolled in a develop- I mental followup program. Assessment was performed using Bayley Scale of Infant Development. Mental Developmental Index (MDI) and Physical Developmental Index (PDI) at an adjusted age of 12 months were used to calculate mean values for the groups. Neurologic exam was performed simultaneously. The MDI and PDI has a X of i i00 with a standard deviation (SD) of 16. Infants with MDI or PDI >2 SD below the mean (J69) were considered delayed. Infants with MDI or PDI > i SD below the mean (70-84) were considered at risk for delay. Maternal obstetric records and fetal I monitor tracings of the 140 infants were reviewed. Fetal presentation, method of delivery, and evidence of fetal distress was evaluated. These variables were com- I pared to length of stay in NICU, MDI, PDI and neurological findings. No statistically significant difference in MDI or PDI were observed between infant: delivered vaginally and by cesarean section. Infants of breech presentation had similar MDI and PDI to those of vertex, regardless of mode of delivery. Fetal dis- I tress was not associated with statistically significant differences in MDI and PDIo

Twenty children (14%) carried a diagnosis of hydrocephalus or cerebral palsy at I their last examination (age 1-4 years). Fourteen were delivered by cesarean sec- tion. No significant association between mode of delivery and neurologic abnormal- ities was found. A high association between neurological and developmental assess-. I ments was noted. Seventeen of the 20 children had 12 month MDI or PDI s~res > i SD below the mean. Ten of 17 were delayed and 7 were at risk for delay. The other 3 neurologically abnormal children had MDI and PDI values in the normal range at 12 months. Two children without neurologic abnormality had MDI or PDI scores con- I sistent with delay at 12 months, and 9 children were at risk for delay. In all, 32 children had had neurologic abnormality, developmental delay, or risk for devel- I opmental delay. The remaining 108 were normal. The 12 month followup data would indicate that method of delivery, fetal presenta- tion, and fetal distress are not associated with significant differences in early I development. Seventy seven percent of surviving LBWI were without neurologic ab- normality or developmental delay at one year of age. I I

37 I Society of Per±natal Obstetricians Armua[ Fleeting San Antonio, Texas I February, 1982

PLASMA VOLUME DETERMINATION IN PREGNANCIES COMPLICATED I BY CHRONIC HYPERTENSION

Baha M. Sibai, M.D., Thomas N. Abdella, M.D., Garland D. Anderson, M.D., Jack H. I McCubbin, M.D. (Div!sion of Maternal/Fetal Medicine, Department of Obstetrics and Gynecology, University of Tennessee College of Medicine).

I The purpose of this blinded, prospective study was to evaluate the potential use- fulness of plasma volume determinations in the clinical management of pregnancies complicated by chronic hypertension. The study group consisted of 31 pregnant I women with a documented history of severe chronic hypertension. Using the Evan’s Blue dye-dilution technique apparent plasma volume was serially measured at 20-25 weeks gestation, 26-29 weeks gestation and 8 weeks post-partum. The results of I these tests were not made available to the primary physicians caring for the patients. The relationship of plasma volume to clinical course, per±natal outcome and other laboratory findings was subsequently analyzed.

I The patients were categorized into three groups based on infant outcome: i. appropriate for gestational age (AGA); 2. small for gestational age (SGA); 3. intrauterine fetal demise (IUFD). The average age, parity, height, and weight I of the patients in each subgroup were similar. There were no significant dif- ferences in mean arterial blood pressure or duration of hypertensi

These results suggest that plasma volume measurements may be useful in the I management of pregnancies complicated by chronic hypertension. Further prospectiw research is needed to determine if the clinical application of plasma volume determinations can improve per±natal outcome in these high-risk pregnancies. I TABLE I: Mean plasma volume in ml/Kg (~ 1S.D.)

(a)AGA (b)SGA (c)IUFD significance

I 20-25 weeks gest. 45.5 + 8.8 42.2 + 6.5 35.8 + 2.6 avsb p>0.1 bvsc p

I 39 Society of Perinatal Obstetricians I Annual Meeting San Antonio, Texas February, 1982

I ANTEPARTUM PREDICTION OF THE POSTMATURE INFANT

William Rayburn, M.D., Mary E. Motley, L.P.N., Laurence Stempel, M.D., R. Michael Gendreau, M.D., I Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, Ohio.

Approximately 7% of all pregnancies remain undelivcred for two or more weeks beyond the esti- I mated date of confinement. An increased risk of pcrinatal morbidity and mortality has been reported, especially among those fetuses with signs of postmaturity. This prospective investigation was there- fore undertaken between September 1979 and May 1981 to determine whether present antepartum fetal assessment methods used in our clinic were helpful in predicting a postmature infant. Thirty- I two (22%) of 147 strictly defined postdate pregnancies delivered infants with classic signs of post- maturity (skin changes and long, lean bodies). I Clinical findings, fetal heart rate testing (primarily nonstress tests), and fetal movement charting were not found to be reliable predictors. Single-voided estrogen/creatinine (E/C) determinations were significantly (p < .0001) lower among fetuses with subsequent findings of postmaturity when com- pared to those without such signs, and all subnormal values were associated with postmature infants. I Twenty-four of 29 pregnancies with oligohydramnios diagnosed by ultrasonography delivered post- mature infants, while 110 of 118 pregnancies with either no pockets or an adequate volume of am- I niotic fluid delivered infants who were not postmature. Predictive of Predictive of Postmature Term-Appearing I Sensitivity Specificity Infant Infant Fetal heart rate testing 3/32 (9%) 115/115 (100%) 3/3 (100%) 115/144 (80%)

I Fetal movement charting 0/32 (0%) 1151115 (100%) 010 (-Yo) 1151147 (78%)

Urine cstrogen[creatinine 12/15 (80%) 50/50 (100%) 12112(100%) 50/53 (94%)

I Grade III placenta 15/15 (100%) 7162 (11%) 15170 (21%) 717 (100%) I Oligohydramnios 24/32 (75%) 1101115 (96%) 24129 (83%) 110/118 (93%) Visible fetal body motion 11[32 (34%) 1091115 (95%) 11/17 (65%) 109/130 (84%) I Fetal breathing 15/32 (47%) 83/115 (72%) 15147 (32%) 83/100 (83%)

Of the present fetal surveillance techniques used in our clinic, subnormal E/C levels and ultrasonic I evidence of oligohydramnios were found to be the most reliable predictors of a postmature infant. We now recommend that estrogen or estriol determinations be obtained routinely in those postdate preg- nancies without apparent complications and when the cervix is unripe. Real-time ultrasound examina- tion should also be performed to search for oligohydramnios. Should an abnormal result be present, I delivery with optimal fetal monitoring and precautions against meconium aspiration are advised. I I I

41 Society of Perinatal Obstetricians Annual Meeting San Antonio, Texas February, 1982

MYO-INOSITOL HOMEOSTASIS IN FETAL RABBIT LUNG

J. G. Quirk, M.D.,Ph.D..J.E. Bleasdale, Ph.D., Departments of Obstetrics and Gynecology and Biochemistry, Cecil H. and Ida Green Center for Reproductive Biology Sciences, University of Texas Southwestern Medical School at Dallas, Texas 75235 (Sponsor: N. F. Gant, M.D.

The mechanism whereby the ratio of phosphatidylglycerol to phosphatidyl- insoito] (PG/PI) in lung surfactant increases during fetal lung deve!opment is unknown. PG and PI are each synthesized from CDP-diglyceride. Late in gestation, fetal rabbit lungs actively synthesize PI for surfactant. In this species, only at birth does the PI content of surfactant decrease with a concomittant increase in PG. To examine the possibility that this develop- mental change is influenced by the availability of myo-inositol, potential sources of myo-inositol for the developing rabbit lung were investigated. On day 28 of gestation the myo-inositol content of fetal rabbit lung tissue was (1.9 nmol x g wet weight) the same as that of adult lung tissue. At this time in gestation, the activity of D-glucose-6-phosphate:L-myo-inos~ol-1- phosphate cyclase (cyclase) in fetal lung tissue (81.0±9.0 nmol x g tissue] x h-*) was ~igher than that found in adult lung tissue (23.2±1.0 nmol x g-* tissue x ~-*) and was ~lso hiaher than that of day 28 fetal liver (17.5±3.3 nmol x g-- tissue x h-*) wher~ a similar developmental decrease in cyclase activity was observed. Day 28 fetal rabbit lung tissue was found also to take up m~o-inositol by a specific, energy-dependent, Na -requiring mechanism. Half-maximal uptake of myo-inositol by fetal rabbit lung slices was observed when the concentration of myo-inositol in the incubation mediL~nwas 85 #M. When the myo-inositol concentration was I mM (but not 100 ~M) the addition of glucose (5.5 mM, but not fructose, pyruvate, lactate or dihydroxyacetone) stimulated myo-inositol-uptake approximately 80%. A similar myo-inositol- uptake mechanism was observed in adult rabbit lung. However, during most of fetal life the serum concentration of myo-inositol is high enough to saturate the myo-inositol uptake mechanism of the fetal lungs, but adult serum levels of myo-inositol are insufficient to support maximal uptake of myo-inositol by adult lungs. On day 28 of gestation the conentration of myo-inositol in fetal serum (175.1±12.0 MM) was much less than on day 25 of gestation, but more than that found on day 30 of gestation. A post-partum increase in the concentration of myo-inositol in serum was followed by a rapid decline toward the levels of myo-inositol found in adult serum. The concentration of myo-inositol in the serum of pregnant adult female rabbits (47.5±5.5 ~M) was significantly lower than that of non-pregnant adult female rabbits (77.9±9.2 MM). The large amount of myo-inositol in fetal rabbit serum probably originates from the placent~ where on day 28 of gestation a very high cyclase activity (527±64 nmol x g tissue x h-*) was measured. The gestational decline in serum myo-inositol con- centration, together with decreasing cyclase activity of the lungs is consistent with the view that maturation of the lungs is accompanied by decreased avail- ability of myo-inositol. In the fetus of the woman with diabetes mellitis (Class A,B and C), the developmental change from the production of lung surfactant rich in PI to one rich in PG is delayed. The cause of the delay is unknown. However it is known that the diabetic patient is inositol intolerant as well as glucose intolerant. If an imbalance in inositol homeostasis in the pregnant diabetic woman alters inositol metabolism in her fetus, this may affect adversely its production of surfactant.

43 Society of Perinatal Obstetricians Annual Meeting San Antonio, Texas February, 1982

ACCELERATED PULMONARY MATURITY AS MEASURED BY THE BECKMAN FSI CASSETTE: I A RELIABLE DISCRIMINATOR BETWEEN THE SGA AND AGA VERY PRETERM FETUS J. Lipshitz, W.D. Whybrew, G.D. Anderson, B. Sibai, T. Abdella, J. Dacus (Division of Maternal/Fetal Medicine, Department of Obstetrics and Gynecology, I University of Tennessee College of ~edicine, Memphis, Tennessee)

I Amniotic fluid was obtained within 72 hours of delivery from 71 mothers whose babies were_< 34 weeks gestation and/or < 2,000 gm. The fluid was centrifuged at i000 x G for five minutes. One aliquot of fluid was used to perform an L/S ratio, which was used for clinical management decisions. The remaining fluid was I frozen at -20°C. When all the specimens were collected, they were thawed and 0.5 ml amniotic fluid was added to each of six test tubes containing different volumes of 95% (V/V) ethanol in the Beckman FSI Cassette. The Cassette was then I shaken vigorously for 30 seconds, and allowed to settle for 15 seconds. The air- liquid interface was observed for the presence of an uninterupted ring of foam. The FSI value is designated as the highest ethanol volume fraction capable of I supporting a stable ring of foam. Results of the FSI tests were reported without knowledge of the L/S ratio or clinical outcome of the babies.. Gestational age iwas determined by pediatric evaluation.

I Of the 71 babies, 62 were < 2,000 gm, 48 were < 34 weeks gestation, 29 were small for gestational age (< 10th percentile - SGA) and ii had severe respiratory I distress syndrome (RDS). The following conclusions carl be drawn for the results (See Table). I (i) Intrauterine growth retardation accelerates functional lung maturity in the very preterm fetus. (2) The FSI demonstrated maturity (> 47) in 80-90% of the SGA babies whereas the L/S ratio failed to do so in 50-60%. (3) The FSI test can be used to distinguish the SGA from the AGA fetus in the < 1500 gm and < 32 week I groups (the weight and gestational age may vary according to the population studied). (4) As gestational age and weight increases beyond 32 weeks and 1500 gm, the ability of the FSI test to discriminate between the SGA and AGA fetus is I progressively lost due to the onset of "normal" lung maturity. (5) An immature FSI (< 47) was predictive of RDS in 61% of the < 2,000 gm babies and 77% of the I ~ 34 week group. The L/S ratio was predictive in 40% and 42% respectively. TEST 26 - 34 wks Gest 26- 32 wks Gest < 1500 GM ]500 - 1999 GM I FSI SGA AGA P-VALUE SGA AGA P-VALUE SGA AGA P-VALUE SGA AGA P-VAI, UE > 47 19 16 13 3 18 0 7 19 < .01 < .002 < .001 .87 I < 47 1 12(lo) 0 7(7) 2 7(5) 2 7(6) L/S

> 2:1 I0 14 5 2 8 0 7 18 I .77 .60 .13 .82 < 2:1 I0 14(10) 8 8(7) 12 7(5) 2 8(6)

P-value derived from X2-Test with Yates Correction I Values in parenthesis = number of neonates with RDS I 45 Society of Per±natal Obstetricians Annual Meeting San Antonio, Texas February, 1982

THE USE OF AMNIOTIC FLUID 3-METHYLHISTIDIbE TO CREATININE MOLAR RATIO FOR I THE DIAGNOSIS OF INTRAUTERINE GROWTH RETARDATION

M. Miodovnik, M.D., J. P. Lavin, M.D., Z. Gimmon, M.D., L. L. Edwards, B.A., I J. Hill, R.N., J. E. Fischer, M.D., T. P. Barden, M.D. (The Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology and The Hyperalimentation Unit, Department of Surgery, University of Cincinnati I Medical Center, Cincinnati, Ohio) In order to determine if the level of the amniotic fluid 3-methylhistidine to creatinine molar ratio (3MH:CR) could prove useful for the antepartum I detection of intrauterine growth retardation (IUGR), the 3MH:CR was retrospectively determined in three groups of human amniotic fluids. Group A consisted of amniotic fluids from pregnancies yielding IUGR I fetuses whose birth weight was less than or equal to the tenth percentile for gestational age; group B consisted of amniotic fluid from pregnancies yielding infants whose birth weight was greater than the tenth but less than or equal to the 25th percentile for gestational age; group C consisted I of amniotic fluids from pregnancies yielding infants whose birth weight was greater than the 25th but less than or equal to the 75th percentile for gestational age, The mean 3MH:CR x 10-3 for groups A, B, and C were I 15.9 ± 1.9, 5.4 ± 0.8, and 6.2 ± 0.5 respectively. The mean 3MH:CR x 10-3 was statistically different between group A and group B (p < 0.001) and between group A and group C (p < 0.001), but not statistically different I between the two control groups. Employing an upper limit of normal of 8 for the 3MH:CR x 10-3, 13 of 15 IUGR neonates were correctly identified as IUGR, and 23 of 27 neonates were correctly identified as being of normal birth weight for gestational age (sensitivity 87.6%, selectivity 85.2%, I incidence of correct diagnosis 85.7%). No consistent relationship was shown to exist between maternal serum and amniotic fluid 3-methylhistidine level. There was no statistically significant relationship between I 3MH:CR x 10-3 and gestational age. The comparison of the data generated in this study to that obtained with previously reported ultrasonic and biochemical techniques suggest that the amniotic fluid 3MH:CR ratio may I prove helpful in establishing the antenatal diagnosis of IUGR, particularly in cases where the gestational age is uncertain. I I I I I

47 Society of Per±natal Obstetricians Annual Meeting San Antonio, Texas February, 1982

MATERNAL DIETARY RESTRICTION AND REPLETION: EFFECTS ON I CARDIAC OUTPUT AND PLACENTAL BLOOD FLOW IN THE RAT R.A. Ahokas, Ph.D., G.D. Anderson, M.D., J. Lipshitz, M.D. and K. Broyles, B.S. (Department of Obstetrics and Gynecology, Division of Maternal and Fetal Medi- I cine, University of Tennessee College of Medicine, Memphis, TN)

Maternal cardiac output (CO), total uterine blood flow (UBF) and placental blood I flow (PBF) were measured in pregnant rats fed; I) ad libitum throughout gestation (control), 2) 50% of the average daily amount of food consumed by the controls from day 5 on (restricted), and 3) 50% of the average daily amount of food con- sumed by the controls from day 5-14, but ad libitum from day 15 on (repleted). I On days 14, 20 and 21, dams from each group were anesthetized with pentobarbitol (30 mg/kg) and 15 u radiolabelled microspheres were flushed into the left ventri- cle of the heart while an arterial reference blood sample was withdrawn at a rate I of 0.5 ml/min. Dietary restriction throughout gestation caused a 20% reduction in mean fetal weight relative to the controls (4.637 ± 0.II0 vs 5.814 ± 0.888 g) by day 21, while repletion of the diet of restricted dams from day 15-21 caused I only a 4% reduction in mean fetal weight (5.542 ± 0.098 g). Total CO was reduced 26-30% by dietary restriction as early as day 14 of gestation, and dietary reple- tion from day 15 on did not significantly increase CO (see table). CO per unit body weight was similar in all groups at all ages. The decreased CO was due to I decreases in both heart rate and stroke volume, and mean arterial blood pressure was similar in all groups. There was no significant difference in UBF or PBF between controls and diet restricted dams at day 14 of gestation. By day 20 and I 21, however, there was a 64% reduction in UBF and PBF in the restricted dams which resulted from the decreased CO as well as a 33-44% reduction in the fraction of CO (%C0) distributed to the uterus and placentas (see table). Dietary repletion I increased UBF and PBF to near control values primarily by increasing the fraction of CO distributed to the uterus and placentas.

GESTATIONAL DIETARY CO UBF PBF I AGE REGIMEN ml/min % CO ml/min %C0 ml/min ml/min/g Control 85.7±9.9 1.4±0.1 1.3±0.3 .32±.02 .28±.04 .13±.02 I 14 days Restricted 55.9±6.8* 1.6±0.1 0.9±0.1 .35±.07 .18±.02 .14±.01 Control 110.5±6.7 7.9±0.3 8.8±0.6 6.2±0.2 7.0±0.5 1.0±0.I 20 days Restricted 78.8±6.9* 5.2±0.8* 3.9±0.4* 3.3±0.5* 2.5±0.2* 0.6±0.1" I Repleted 91.1±8.1 9~3±1.5± 7.9±0.6± 7.7±1.4± 6.5±0.6± I.I±0.I± Control 108.6±10.6 10.6±0.9 II.0±0.9 8.9±0.7 9.3±0.8 1.4±0.1 21 days Restricted 75.7±8.4* 6.9±1.2" 4.8±0.7* 5.5±1.1" 3.8±0.6* 0.8±0.1" I Repleted 83.4±8.4 10.7±1.54 8.7±1.41 9.3±1.31 7.5±1.2± 1.4±0.2± Values represent mean ± SEM. *Significantly different from the control P < 0.05. I ±Significantly different from the restricted group P < 0.05. The results strongly suggest that maternal malnutrition induced fetal growth re- tardation may be the result of inadequate expansion of maternal CO and a redistri- I bution of blood away from the placentas reducing the supply of nutrients available for fetal growth. When the maternal nutrient supply is again adequate normal blood flow to the uterus and placentas is established and fetal growth is I increased.

I 49 Society of Perinata[ Obstetricians I Annual bleeting San Antonio, Texas I February, 1982 NORMAL PREGNANCY IS A STATE OF PIIYSIOLOCIC ABSORPTIVE IIYPI{RCALCLURIA. Coustan, M.D., N.D. Ravin, M.D., 3.M. Certner, M.D.,-A.S. K] iger, ~[.l)., and A.E. Broadus, M.D. (Departments of Obstet~-[es and Gyncco!ozy, Pedfatrics, I Medicine, Yale Medical School, New flaw, n, (’.t.) "The term newborn infant wekzhing 3.6 kg coutains ~pproximately 28 ~,,m calcium, all of which must be transferred lcom the mother. ]n order to supply I this extra calcium for the fetus, authocit ic~{ have recommended calcium supp]e-- mentation for pregnant women, increasing the daily calcium intake [o anywhere from 1.2 to 2 gm daily. I Increased circulating 1,25-dihydroxyvitamin D (1,25-(0H) 2D) during normal pregnancy has recently been reported. This observation is in keeping with pre- vious studies documenting increased intestinal calcium absorption and strongly I positive calcium balance during pregnancy, and these aIterations have been wkdcly regarded as representing physiological adjustments to fetal, mineral demands. The ialternate view, that the increase in 1,252(01I)2D in thea maternal circulation might anticipate rather than reflect fetal mineral demands, and that calcium supple- I mentation in this setting might be associated with an undesirable maternal exce~{s of calcium, has not been considered. In order to systematically evaluate the various parameters of calcium recta- I bolism in pregnancy, 28 studies were performed kn 12 normal women during one m()re t_rimesters of pregnancy, t,;,~ch study consisted of: n) the measurement o[ 24- I hour calcium exc~-ekion ou a modestly ~;~tl~plemented (~{()(3-12(]() rag) calcium SOriUll c[lJcium, and l]lasm

i ii 95.5+32.3 0.10+.06 1.60+0.69 258+124 0.21+.07 9.2+0.4 I 2 9 I16.0~33.5 0.125.06 2.1551.i3 3305145 0.245.09 8.950.2 3 8 119.6531.0 0. Ii$~ 06 1.9150.74 346~189 0.235.11 8.6~0. I I ~orma]. Value ~65 ~.I.6 <2.50 "<’300 < 0.20 ~ q.] The mean values for plasma ],25-(()}1)~)]), calcium excretion, and intestinal :alcium absorption were approximately twi~e no~’mal throughout pregnancy. These :hanges were observed as early as the first trimes[-c~-. The peak values for I ium excretion occurred during the thlrd trimester, the period oi: m~x:imal ~inera] demand and the per~od during which preview,s dozma wou~d have prcdicttM low ~alues. Fasting calcit~m excretion and NcAVIP ~-emained normal -in each trimest~.~-, I that the hypercalciuria was clearly absorptive in nature. It was of ~nterest th~L mean 1,25-(O1{)2D levels and 24 hour ur-inary calcium excret-ion in the last two mesters of pregnancy were as high as, or higher than, those found iu 35 wel characLerized non-pregnant patients witl~ absorptive hypercalc]uria (mean 1,25-(O[1) I 2D levels 79 pg/ml, mean 24 hour urine calcium excretion 353 rag/day. It is concluded that pregnancy, even in its very early stages, is a state of physiologic absorptive hypercalciuria. This cannot be explained by changes in I renal plasma flow alone, since fasting calcium excretion is not el_crated. The routine supplementaion of dietary calcinm during pregnancy m~st be brought I quest ion.

51 Society of Perinatal Obstetricians Annual Meeting I San Antonio, Texas February, 1982

I Effect of Calcium Supplementation on Blood Pressure in Normal Pregnant Women J.M. Belizan, M.D., Ph.D., and Jose Villar, M.D., M.P.H., M.Sc., Department of Obstetrics, University of Rosario, Argentina and Departments of Maternal and Child I Health and OB/GYN - The Johns Hopkins University, Baltimore, Maryland 21205 In a previous report, we suggested that calcium intake could be inversely re- lated to P.I.H., in the sense that women with low calcium intake would have a higher mean blood pressure (BP), predisposing them to develop P.I.H., (Belizan and Villar, I A.J.C’.N., 33:2202, 1980). Further, Ca-deprived pregnant and non-pregnant rats had significantly higher mean B.P. when compared with the normal Ca diet control group (Belizan, et al., A.J.O.G., 141:163, 1981). Here we report on a study of 36 normal I pregnant women, ~ith single fetus, from the 15th week of amenorrhea. They were ass- igned to a 1 g elemental Ca supplement g~oup (n=ll), To a 2 g elemental Ca supple- ment group (n=ll), and to a placebo group (n=14). B.P. was measured in lateral, i dorsal and seated positions. Five measures were taken in each position during every session and their mean values were used in the analysis. A 24 hour dietary recall was performed five times during gestation for each subject at her home. No differ- ences were observed at basal values of age, parity, blood pressure, Ca intake and ¯ ! weight at the first visit among the three groups. Total daily Ca intake (without the supplementation) was similar in the three groups throughout pregnancy with a range between 515-971mg/day. As Figure i shows, diastolic BP had declined in the I two Ca groups by the 6th week after the beginning of treatment by 6-9% of the initial value when compared with the placebo group (p<0.05). By the 32nd week both control and 1 g Ca groups showed a rise of diastolic BP while the 2 g Ca group remained Sig- nificantly lower (p<0.05) at the 36th week of gestation. Preliminary laboratory re- i sults suggest ~hat this effect may be mediated by a reduction of parathormone levels as a consequence of the high Ca intake. This study gives support to the hypothesis that high Ca intake can reduce the chances to develop P.I.H., .by lowering diastolic I BP rise i~5_the third trimester of .pregnancy. I

I Beginning of " I

Normal Pregnant I DIASTOLIC ~- C~ BLOOD ~’~ Women (n=36) PRESSURE (X + I.S.E.) *p<0.05 ~NOVA I vs Control Grou ( Dorsal i position ) I I I i I 53 Society of Perinata[ Obstetricians Annual Meeting I San Antonio, Texas February, 1982 I AMNIOTIC FLUID ERYTIIROCYTES. A TECfthbt ~’~, FOR iS{ !,A’7!{)N AND POSSIBLE I UTILIZATION IN ANTENATAL DIAGNOSIS D.M. lk~ran, Ph.D., fI.E. Fudel , M.D., F.A, and Mole~’ular Biology, ,~nd Obstetrics and I Section, Medical College of Georgia, Augusta, Georgia). Ninety-Seven Amniotic fluid (AF) specimens were obtained from 73 patients at th~: time of clinically indicated an~]iocenteses and were studied for the prcs~:nce, I quantitq and type of er’ythrocgtes. The am~foc~.,nteses were performed -~ varq~n,] gestational ages; 13 to 39 week’s, the ~joritg (78%) were from third t_rifi~estt,i gestations. The specimens were centrifuged, the cell pellet was then !a~]~.~r’cd on to a discontinous hypaque gradient (22% layezed on 24%), then cwntr/fugod I and the red cells(RBCs) at the interface Detween the 2 hypaque densi£i{:s retr[~t,,,d with a Pasteur pipet. Th~) conc{,ntration of the RBCs was subsequentl[] d~)~r’mi[;c,~ with a he~tocvto~ter, ff the[’e we[e >100,000 RBCs recovered, the r,itio of I F-cells (Hb-F containing RBCs) was deter~ned by an indirect i~nunofluorescen~" technique utilizing a rabbit anti-human HbF serum and a fluorescir~-con/ugat,=’d I goat anti- rabbit i~unoglobul.fn serum. There w(,’,e 18 gr{,ssly blood~] sp~t..imens that were electively included in the study. Of the ren~ining 79 "cl~:~ar" samples i0 (13%) showed a pink ~:ell pelle,t on centrifugation indicating the presence el at l~,,~.;t 5x[O6 l{l{Cs. ’l’lu.. }e~ining I 69 (~7%) samples lacked any visible indication of the presence of RBCs, however 35 s.~mples (or 44% of all "clear" samples) had microscopically detectab.le (>I000) RBCs. Out of the 3i samples containinq :’Io5 RBCs, 18 wor~ subj<,cted I to the i~unofluorescent stud~]. The F-cell ratio ranged from ~-97% with an aver’age of 23% indicating that the F-ceils an are at least partly fetatly I de r i ved. " Using this technique of r~;~<’s isolation, we wore able to demonstrate the presence of ,~ signifficant nu~r ~f RBCs - that are at least partially of fetal origin - in "clear" AF obtained at amniocentesis. Using available antibodies to I diff(~rent hen~globin typms, it is possible to use these RBCS for the in utero diagnosis of cert,~in he~,~,IJ.~hinoI,ath.ies such as sickle cell anemia, a~d ~]ybe other red cell a~nalies. This technique is probably feasible in 50-60% of all I amniocont~ses. It ta~:es only hours to ~sofate th(, RBC~, to determine the F-cell ratio and then proceed ~o perform the defintive test in question. I lts succosscul us~~ m~ c,bivate the need for fetal blood sampling through fetoscopy - a much more hazardous procedure than ar~iocentesis - in a least I some Of the pat.fonts requesting antenat~l diagnosis. I I I I 55 Society of Perinatal Obstetricians Annual Meeting I San Antonio, Texas February, 1982

I ABSTRACT

I TITLE: FETAL ACTIVITY PERIODS IN DIABETIC AND NON-DIABETIC PREGNANCIES CLEVELAND METROPOLITAN GENERAL HOSPITAL, DIERKER, L.J., PILLAY, S., I SOROKIN, Y. AND ROSEN, M.G. Behavior after birth can be described in terms of sleep and awake states defined on the basis of observations of eye, breathing and body movements, heart rate variability, EMG and EEG recordings. Observations of human fetal behavior I are more limited for ethical reasons, but can be described in terms of heart rate variability, body movements and breathing movements. The ~resent study was undertaken to describe changes in active and quiet periods of fetal behavior I defined on the basis of heart rate variability and fetal movements in diabetic women studied at 28 to 32 weeks and at 36 to 40 weeks gestational age and compare them to a group of normal AGA fetuses at the same ~estational age. I Patients were studied after meals in a quiet room in the semi-~owler position. FHR was detected using abdominal fetal ECG. Fetal movements were detected using two tocodynamometers on the maternal abdomen. Recordings were I displayed on a 4-channel recorder at 30 cm per minute. Each one minute epoch was defined as active or quiet on the following criterian: Quiet:long term (I minute) variability <15 beats per minute and no fetal movements >i second in duration. One minute epochs not fulfilling these two criteria were classified I as active. An active or quiet period was defined as three consecutive active or quiet epochs. A change in activity level was defined as three consecutive I epochs of the other activity level. All 17 diabetics were insulin-dependent and managed conventionally. The 34 normal patients were at low antepartum risk, delivered AGA infants at term with Apgar scores >6. Blood sugars were not evaluated durin~ the studv. No I medications were taken except for iron and vitamins. Gestational a~e at the time of the study was confirmed after birth using a Dubowitz exam. Only one fetal tracing was evaluated per patient to maintain independence I of the data. The results indicate that the number of activity periods per hour and the averaged active period and quiet period duration all showed significant differences between the 28-32 weeks group and the 36-40 weeks groum of normal I patients. TABLE If

I NORMAL DIABETIC 28-32 wk. 36-40 wk. SIGNIFICANCE 28-32 36-40 SIGNIFICANCE n=14 n=20 n=8 n=9 I PERIODS/HOUR 4.98 2.15 p < .001 4.94 4.75 N.S. ACTIVE PERIOD DURATION 16.1 36.2 p < .001 13.6 16.6 N.S.

QUIET PERIOD DURATION 16.2 26.0 p < .025 16.8 12.5 N.S. I The normal population at 36 to 40 weeks gestation had fewer active-quiet periods per hour with correspondingly longer active and quiet periods. There was no significant change between the 28-32 and 36-40 week groups in the diabetic I population. These findings suggest a delay in this apparently brain-mediated function in the diabetic population. I

57 Society of Perlnatal Obstetricians Annual Meeting San Antonio, Texas February, 1982

MATERNAL GLUCOSE VARIABILITY AND NEONATAL;OUTCOME IN THE PREGNANT DIABETIC R. Artal," M.D., S.H. Golde, M.D., J. Gratac6s, M.D., S.N. McClellan, M.D., M. Montoro, M.D., Jo Mestman, M.D. (Department of Obstetrics and Gynecology, Women’s Hospital, LAC-USC Medical Center, Los Angeles, California) Maternal ~lucose control is considered the major determinant of neo- natal complications (NNC) among infants of diabetic mothers (IDM). This study was undertaken to evaluate the correlation between mater- nal glucose variability and neonatal outcome. 142 pregnant, insulin dependent diabetics were stu~ied~ All patients were managed identi- cally and had been hospitalized forat.least 21 days Drior to deliv- ery. A coefficient of variation (CV) was established for the daily fasting to 4:00 p.m. plasma glucose and correlated to the incidence of neonatal complications. These results are shown below. Hyper- glycemia and hypoglycemia are defined as plasma glucose >200 and < 60, respectively¯ The data was analyzed by one-way analysis of ~ariance. It appears from these data that 0 variability alone won’t necessarily insure the absence of neonatal complications.

TABLE Glucose CV (%~ 0 1-9 .i0-19 20-29 30-39 >40 p .n ii 38 41 16 22 ~ [4 _ FPG 74.8+ 104.9+ 106.6+ 123.6+ 113.5+ 146.5+ 0. 001 (mg %) 2.67 1.8-- 1.6~ 9.7- 4.3 16.0 4’:00 D.m. PG 87+ i01 .8+ 115.8+ 140.2+ 152.3+ 180+ 0. 001 (mg %) 1724 2 .4~ 2.3~ 7. i~ 4. i~ 1475 .Hypoglycemia 0 5 ¯ 0+ 3.6+ 0 2.69 4.1+ N.S. (%) -- 4 .0 1.4 -- 0.33 0.53 Hyperglycemia 0 2 .0 3.0+ 5.3 4.35+- 11.71+ 0.004 (%) .... 1.5 1.7 0.59-- 2.32-- Single NNC (%) 45 58 63 81 72 78 0.021 Mult. NNC (%) 27 18 22 43 36 35 0.07 Birth 3677+ 3723+ 3594+ 3758+ 3580+ 3816+ N.S. Weight 138- 116- 107 161 140-- 177-- *+i SEM NNC’s recorded were hypoglycemia, hyperbilirubinemia, hypocalcemia, polycythemia vera, and transient tachypnea. There were 4 stillbirths in this group of natients--3 of which had congenital malformations incompatible with life. 49 patients, having a CV of 15.56+2, gave birth tO infantswithout neonatal complications. The remaining 93 patients delivered infants with single or multiple complications and had a cv of 22.08+2 (v 0.04). - CONCLUSIONS: i) These data indicate that there is a significant association between the maternal CV for glucose in the last weeks of re~nancy and neonatal outcome; 2) episodesof hypo- and hyper- glycemia are more likely to occur in the patients with a higher CV; l.p3) there is ~Q ~orrelation betw~ C/V and birth weights,

59 I I I I I

I ABSTRACTS SUBMITTED I TO THE SOCIETY I I I I I (in alphabetical order by first author) I I I I I I Society of Perinatal Obstetricians Annual Meeting San Antonio, Texas February, 1982 I A PROSPECTIVE INVESTIGATION OF THE INDICATIONS FOR CESAREAN SECTION Thomas N. Abdella, M.D., John Ao Garbaciak, M.D., and Garland D. Anderson, M.D. (Division of Maternal/Fetal Medicine, Department of Obstetrics and Gynecology, I University of Tennessee College of Medicine, Memphis, Tennessee)

The primary purpose of this prospective study was to analyze in detail the reasons I for cesarean sections performed at our institution. In addition, the relation- ship between specific operative indications and maternal/fetal outcome was investigated.

I The population consisted of all patients undergoing cesarean births at E.H. Crump Women’s Hospital and Perinatal Center since May i, 1981. Comprehensive data zode sheets were filled out by the primary surgeons, usually prior to the start I of the operation. In each case, a specific effort was made to accurately identify and prioritize the precise reasons for the cesarean section. Detailed data to I support the primary and secondary indications was also recorded. During the first 5 months of the study, 400 of 2996 deliveries were by cesarean section, for an overall rate of 13.4%. For 133 (33.25%) the primary indication wa I previous cesarean section. Table I summarizes the indications for the remaining 267 operations.

Most previous studies addressing this subject were retrospective analyses based I on chart review, birth certificate data, or large, computerized perinatal informa- tion systems. Our results suggest that these approaches may not be sufficient to accurately determine the true reasons for cesarean sections. The decision-making I process leading to cesarean section is obviously complex. Multiple indications frequently coexist and the determination of the "primary" indication is sometimes difficult. Furthermore, the commonly reported categories for cesarean section I indications are broad and imprecise. A proper understanding of the true reasons for cesarean section requires accurate information based upon intensive prospec- I tive investigations. I TABLE I : Indications for primary ce’sarean sections primar7 secondar7 either

dystocia ...... 94(35.2%) 5(1.9%) 99(37.1%) I (arrest of dilitation - 63) (failure to descend - 31)

fetal presentation/lie ...... 76(28.5%) 22(8.2%) 98(36.7%) I (breech -59) (other - 17) 88(33.0%) I fetal distress ...... 70(26.3%) 18(6.7%) others ...... 27(10.1%) 39(14.6%) 66(24.7%) I

63 Society of Perinatal Obstetricians Annual Meeting I San Antonio, Texas February, 1982 I

THE RELATIONSHIP OF HYPERTENSIVE DISEASE TO ABRUPTIO PLACENTAE I

Thomas N. Abdella, M.D., Baha M. Sibai, M.D., James M. Hays, Jr., M.D., Garland D. Anderson, M.D. (Division of Maternal/Fetal Medicine, Department of Obstetrics and Gynecology, University of Tennessee College of Medicine, Memphis, Tennessee.) I I The primary aim of this clinically-oriented, retrospective study was to investi- gate the relationship between hypertensive disease and abruptio placentae. The study population was limited to the obstetrical service of a single institution during a recent 42-month period. Data regarding clinical course, laboratory find- I ings, and perinatal outcome was abstracted from the original medical records by the principle investigators. The information was then entered into a microcompu- ter for analysis. I

Between July i, 1977 and December 31, 1980, 274 of 24,258 deliveries at the study institution were complicated by documented abruptio placentae, for an overall in- I cidence of 1.13%. Among patients with hypertensive disorders, the incidence was substantially higher (Table I). Furthermore, abruption in the presence of hyper- tensive disease was clearly associated with an increased rate of fetal and neo- natal death. The degree of this association varied substantially with the type of I hypertensive disorder (Table II).

Pregnancies complicated by hypertensive disease are at increased risk for abruptio I placentae. The degree of this increase is clearly dependent upon the specific type of hypertensive disorder. Additional research is needed to determine the specific changes in clinical management most effective in reducing the perinatal I morbidity and mortality attributable to abruptio placentae in these high-risk pregnancies. I

TABLE I: Incidence of abruptio placentae

total births w/ abruption incidence (%) significance I

chronic hypertension 290 29 10.0% p < 0.00] pre-eclampsia 2,320 54 2.3% p < 0.001 I eclampsia 55 13 23.6% p < 0.001 all deliveries 24,258 274 I. I% I TABLE II: Perinatal mortalities associated with abruption and hypertension survi vi ng neonata] fetal total infants deaths deaths cases I no hypertension 133 (68.2%) 26 (13.3%) 36 (18.5%) 195 chronic hypertension 7 (41.2%) 0 (0%) 10 (58.8%) 17 pre-eclampsia 32 (76.2%) 4 (9.5%) 6 (14.3%) I 42 superimposed pre-eclampsia 5 (41.7%) e (16.7%) 5 (41.7%) 12 I

64 I Society of Perinatal Obstetricians I Annual Meeting San Antonio, Texas I February, 1982

I CONTEMPORARY MANAGEMENT OF THE PLACENTA PREVIA: A PROSPECTIVE EXPERIENCE AT MARTIN LUTHER KING, JR., GENERAL HOSPITAL I JANUARY 1975 - DECEMBER 1980 J. J. Arce, M.D., E. Skelton, M.D., and E. C. Davidson, Jr., M.D. Department of Obstetrics & Gynecology, Martin Luther King, Jr., I General Hospital and Charles R. Drew Postgraduate Medical School

During the period between January I, 1975 through December 31, 1980, I a study was undertaken in pregnant patients attending the Obstetric Service at Martin Luther King, Jr., General Hospital in Los Angeles, California. All patients requiring ultrasound examination in which I a finding of placenta previa was observed, were serially followed throughout gestation. A total of 186 patients were managed under this protocol. Fifty-four patients had a final diagnosis of complete I or partial placenta previa. During the same period, 26, 240 patients were delivered at this institution giving an incidence of 1:484 patients. The clinical I patient’s characteristics of revelance is presented. The overall perinatal mortality was fifty-five per thousand; There were no stillbirths. Three neonatal deaths are responsible for this figure, and one newborn died of a major congenital anomaly for a corrected I perinatal mortality of forty-six per thousand. This represents the lowest statistic in the present world literature.

I Special attention on follow-up with early hospitalization for recurrent bleeding, adequate blood replacement and serial biophysical studies including ultrasound (90%), non-stress testing (84%), and I amniocentesis (70%), to detect lung maturity are the significant measures responsible for these results on fetal survival. I I I I I I I 65 SocicEy of l~e~i~l, ~a[ Obscct~-icians Annual Meeting I San Antonio, Texas l’~ebrua ry, 1982 I BENEFITS OF ULTRASOUND FOR GENETIC AMNIOCENTESIS I

J.W. Arias, M.D., L.R. Saldana, M.D., A.R. Katz, M.D., M. Rivera-Alsina, M.D. and C.T. ’Walker, R.N. (Department of Obstetrics and Gynecology, University of I Texas Medic~l School at Houston, Houston, Texas)

Controversy exists about the routine use of ultrasound prior to genetic I amniocentesis. Some investigators have concluded that ultrasound prior to 2nd trimester amniocentesis does not reduce the incidence of bloody taps but may uncover factors which could influence future obstetrical management. I Others have noted no significant difference in the number of successful amniocentesis when comparing patients with and without sonographic aid before the procedure. We report our experience over a two year period with genetic I amniocentesis guided by sonography. Two hundred and three patients underwent 2nd trimester genetic amniocentesis. All had ultrasonic evaluation immediately prior to and following the procedure. The most fr~quen’[ indication was advanced maternal age followed by patients with previous I offspring affected by chromosome abnormalities or neural tube defects. For all procedures, a 20 gauge, 3 I/2 inch needle was used. Mean gestational age was 17.0 weeks + S.D. (1.4 weeks). The incidence of bloody taps was low I (Ii patients = 5.4%~. Placental location did not significantly influence the incidence of bloody taps. Successful sampling occurred in 88.1% of patients following a single needle insertion. Eleven patients required 2 insertions (5.4%) and 13 (6.4%) patients had three or more attempts before an adequate I sample could be obtained. Adjustments of gestational age by 2 weeks or more was done in 44 patients (21.6%) following initial sonographic assessment. Fetal loss occurred in 2 patients within one week of the amniocentesis for a I rate = .98%. Detection of congenital anomalies incompatible with life and multiple gestation during the preamniocentesis sonogram occurred in 2 patients. Five patients (2.4%) were found to have chromosome abnormalities. I These included: Trlsomy-21 (1), Mosaic Klinefelter’s syndrome (1), Robertsonian translocation (1), 47 xxx (triple x syndrome) (I), 46,xy, 9ph+ (Normal variant) (]). I Comment: From the data presented, we conclude that sonographic guidance prior to 2nd trimester genetic amniocentesis is benefical for the following rea son s : I a) It turns amniocentesis into a blindless procedure. b) G estational age can be adjusted so that alterations in future obstetrical management are less complicated based on accurate dates. I c) Early detection of multiple gestation and some major anomalies can be accomplished with obvious benefits for patients and physicians. d) In this series, the incidence of bloody taps was approximately I/2 of that reported by others. I e) Objective confirmation of fetal viability utilizing real-time ultrasonograpby before and after amniocentesis. I I 66 I Society of Perin~tal Obstetricians I Annual Meeting San Antonio, Texas I February, 1982

I VALIDITY OF TRANSCUTANEOUS PO2 (tcPO2) IN THE HUMAN FETUS

L. V. Baxi, M. D., R. H. Petrie, M. D., and L. S. James, M. D. (Section of Perinatal Obstetrics, Division of Perinatal Medicine, College of Physicians I and Surgeons of Columbia University, New York, New York) Continuous measurement of tc ¯ PO2 has attained an important place I in neonatal monitoring. Its role in fetal monitoring is still investigational. Its validity is confirmed by some and question- I ed by others. The present study investigates its validity and shows the correlation between tcPO2, capillary PO2, umbilical I arterial and venous PO2 (Uaand UvPO2) in the human fetus. Fetal capillary sampling was carried out either concurrently or at the I end of tcPO2 monitoring in 15 patients. The last tcPO2 values just prior to delivery were compared to umbilical arterial and I venous PO2 in 20 patients. The time interval between the last tcPO2 and umbilical arterial and venous PO2 varied from 40 sec- onds to a few minutes. In general there was a close agreement I of values with the capillary PO2 being higher than tcPO2 in i0 patients and lower in 5 patients. The marked difference noted I in the two values in 3 patients was due to possible faulty cap- illary PO2 value in one and faulty tcPO2 reading in the other two I which was secondary to marked caput and advanced second stage measurement. There was a poor correlation between UvPO2 and I tcPO2 with the former being uniformly higher. The correlation coefficient between UaPO2 and tcPO2 was 0.7. tcPO2 monitoring appears to be a good indicator of umbilical arterial oxygenation I in the human fetus, provided factors affecting its value are I taken into consideration. I I I 67 I Society o[ Perinatal Obstetricians Annual Meeting San Antonio, Texas February, 1982

THE PRESENCE OF AN ONCOFETAL ANTIGEN COM,.CON TO PLACENTAL AND FETAL TISSUES ON ULTRAVIOLET LIGHT AND METHYLCHOLANTHRENE I INDUCED TUMORS OF C3H AND BALBIC I~ICE

James H. Beeson, Raymond A. Daynes, and James R. Scott (Departments of I Obstetrics and Gynecology and Pathology, University of Utah, Salt Lake City, Utah 84132) I Previous studies have determined that both ultraviolet light (UV) and methylcholanthrene (MCA) induced tumors express a number of tumor antigens. The tumor specific transplan~ntigens (TSTA) are the best studied, as they represent markers unique to each individual tumor, recjardless of etiology. ! Recent evidence has established the existence of tumor-associated transplantation antigens (TATA) which are common to tumors induced with the same carcinogen (either MCA or UV). Both the TSTA and the TATA have been defined function- I ally in tumor transplantation experiments and both function as effective rejection antigens. A third type of tiJmor antigen is the tumor associated antigen (TAA). To date, TAA have only been defined by 51C~r-release I cytotoxicity assays. TAA appear to be shared by all tumors tested, regardless of etiology.

In this study, cytotoxic T-lymphocytes (CTL) generated from the popliteal I lyml~h nodes of C3H strain mice which were immunized with a UV ind~uced tumor, were capable of effecting lysis of both the immunizing tumor as well as syngeneic fetal fibroblasts and placental cells. Both the fetal fibroblasts and I placental cells functioned as effective blockers of TAA specific lysis in cold-cell inhibition experiments, but did not inhibit CTL mediated lysis of the immunizing tumor. Cultured fetal fibroblasts as well as placental cells could stimulate the induction of CTL when inoculated into the footpads of normal C3H mice. I These CTL were capable of effecting lysis of all test tumors, regardless of H-2 haplotype, as well as the fetal and placental cells: These results suggest that .common antigenic determinants (possibly TAA) are present on both I embryonic tissues and tumors of murine origin. I I I I I I

68 I Society of Perinatal Obstetricians I Annual Meeting San Antonio, Texas I February, 1982

I PREDICTION OF RESPIRATORY INSUFFICIENCY DURING PREMATURE LABOR INHIBITION WITH BETASYMPATHOMIMETICS.

I T.J. Benedetti, M.D., T. Johannsen, D. Luthy, M.D. and R. Albert, M.D. (Department Obstetrtics and Gynecology and Medicine, University of I Washington, Seattle, Washington.) Maternal cardiovascular complications have been observed in i-5% of patients treated with betasympathomimetics for premature labor. To detect early respiratory insufficiency we performed serial pulmonary I function tests (PFT) on pregnant patients. PFT’s performed were Forced Vital Capacity (FVC), Forced Expiratory Volume (FE~I), and Midmaximal I Expiratory Flow (FEF2s-75). FVC, FEVI and FEF25-75 were unaltered by gestational age (n=60) or early labor (n=ll). Twelve patients received betasympathomimetic therapy for premature labor inhibition. Ten remained assymptomatic and I showed no significant changes in PFT’s. Two patients showed signifi- cant decreases in FVC (17%, 28%) and subsequently developed symptoms of respiratory distress. Serial arterial blood gas determinations during I betasympathomimetic therapy showed a statistically significant correla- tion (p <.01)between FVC and PO2 and FVC and Alveolar arterial oxygen I gradient (A-a 402). (r=.75,.76 respectively). These data suggest that serial measurements of FVC may aid in the early recognition of respiratory insufficiency during Betasympathomimetic I therapy. I I I I I I I

I 69 Society of Perinatal Obstetricians Annual Meeting San Antonio, Texas I February, 1982 I ROLE OF METHOD OF DELIVERY ON THE NEONATAL OUTCOME OF THE PREMATURE CEPHALIC INFANT

M.D. Berkus, M.D., A.C. Cruz, M.D. (Department of Obstetrics and Gynecology, I University of Florida, College of Medicine, Gainesville, Florida)

The method of delivery has been implicated as a significant factor in the final I outcome of the neonate. This is especially true in the premature infant, both in the cephalic and breech presentations. To evaluate the role of the method of delivery on the neonatal outcome, a retrospective analysis of the data from the I Obstetric Statistical Cooperatives from 1971-1978 was done. There were 265,459 single births in all the member hospitals of which 6603 were liveborn in cephalic presentation, weighed between 500 to 2000 grams and had no major congenital anomalies or serious iso-immunization. I

The neonatal mortality was 234/1000 for the group. Of the 5482 infants delivered vaginally, the mortality was 25.3% compared to 19.9% for the 1121 delivered by I cesarean section. The difference was statistically significant and this was primarily due to outcome in the less then i000 grams infant (VLBW). I Respiratory distress syndrome was noted in 36.3% of infants delivered vaginally with a~mortality of 39.9% in contrast to 39.8% incidence in those deliveries by cesarean section with a mortality of 34%. This shows a statistically signifi- cant decrease in the mortality associated with RDS when a premature infant was I delivered abdominally especially in VLBW infants.

An Apgar score of less than 6 at i minute was recorded in 31.7% of those deliv- I ered vaginally and 44.8% of those delivered by cesarean section. The difference is statistically significant and the associated mortality was 50% more for the vaginal group. I This retrospective review suggests that abdominal delivery may be the preferred method for VLBW infants. The recent successes of our pediatric colleagues with very small infants demand a serious review of some of our obstetric practices. I Early cesarean section for the VLBW infants may improve the outcome for this already compromised group. I I I I I I 70 I Society of Perinatal Obstetricians Annual Meeting I San Antonio, Texas February, 1982 I THIOCYANATE AND DRINKING DURING PREGNANCY Sidney F. Bottoms, M.D., Nancy E. Judge, M.D., Paul M. Kuhnert, Ph.D and I Robert J. Sokol, M.D. (Department of Obstetrics and Gynecology, Cleveland Metro- politan General Hospital/Case Western Reserve University) Alcohol appears to have a relatively direct effect in decreasing fetal growth. I However, it also appears that other factors associated with alcohol consumption may also contribute to lowered birthweight. Three studies have suggested that beverage source of alcohol may be a determinant of decreased intrauterine growth I and that beer may have a comparatively greater effect than wine and liquor. Beer is reported to contain thiocyanate (SCN), a substance which has been implicated as a determinant of fetal growth retardation in relation to cigarette smoking. Our purpose is this study was to determine whether beer drinking is associated with I increased fetal serum SCN levels. We correlated maternal and fetal SCN with maternal characteristics (age, marital status, race, parity and prepregnancy weight), gestational age and substance use I (tobacco, beer, wine, liquor and marijuana) in 82 clinic patients, and considered p < 0.05 to be statistically significant. Maternal and fetal SCN were highly correlated (r=+0.96, p < 0.001). The following variables were significantly cor- I related with fetal SCN:

VARIABLE r p I Cigarette smoking +0.72 <0.001 Cigarettes/day +0.80 <0.001 Beer drinking +0.27 <0.05 Ounces of alcohol consumed as beer/day +0.29 <0.01 I Liquor drinking +0.32 <0.005 Marijuana use +0.23 <0.05 Most recent marijuana use +0.24 <0.05 I Thus, as represented in this study, substance use was significantly related to FSCN; maternal characteristics and gestational age were not. Since many types of substance use were significantly correlated with fetal SCN, I and since some types of substance use were significantly correlated with other types of substance use (most notably smoking), stepwise multiple regression was performed to adjust for covariance. Only the following three variables were found I to be significantly, independently correlated with FSCN: CUMULATIVE % VARIABLE F(variable) p(variable) OF VARIANCE p(regression) Cigarettes/day 142 <0.001 64 <0.001 I <0.005 68 <0.001 Smoking 10.8 Ounces of alcohol consumed as beer/day 9.28 <0.005 71 <0.001

I Thus, after controlling for maternal characteristics, gestational age, and toba- cco and marijuana use, the quantity of beer consumed was found to have a signifi- cant positive correlation with fetal serum SCN (p < 0.005). Consumption of other types of alcoholic beverages was not significantly associated with elevated fetal I serum SCN, although the numbers of wine and liquor drinkers in this study were limited. Further research is warranted to explore the possibility that the correlation of beer consumption with increased SCN might provide at least one I explanation for the reported linkage of diminished fetal growth and beer drinking. I

71 Society of Perinatal Obstetricians Annual Meeting San Antonio, Texas I February, 1982

GROWTH OF THE HUMAN FETAL KIDNEY: SONOGRAPHIC MORPHOMETRY IN THE NOR~IAL AND I ABNORMAL FETUS

N.A. Callan, M.D., C.S. Otis, B.S., and S. Weiner, M.D. (Department of Obstetrics I and Gynecology, Section on Perinatology, Pennsylvania Hospital, University of Pennsylvania, Philadelphia, Pennsylvania) I

Numerous reports of antenatal detection of kidney disease using sonography have appeared. However, few have described the normal morphologic development of the human fetal kidney throughout gestation. The availability of easily obtained I linear sonographic measurements of the growing fetal kidney is vital as a back- ground for detecting and understanding abnormalities. This study establishes normal fetal kidney growth patterns, and describes a simple and sensitive I technique to detect abnormal kidney size in a fetus without knowledge of gesta- tional age. I Using both realtime and static ultrasound equipment, the kidneys were visual- ized on transverse views of the abdomen in 100 normal fetuses, from 15 to 40 weeks gestation. The fetal biparietal diameter (BPD) and antero-posterior (APD) and transverse (TD) diameters of the kidneys were measured using electronic I calipers. The average kidney diameter (AKD) was then calculated, using the formula (APD + TD)/2 = AKD. The AKD/BPD ratio was calculated, and a normal curve of AKD versus BPD generated. I

In the normal fetuses, the AKD grows in linear fashion, and is closely cor- related to the BPD (r2 = 0.99). The ratio of AKD/BPD was nearly constant through- I out gestation, with a range of 0.26 to 0.29. By reference to the AKD versus BPD curve or calculation of the AKD/BPD ratio, the normalcy of fetal kidney size can be easily determined. I In three fetuses with pathologic urinary tract development (multicystic kidneys, prune-belly syndrome, and hydronephrosis), the abnormal kidney growth is clearly demonstrated. Although these kidneys also grew in a linear fashion, I their rapid enlargement was 4 to 10 standard deviations above the mean of the normal fetuses. The differences were significant for the AKD versus weeks gesta- tion (p

The technique described is simple and rapid, requiring only standard ultra- I sound equipment and easily obtained measurements. It has proven to be as sensi- tive as a comparison of fetal kidney size to the abdominal dimensions, which may be altered by a dilating urinary tract. Finally, oligohydramnios, frequently I found in fetal renal disease, will be explored for its effect on BPD and ab- dominal size. I This study provides practical sonographic measurements of fetal kidney growth. When combined with observations of fetal bladder filling, urinary tract structure and function can be more thoroughly evaluated. I I 72 I Society of Perinatal Obstetricians Annual Meeting I San Antonio, Texas February, 1982 I PREDICTION OF COMPROMISED FETAL GROWTH IN DIABETIC PREGNANCY USING SEQUENTIAL I SONOGRAPHIC MEASUREMENT M.W. Carpenter, M.D., D.R. Coustan, M.D., and J.C. Hobbins, M.D. (Department of Obstetrics and Gynecology, Yale University School of Medicine, New Haven, I CT) Maternal insulin requiring diabetes may predispose a fetus to either macrosomia or retardation of growth. Predicting such growth abnormalities using clinical I criteria for diabetic severity has been inaccurate. Norms for fetal growth have traditionally been based upon measurement of premature neonates at various stages of development. The quality of growth of a given fetus could only be I inferred at delivery when it was compared to these norms. Sonographic imaging has provided a means of serial fetal measurement during gestation. We investi- gated the use of serial sonographic fetal measurement in predictingfetal I growth retardation or macrosomia in diabetic pregnancy. Thirty-three metabolically well-controlled Class B-FR diabetics had sonography performed a mean of seven times from 18 to 40 weeks gestation. Total intra- I uterine volume (TIUV), biparietal diameter (BPD), head circumference (HC) and abdominal circumference (AC) were documented in calibrated photographs. Groups of images from each observation were randomly sorted and measured in a blinded I fashion. Growth rates (A size/A time) were calculated as least squares slopes for each dimension during the 18 to 40 gestational Week interval. Two neonatal outcome variables were used as markers for fetal growth status. The first was birth weight standardized for gestational age, birth order, gender, and I maternal height and weight expressed as a birth weight centile. The second was caliper measured neonatal skinfold thickness.

I Traditionally used predictive variables as the White classification or duration of diabetes showed no association with the standardized birth weight centile or skinfold thickness. However, the least squares slopes of TIUV and AC measure- I ments had strong association with birth weight centile showing a Pearson’s coefficient of r = .467 and r = .450 respectively (p = <.01 for each). The range of values for rate of growth for TIUV and AC was divided into quartiles. Those fetuses in the highest quartile of TIUV and AC growth rates had signifi- I cantly increased birth weight centiles and skinfold thicknesses (p<.02 for each). Fetuses with the lowest quartile of TIUV growth rates had significantly I (p<.0001) thinner skinfold thicknesses. Calculation of TIUV and AC growth rates during diabetic pregnancy may provide an improved means of predicting abnormal fetal growth. Confirmation of the utility of these sonographic growth rate variables will require study of larger I numbers of diabetic gravidae. I I I I 73 Society of Perinatal Obstetricians Annual Meeting San Antonio, Texas I February, 1982

Factors affecting maternal sensitivity to fetal body movement (FBM) beyond 28 I weeks gestation. By Prasanta C. Chandra, M.D., FACOG, Carol Michalczyk*, and Harvey Kushner, Ph.D. from Department of Obstetrics & Gynecology and Physiology, Hahnemann Medical College & Hospital, Philadelphia, PA I *Sponsored by March of Dimes Birth Defect Foundation. A total of 1053 fetal body movements (FBM) were observed on 30 high-risk patients at 28-42 weeks gestation, within one hour postprandial. Real time B-Scan (RTBS), I visualization was used to determine the FBM. Patients were not allowed to watch the TV screen. They were not required to discriminate between multiple and isolated movements. From 38 evaluations, 79%_+ 18% (mean ± SD) of visualized multiple FBM were identi I fied by the patients & 51% ± 30% (mean ± SD) of visualized isolated FBM were identified. The sensitivity to multiple FBM is significantly greater than the sensitivity to isolated FBM (PcO.OI). I The sensitivity to multiple FBM was not signifi_cantly different (Z=I.48) between these patients with posterior ~lacenta (N=I2, X=73%, SD=16%) and those patients with anterior placenta (N=26, X=82%, SD=18%). There was no statistically significant difference between prim~gravida and multi- I gravida patients with respect to sensitivity to multiple FBM. A correlation analysis was applied to the sensitivity rates for multiple FBM and each of the variables; gestational age, placental thickness and amniotic fluid depth. There I was a statistically significant correlation found with gestational age (Fig. I) but not with placental thickness or amniotic fluid depth. In addition, the multiple FBM to isolated FBM ratio (M/I) as calculated from the movements deter- I mined on the ultrasound significantly correlated with gestational age (Fig. 2). Although maternal perception of multiple FBM ranged from 11-100%, most gravidas could accurately detect 79% of multiple FBM. By screening mothers with RTBS, those reliable in perceiving FBH can be selected and encouraged to conduct study I in their homes to assess dialy fetal activity. Key words: Multiple FBM - movement of at least two fetal limbs and fetal torso as seen by ultrasound. I Isolated FBM - single limb motion isolated from other body movement as seen by ultrasound. I 100’

90’ I 50’

80’

40, 70 I 8o 60

2.0 I 50

10, 4O N=38 r= 55 t S.E. (n_>4) I t S.E (n~4) 80

Gestahon in weeks Gestation in weeks I Fig. 1 Fiq. 2 I 74 I Society of Perinatal Obstetricians Annual Meeting San Antonio, Texas February, 1982

EARLY INTRAUTERINE GROWTH RATE PATTERNS IN I TWIN GESTATIONS

Molly Chatterjee, MD, Marvin Lavenhar, PhD, Leslie Iffy, MD Departments of Obstetrics and Gynecology & Preventive Medicine, I CMDNJ-New Jersey Medical School Newark, New Jersey In a series of previous reports based on the analysis of 1600 embryos and fetuses obtained by artif±cially induced abortion, it has been documented that intrauterine growth rate I follows a rather predictable course in the human species. It has been shown that neither maternal race, nor age, parity, sex of the fetus or season of the year at the time of conception have an influence upon the linear growth of the fetus dring the I first half of gestation. In contrast, the season of fertili- zation influenced the early fetal crown-rump length: body weight ratio significantly. Higher than average body weights were noted following summer conceptions whereas the weight of fetuses conceived during the fall were under the average. I The earlier mentioned material included 41 twin embryos and fetuses ranging between 61 and 140 days in menstrual age. Two particular parameters of growth were analyzed in the present study: I a) ~The relationship between crown-rump length and body weight; ~ b) The relationship between menstrual age and crown-rump length. The standards obtained on the basis of the analysis of I singleton embryos and fetuses were used for comparison in the current study. Embryonic and fetal weight in relation to crown-rump length was very closely the same in twin pregnancies as in cases of singletons. This finding indicates that the deceleration of I weight increase that predictably deve!q~s during the advancedstages of multiple gestations does not occur during the first half of pregnancy. Paradoxically, the menstrual age versus crown-rump length I relationship displayed a tendency for lower than average fetal size in this study. Since in case of growth retardation decrease of weight precedes the deceleration of linear growth, the above finding cannot be explained in terms of "growth retardation~ On the other hand, the finding is consistent with the hypothesis, I that twin gestations ~Dpear with increased frequency in relation to fertilizations that occur late in~ the intermenstrual cycle. The information provided by the earlier, and already reported, phases of this research supported the findings of animal experi- I ments that indicated that the rate of early intrauterine growth is predictable and constant and differences among pregnancies with comparable menstrual age derive from different onsets of embryonic growth rather than different rates of growth in early gestation. On the ground of this information, the above outlined data I based on twin embryos and fetuses are consistent with the presumed association of delayed ovulation end certain cases of multiple gestation. The nature and scope of this study does not permit I speculation with regard to relationship between the zygozity of the twins and the above summarized phenomenon. I I I 75 Society of Perinatal Obstetricians Annual Meeting San Antonio, Texas I February, 1982

COMPARISON BETWEEN M~GNESIUM SULFATE (MgSO4), TERBUTALINE (T) AND A PLACEBO I FOR INHIBITION OF PRETERM LABOR: A RANDOMIZED STUDY D.B. Cotton, M.D., H.T. Strassner, M.D., L.M. Hill, M.D., B.S. Schifrin, M.D. and R.H. Paul, M.D. (Department of Obstetrics and Gynecology, University of Southern California School of Medicine and Women’s Hospital, Los Angeles I County-USC Medical Center, Los Angeles, California

MgSO4 has been promulgated as a safe and effective agent for inhibiting I preterm labor. Its reported adequacy as a tocolytlc agent, however, has not been substantiated by randomized controlled trials. To assess the efficacy of MgSO4, we initiated a prospective, randomized study comparing the I capabilities of MgS04, T and a placebo for labor inhibition. The study population consisted of 54 patients in whom the diagnosis of preterm labor was made. The criteria for prematurity were: l) gestational age between 26 and 34 weeks as best estimated by last menstrual period and biparietal diameter (BPD) I on real-time ultrasound (US); and 2) estimated fetal weight between 750 gms and 2000 gms. The diagnosis of labor was made if following hydration persistent uterine contractions occurred at a frequency of at least 3 in a lO I minute period and cervical exam suggested active labor. Criteria for the latter included any of the following: l) evidence of progressive cervical dilatation 2) cervical dilatatlon > 2 cm 3) cervical effacement > 80Z 4) I spontaneous rupture of membranes. Patients > 4 cm dilated were not in~luded in the study. After the diagnosis of labor was made an US exam was performed to assess BPD, placental localization and the presence or absence of amniotic fluid (AF). If a pocket of AF was visualized an amniocentesis was performed I and the AF analyzed for lecithln-sphingomyelin ratio, phosphatidylglycerol and the presence of bacteria on gram stain. Any patient with evidence of fetal pulmonary maturity or bacteria on gram stain was eliminated from the study. I Following US exam the patients were randomized into one of three treatment groups: MgSO4; T; or 5Z dextrose in Lactated Ringer’s (DS/LR). Patients assigned to MgSO4 received 4 gms IV over 15 minutes and then 2 gms/hr. Patients receiving T were started at 9 ug/min IV and the dose tltrated to I levels of as high as 25 ug/min depending on the uterine response. Patients in the placebo group received a continuous infusion of DS/LR at 125 ml/hr. Success was defined as postponement of delivery for at least 48 hours after I initiation of therapy. Delivery was successfully delayed 48 hrs in 7 of 19 (37Z) patients receiving D51LR, 6 of ]6 (38Z) receiving MgSO4 and 53% (lO of 19) of those receiving T. These differences were not significant (NS). The I mean number of days gained from the initiation of therapy till delivery were as follows: DS/LR, 7.1 + 14.q (SD); MgSO4, 3.0 + 6.0 and T, 12.0 + 14.9 (NS). The groups were analyzed as to the impact o~-ruptured membranes]ROM). Dellvery was successfully delayed 48 hrs with ROM in 2 of I0 patients I receiving DS/LR; 3 of 8 (38Z) receiving MgSO4; and 3 of 4 (75Z) administered T. Overall, 8 of 25 (32Z) patients with ROM had delivery postponed for 48 hours compared to 15 of 29 (52Z) with intact membranes (NS). Despite a trend I toward increased efficacy in the T group, especially when membranes were ruptured, there were no significant differences between the 3 treatment groups with regards to capability for delaying delivery at least 48 hours. There were I no significant differences between the groups with regards to gestational age at delivery, birthweight or neonatal survival. The trend toward increased efficacy with T suggests that it may be the best clinical option available among the agents studied. The fact that delivery occurred in less than 48 I hours in close to I/2 of patients under the best of circumstances emphasizes the need for more potent techniques in the field of labor inhibition. I

76 Society of Perinatal Obstetricians Annual Meeting San Antonio, Texas February, 1982

I Comparison of Biparietal Diameter (BPD), Head Circumference (HC) and Abdominal Circumference (AC) ~rowth Curves Obtained in Longitudinal and Cross-Sectional I Studies of Normal Fetal Growth. Russell L. Deter, Ronald B. Harrist, Robert J. Carpenter, Frank P. Hadlock and Clark M. Hinkley, Departments of Obstetrics/Gynecology and Radiology, Baylor College of Medicine and Department of Biometry, University of Texas School of Public Health, Houston, Texas.

This study compared BPD, HC and AC growth curves obtained in longitudinal (20 I patients) and cross-sectional (BPD:533 patients; HC, AC:252 patients) studies of normal fetal growth. Individual longitudinal ~rowth curves were obtained from serial uitrasound examinations made at 3 week intervals in patients with known dates o~ conception. llathematical functions were fitted to the data from each individual and the average growth curve determined by averaging model coef- ficients. These models of the averane growth curves were used to calculate pre- dicted values at different conceptua~ ages (CA). Variability was assessed by calculating the standard deviation of predicted values obtained from individual curves at different conceptual ages. In cross-sectional studies, the least squares method was used to establish to optimal models describing the channe in I parameter (BPD, HC, AC) with approximate conceptual age (menstrual age minus 2 weeks). These models were used to calculate predicted values at different conceptual a~es. Variability was evaluated by plottin~ residuals (differences between observed and predicted values) against CA.

Averaqe longitudinal and cross-sectional BPD ~rowth curves were slightly convex in shape without evidence of a sianificant plateau. The linear-cubic model fit I both data sets optimally{ Iong:~=99.4 (±.4 S.D.)%; cross:R~=99.0% }. Compar- ison of predicted values qave a mean of 2.0% (range:O% to 6.7%) for the absolute values of the percent difference. In the lon~itudinal study variability was significantly Inwer before 21 weeks (CA) but ~eyond that point a relationship with C# was not detected. The cross-sectional study gave similar results.

I Both average HC growth curves showed a biphasic pattern, linear growth occurring up to 26-28 weeks (CA) followed by curvilinear growth to 38 weeks(~A). # plateau near term was seen in 7 of the 20 individual longitudinal nrowth curves. The linear-cubic model fit both data sets optimally’{lona ~=9~.4 (±.3 S.D.)%; cross: R~=97.3% }. Comparison of predicted values gave a mean of 2.0% (range:O% to 8.9%) for the absolute values of the percent difference. The variability in both studies showed an increase after 26-2~ weeks (CA), this chan~e bei~n more marked in the cross-sectional data.

Linear growth of the AC throughout ~regnancy was seen in both the lonnitudinal I and cross-sectional studies, The linear model fit both data sets optimally ’{ lon~:~~= 99.~ (±.6 S.D.)%; cross~~= 95.5% } Comparison of predicted values ~ave a mean of 1.~% (range:O% to 4.?%) for th~ ~solute values of the percent difference. V~riability in both studies inr~ased progressively with CA. I Analysis of the cross sectional data indicated that the variability was related to the predicted values i~ a coqstant way at all conceptual ages.

I The e~]ellent agreement¯ seen in these 1 on~.i~’,#i ~ ~,n~] and cross-sectional studies indicates that the growth curves obtained are "~liable estimates of the popula- tion growth curves and that potent~l sources ~f error are not significant.

77 Society of Perinatal Obstetricians Annual Meeting San Antonio, Texas I February, 1982

THE CORRELATION BETWEEN GESTATIONAL AGE AND FETAL ACTIVITY PERIODS I LEROY J. DIERKER, JR., MORTIMER G. ROSEN, SASI PILLAY AND YORAM SOROKIN CLEVELAND METROPOLITAN GENERAL HOSPITAL, CLEVELAND, OHIO Patterns of human behavior after birth are described in terms of sleep or I awake activity called behavioral states. Observations after birth are based onEEC patterns, eye movements, EMG, body movements, respiratory rhythm and heart rate variability. Observations in the human fetus are currently less complete because I of ethical considerations. More limited observations usin~ heart rate variability and fetal movements (FM) were used in this study to define cyclic periods of fetal activity during the third trimester of pregnancy in a normal population. I Mothers were at low antepartum risk and developed no significant complications before delivery. All delivered AGA infants at term with Apgar scores >6. Gestational abe at the time of the study was confirmed by Dubowitz examination after delivery. FHR was detected using abdominal ECG, ~M were detected using two I tocodynamometers on the maternal abdomen. Data were displaed on a 4 channel recorder at 30 cm per minute. Both FHR variability and F~ were evaluated independently using a template to avoid subjective interpretation. Each one minute I period (epoch) was classified as quiet if the long term (one minute) FHR variability was <15 bpm and FM was

8 r.052 I p< o/

6 5 I >. 4 >. I I GESTATIONAL AGE IN DUBOWITZ WEEKS These findings demonstrate fewer active-quiet cycles her hour in the older fetus with longer active and quiet periods. This change in pattern in active and ,quiet periods of fetal behavior, which is a brain-mediated function, may provide I ~ method of evaluating one aspect of fetal brain maturation and a marker for determining the effect of abnormal maternal and fetal conditions on this aspect of human development. I I I

78 Society of l’erlnatal Obstetricians Annual Meet InR I San Antonio, Texas February, 1982 I Aggressive Obstetrical Management in Late Second Trimester Deliveries I W. P. Dillon, M.D., E. A. Egan II, M.D. Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine and the Department.of Pediatrics, Division of Neonato]ogy, State University of New York at Buffalo School of I Medicine, Children’ s Hospital of Buffalo) Substantial improvement in the survival of very low birth weight infants (750- 1500 grams)_ has solidified the general policy that the well-being of the fetus I should be a major consideration for any woman in the third trimester. Hc~ever, there is very limited data available on the outccme of infants delivered be- tween 24 and 27 weeks of gestation. 5~ch debate has occurred over whether I aggressive ~bstetrical management in the late second trimester is productive or even appropriate. A conviction .in our perinatal service emerged in 1977 that infants born between 24 and 27 weeks were viable and that neonatal inten- I sive care for these very premature infants was worthwhile. Our experience frcm July 1977 to June 1980 is presented. From among the 8502 patients admitted to the labor and delivery suite of Children’s Hospital of Buffalo during this 3 year period, 62 patients who delivered at a gestational age judged, prenatally I to be between 24 and 27 weeks and had a live fetus in admission were included in this study. Assist of gestational age was to the nearest completed w~ek using a ccmbination of ultrasound, physical exam-and menstrual history. Ob- I stetrical strategies included continuous electronic fetal monitoring utilizing the usual criteria of decelerations and absence of baseline variability as the primary index for fetal distress, tocolysis when appropriate utilizing either I ethanol or terbutaline; expectant management of premature rupture of membranes, and acceleration of fetal lung maturity with betamethasone if delivery ~s not imainent. Delivery of the fetus by cesarean section was recommended in cases of fetal distress identified by electronic fetal monitoring or other than vertex I presentation. The majority of patients, 42 (68%) were admitted in labor and half of these (21) were so far advanced that only atte~npts to perform a non- hypoxic~ non-stressful delivery could be perfomned. As expected, survival in I the 24 to 27 week range is quite sensitive to gestational age. Table 1 iden- tifies the survival for each week of gestation and the mean birth w~ight of both ~hose who survived and those who died. Of all the obstetrical strategies I used, betar~thasone treated infants had a significantly higher percentage (p<0.03) of survivors than did untreated infants. The mean hospitalization time for the 34 surviving infants was 103+7 days S.E.. Three (9%) of the sur- vivors were discharged with major complications. No infant in this series had I sepsis. I Table 1. Comparison of’Neonatal Outcome by Weeks’ Gestal.)n Survivors B,rth weight ~evks’ Kestation No. No, [~ercen~ Lived Died Tota i

I 24 11 4 36 822 ± I02’ 608 z 55 . 685 z 129 25 16 6 3~ 7~) Z 112) 753 Z 177 744 ± 152 26 18 II 61 800 ± 97~ 776 ± 120 791 ± 104 I 27 |7 13 76 879 z I17 8."43 z 125 868 ± I17 1 olal 62 34 55 820 z 114 733 . 147 781 ± 137 Mean z 2 Significantly higher (P < .0l) than those who died at 24 weeks. I Not significantly d)~erent ~ those who d~ed.

I 79 Society of Perina~al Obstetricians Annual Meeting I San Antonio, Texas February, t982 I COMPARISON OF TECHNIQUES FOR OBTAINING ENDOMETRIAL CULTURES IN THE PUERPERAL PATIENT

Patrick Duff, M.D., Ronald S. Gibbs, M.D., Jorge D. Blanco, M.D. and Patricia I St. Clair, B.S. (Department of Obstetrics and Gynecology, Division of Maternal- Fetal Medicine, University of Texas Health Science Center at San Antonio, Texas.) I The purpose of this prospective investigation was to compare four different tech- niques for obtaining endometrial cultures in puerperal patients. Fifteen uninfected women undergoing elective postpartum tubal ligation participated in I the study. During the course of the operative procedure, four culture specimens were obtained from each patient in the following sequence: transfundal aspiration transcervical brush biopsy of the endometrium through a double-lumened plastic catheter, transcervical lavage of the endometrial cavity through a double-lumened I catheter, and transcervical aspiration of the lower uterine segment through a single-lumened catheter. Quantitative bacterial cultures for aerobic and anaerobic organisms were performed on all specimens. I

Forty percent of the specimens obtained by transfundal aspiration were positive for bacterial growth; colony counts did not exceed 300 colony forming units per I milliliter, however. Forty-seven percent of the specimens obtained by brush biopsy of the endometrium were positive for bacterial growth, and there was excellent correlation, both qualitatively and quantitatively, between these cultures and those obtained by transfundal aspiration. Sixty-seven percent of I the transcervical endometrial aspirates were positive. Cultures performed by this technique had a greater variety of microorganisms and higher colony counts of individual organisms than specimens obtained by either transfundal aspiration I or endometrial brush biopsy. All of the cultures performed by transcervical aspiration of the lower uterine segment were positive for bacterial growth. These specimens demonstrated both a greater variety of organisms and higher colony counts than any of the other specimens. I

On the basis of this study, we conclude that the most satisfactory and clinically acceptable techniques for obtaining endometrial cultures are transcervical intra- I uterine lav~ge through a double-lumened catheter or transcervical endometrial brush biopsy through a similar catheter. S%ngle-lumened lavage, endocervical aspiration, or transcervical passage of a cotton-tipped swab invariably introduce I cervical and vaginal organisms into the culture specimen and produce a misleading impression of the genital pathogens actually present at site of surgical infection. I I I I I 80 I Society of Perinatal Obstetricians I Annual Meeting San Antonio, Texas I February, 1982

PREDICTIVE VALUE OF INTRAPARTUM ELECTRONIC FETAL MONITORING IN PRE-TERM I INFANTS

J.F. Evans, M.D. and F. Arias, M.D.,Ph.D. (Department of Obstetrics and I Gynecology, Washington University Medical School, St. Louis, MO 63110) This study was designed to assess the capacity of electronic Fetal Heart Rate monitoring in predicting the presence or absence of neonatal depression I in pre-term infants. Fetal monitoring traces were evaluated by both numerical analysis as well as subjective clinical impression. In order for recordings to be considered, it was required that they had a minimum I of 10-15 minutes of readable recordings with contractions. The study included only infants with a birth weight under 2,000 grams and adequate for gestational age. The Bayes theorem was used to calculate both positive I and negative predictive values. The APGAR score at 1 & 5 minutes and the need for positive pressure ventilation for more than one minute were used as indexes of neonatal depression.

I For the purpose of analysis the 116 patients were separated into three different birth weight groups (500 to 999, i000 to 1499, 1500 to 1999). The objective interpretation, with numerical values was based on scales I proposed by Schifrin, Martin, Pearson, Earn, and Bowes, and carried out by two examiners, with concurrence. Subjective evaluations were done separately. All patient information was blinded until all evaluations were complete.

I We concluded: i) FHT monitoring has little or no value in predicting the condition of the pre-term infant at birth. 2) As newborn weight increases from 500 to 2000 grams, the I predictive value of FHT is improved. 3) Criteria for evaluating FHT and APGAR scores in pre-term I infants should be different from the criteria used in term babies. I I I I I I

81 Society of Perinatal Obstetricians Annual Meeting I San Antonio, Texas February, 1982 I

ANTENATAL DIAGNOSIS OF SICKLE CELL ANEMIA USING A NEW RESTRICTION ENZYME I

H.E. Fadel, M.D., L.B. Wilson, Ph.D., J.T. Wilson, Ph.D. (Departments Obstetrics and Gynecology, Maternal-Fetal Medicint~ Scctfon and Cell I Biology, Medical College of Georgia, Augusta, Georgia). A new restriction endonuclease enzyme Ddel which digests DNA at the 8-qlobin I gene site was recently discovered. This enzyme has been used success~-ullq in method that involves DNA digestion and blot h~bridization to diagnost, the cell genotype in lymphocytes from the peripheral blood in adults. Individuals with a normal hemoglobin (AA) show 2 bands 175 and 20~ base pairs (bp). Sick]<~ I cell trait individuals (AS) exhibit an additional band 376 bp. Patients with sickle cell anemia (SS) show the band at 376 bp with the concomitant loss of 175 bp band. This is consistent with the loss of the restriction recognition I site for DdeI in the altered codon associated with the sickle cell allel(.~. It: was shown that tht analysis can be performed on as little as 20 ug of cellula~ DNA making it applicable to the small amounts of DNA that can be recovered I amniotic fluid (AF) ~ibrob[asts obtained at amniocentesis.

A pregnant wom,~.’] with sickle, cell trait, whose husband was also a sickle cell carrier, presented hersotf for genetic counseling because of advanced m{}terna I age. At the tin~ o£ an~iocentt~sis, which w~s per£ormed at 16 weeks, fluid obtained was us~.d to test the feasibil~[ty and accuracy of this applied to AF fibroblasts for antenatal diagnosis of sickle cell anemia. I

The ce~is were cultured and at the time of harvesting, DNA was isolat~.d, with Ddel and, the fr~qn~u~ts electrophoresed on [~lyacrylamide gel.. Us/’nq a I strongly radioactive ~{-genc probe, the 8-gene fr._~qments were visualized. were 376 and 201 bp fragments indicating that the fetus has sickle cell anemia. Because of the investigative nature of this new test, these results were not communicated to the patient. The karyotype was normal and the pregnunc,! I continued uneventually. The patient delivered at another hospital and ~t was confirmed that the neonate has sickle cell anemia. We are currently using the same procedure to assure its accuracy on additional patients. I

This new methods proved to be both feasible and accurate. It offers the fol lowing advan tages : I First, the enzyme is specific and there is no heterogeneity (polymorphism) eliminating the need for family studies, while making it applicable to aIl couples at risk. Second, the accuracy has been confirmed albeit in only one I case. Third, the results can be obtained in 2-3 weeks. Finally, amniocentesis is much safer than the other available method for antenatal diagnosis i.e. fetal blood sampling using a fetoscope. I I I I 82 I I Feb

NONSTRESS FHR TESTING IN MULTIPLE GESTATION

I J.I. Fishburne, M.D., P.M. Dix, M.D., M. Penry, M.S., R.No, RDMS, M.F. Swain, R.N., P.J. Meis, M.D. (Department of Obstetrics and Gynecology, Bowman Gray I School of Medicine, Winston-Salem, N.C.) Between 2/i/78 and 9/30/81, 30 patients underwent semiweekly nonsimultaneous nonstress testing for evaluation of twin (29 patients) or triplet (i patient) I gestation. A total of 151 testing procedures were done, 313 individual NSTs being performed. Of these tests 274 (87.5%). were reactive, 35 (11.2%) were nonreactive and 4 (1.3%) were inadequate for diagnosis. Of the 35 nonreactive tests 21 (60%) were further evaluated with contraction stress testing. The I remainder were subjected to repeat NST or delivered prior to r~peat testing. Of those having CST, 8 had oxytocin challenge testing and 13 had spontaneous CST. Of the 21 CSTs, 17 (81%) were negative, 2 (9.5%) were positive, and 2 I (9.5%) were suspicious. Two-thirds of the ~atients were delivered by cesarean section. One of these had a vaginal delivery of the first twin followed by cesarean delivery of the second for fetal distress. Indications for cesarean section included abnormal presentation, pre-eclampsia, failure to progress in I labor, fetal distress and previous cesarean section. One triplet pregnancy was followed with 11 maternal testing sessions, all 33 NSTs being reactive. There was one fetal death associated with extreme discordance and severe I oligohydramnios of one twin. There were no neonatal deaths. The perinatal mortality rate in this selected group of high risk patients was 15.8/1000. Only 4% of the infants born following a reactive NST were found to have a low I apgar score at 5 minu~s. This is compared with a 33% incidence of low 5 minute apgar scores in infants born after a nonreactive test (p~0.05). I I I I I I I I

I 83 Society of Perinatal Obstetricians Annual Meeting ! San Antonio, Texas February, 1982 i THE PREDICTIVE VALUE OF ANTEPARTUM FETAL MONITORING A. Fleischer, M.D., H. Schulman, M.D., No Jagani, M.D., J. Mitchell, M.D., and L.A. Perrotta, M.D. (Department of Gynecology and Obstetrics, and Department of Pediatrics, i Albert Einstein College of Medicine, Bronx, New York) The value of non-stressed antepartum electronic fetal monitoring (E.F.M.) in predicting perinatal morbidity was assessed in 402 women, considered at risk, and who were delivered during January 1980 - I June 1981 at Albert Einstein College of Medicine. Al! were ~37 weeks gestation, singleton, and vertex presentation at the time of delivery. The major indications for antepartum testing were: Post dates (55%); I Hypertension (18%); Intrauterine growth retardation (6%); Diabetes mellitus (6%); Decreased fetal movements (8%); and Poor obstetrical history (5%). The end points of perinatal morbidity used were: Cesarean section for fetal distress; 1 min. or 5 min. Apgar score ~6; Admission to I neonatal I.C.U. for more than 3 days with a diagnosis related to pe~inatal asphyxia (meconitlm aspiration, respiratory distress, per- sistent fetal circulation, etc.); Neonatal death - related to peri- natal asphyxia. I The critical features of any screening test are the definitio~ of a normal vs. an abnormal test, and the predictive value of the test for a given clinical entity. Using the scoring system for antepartum E.F.M. (Fischer-Hammacher, Krebs et al), a normal (negative) test was defined as a score of 7-10 and an abnormal {positive) test a score of I 1-4. The distribution of results were as follows:

348 women = score 7-10 Negative test 38 women = score 5-6 16 women = score 1-4 Positive test I The predictive value of a positive test is calculated using the formula: Pr value of positive test = TP TP + FP I TP = True Positive = Test ~ositive: Disease present F~ = False Positive = Test positive: Disease absent The prevalence of each entity of perinatal morbidity is calculated according to the formula I Prev. = TP + FN TP + FN + TN + FP TN = True Negative - Test Negative: Disease absent I FN = False Negative - Test Negative: Disease present The value of the test can then be assessed, for each clinical entity, by comparing the 2 parameters as shown in Table I. I Predictive value Prevalence Significance of a Poso test 364 Women c/s 75 % 9 % p <0.001 I Apgar score 43 % 7 % p 40.05 Neonatal I.C.U. __ 37.5% 2.4% p 40.05 Neonatal death 18 % 1 % N.S. I

The test achieves statistical significance for C/S, Apgar score and admissions to I.C.U. indicating that a score ~4 can adequately identify both fetal as well as neonatal problems. I Most studies using Reactivity vs. Non-reactivity as their definition of a normal vs. abnormal test, stress the value of a good (Reactive) NST as a reliable indicator of fetal well being, adding at the same time that a non-reactive NST required additional discriminatory i evaluation. By using the scoring system and this type of statistical analysis we were able to demonstra~he the predictive value of ah abnormal test, and therefore lend further support to the idea t~at antepartum non-stress monitoring is a useful tool in identifying the patient i at considerable risk for both fetal and neonatal morbidity.

84 I Society of Perinatal Obstetricians I Annual Meeting San Antonio, Texas I February, 1982 A PROSPECTIVE MULTIINSTITUTIONAL STUDY OF ANTEPARTUM FETAL HEART RATE MONITORING

I R.K. Freeman, M.D., G. Anderson, M.D. and W. Dorchester, B.S.

Women’s Hospital, at Memorial Hospital Medical Center of Long Beach, The Univ. of I Vermont and The Univ. of Ca. at Irvine, Orange, Ca. Eighteen thousand five hundred and twenty-one antepartum fetal heart rate (AFHR) monitoring studies were conducted on 7448 high risk patients in 19 institutions I in the United States between 1976 and 1980. Data was gathered prospectively. Ab- normal test results were most frequent in insulin diabetics (10.37), with hyper- tensive patients having 7.6% abnormal tests and post date patients having only I 3.8%. A perinatal mortality rate of 12.9 0/00 (5.5 0/00 corrected) with a fe- tal death rate of 3.2 0/00 (1.9 0/00 corrected) was found. Non-reactive non- stress (NST) and non-reactive positive contraction stress tests (CST) were as- sociated with significantly increased morbidity and mortality. When patients I were ranked by "worst test result," the presence of persistant late deceleration (positive CST) appeared to be an earlier warning sign of fetal deterioration than I did the loss of reactivity. A comparison of perinatal outcome in patients with primary surveillance utilizing the NST (N=1542) versus the CST (N=4626) was made. The two groups were comparable I with respect to indication for testing. The CST group had pregnancy intervention because of abnormal test results significantly more often than the NST group (4.5% for CST vs. 2.9% for NST p~0.5). The antepartum fetal death rate was sig- nificantly higher in the NST group (7.8% uncorrected 3.2% corrected) than the CST I group (1.1% uncorrected vs. 0.4% corrected) p~O.05. These data suggest CST as primary surveillance offers less risk of fetal death than NST as primary surveil- I lance. I I I I I I I I 85 Society of Perinatal Obstetricians Annual Meeting San Antonio, Texas February, 1982

GESTOGRAM: A GRAPHIC APPNOACH TO OBJECTIVE ASSESSMENT OF GESTATIONAL AG~ ! T. Fukushima, M.D., C.J. Dotson, R.N. and J.J. Arce, M.D. (Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Martin Luther King, Jr. General Hospital and Charles R. Drew Postgraduate ! M~dical School, Los Angeles, CA ) A graphic formula is presented for concise and synoptic display of clinic- ! al and sonographic estimations of uterine or fetal size as correlated to the time variable (menstrual dates). Used prospectively the graph permits early recognition of size-dates discrepancy or developing IUGR; in late pregnancy it is a valuable tool in the mar~gement of unreliable- ! dates or prolonged pregnancies. ! GESTOGRAM 44 ! 4O ! !

¯ Early pelvic ! * CRL/BPD ! !

i0 20 30 40 50 menstrua! ! EDC: dates ~weeks ) ! ! ! !

86 Society of Perinatal Obstetricians Annual Meeting i San Antonio, Texas I February, 1982 ULTRASONIC GROWTH PROFILE OF INFANTS OF DIABETIC MOTHERS

I J. Gandhi, M.D., C.L. Gugliucci, M.D. (Department of Obstetrics and Gynecology, Division of Perinatology, New York Medical College and Metropolitan Hospital I Center, New York, New York) A program of intensive care of pregnant diabetics has been in practice at Metropolitan Hospital Center and New York Medical College for several years. I This ~rogram inclu(~es intensive screening of diabetics in pregnant patients, optimal prenatal care with very rigid metabolic control, maintaining FBS at 60-80mg. per I00 ml., RBS at less than 120 mg. per I00 ml., intensive moni- toring of the fetus for growth pattern and physiologic status, liberal hos- I pitalizaticn policy and timely delivery followed by intensive neonatal care. For the past 6 years, this intensive management policy has been extended to termination of pregnancy in selective cases only, and allowing all others to I continue their pregnancy until sl)ontaneous labor ensues. All diabetic patients are followed by serial ultrasound examination for fetal growth, as an integral component of fetal monitoring. Gestatiomal age of the fetus is first estab- lished by early BPD during the first half of pregnancy, thereafter, fetal I growth is surveyed with serial BPD during the 2nd trimester and BPD and t~ans- thoracic diameter during the third trimester. Recently, fetal growth has been monitored with BPD and abdominal circumference and head, body circumfer- I ence ratio.

Two hundred and twenty seven (227) patients among 680 pregnant diabetics I managed between 1975 and 1981 were selected for analysis of differential growth of the fetal vertex and body. All of them had had multiple ultrasound examinations representing each of the critical periods of fetal growth varia- I tion, preceded by an early establis~ent of gestational age by sonography. One hundred normal pregnant patients with previous Cesarean Sections who had been examined similarly were selected as control. Regression curves were de- I veloped for BPD and TT growth of each group of babies. Statistical analysis was then done of BPD and TT of both groups of babies. Gestatio~al period after 28 weeks was arbitarily divided into 5 observation periods of 2.5 weeks I each. Detailed statistical analysis of the growth pattern of BPD and TT was done of diabetic and the control group of babies for each of these periods. No statistical difference was found in the growth pattern of bipariatel di- ameter of the two groups of babies. However, there was a considerable sta- I tistical difference in the growth pattern of transthoracic diameter of the two groups, that of the infants of diabetic mothers being higher than of the I control group. In our opinion, metabolic derangement in diabetic mothers has no effect on the growth of the fetal head, but has significant influence on body growth of I babies of the most rigidly controlled diabetic mothers. I I

87 Society of Perinatal Obstetricians Annual Meeting San Antonio, Texas I February, 1982 I NON-OPTIIIAL BIRTH OUTCOMES IN MANHATTAN BY CENSUS TRACTS - 1977 through 1979 - A CASE FINDING TECHNIQUE * -

Authors: M. Gewirtz, Ph.D., H.E. Fox,M.D., J. Jones, B.A. (Departments of I Obstetrics and Gynecology, Regional Center for Tertiary Perinatal Care, Presbyterian Hospital, Columbia Presbyterian Medical Center, 630 West 168th Street, New York, N.Y. 10032) I I In order to identify areas requiring intensive perinatal services, a small area analysis of non-optimal birth outcome has been carried out. The study was carried out to highlight those census tracts that have exhibited significantly higher rates of non-optimal birth outcomes, to explore a method of vital I statistics analysis that may be applied year by year to identify small geographic areas of changing perinatal outcome, and to provide a time-line measure of birth outcomes in order to evaluate effectiveness of interventions applied to I improve the quality of reproductive outcome.

The technique used was made possible by the addition of mothersr home addresses to the New York City Health Department computerized birth record file, in 1977. I By means of an address-matching computer program, it is possible to allocate every birth record to its health area and to its census tract within a health area. Non-optimal birth outcome was defined as any birth having birth weight I below 2500 gms, gestational age less than 252 days, 5 minute apgars score less than 8, or a congenital anomaly. For Manhattan, as a whole, the three year average non-optimal birth outcome rate was found to be 16.4%. A regional I distribution of significantly higher non-optimal birth outcome rates is presented, as it the identification of teenage pregnancies as an at-risk population. The potential of small area analysis at the residential block level is identified. I

Potential application of this type of vital statistics analysis for the targetting of intensive perinatal services is discussed. I I I

* This study was made possible by the cooperation of Sol Blumenthal, Ph.D., Director, Office of Biostatistics, New York City Health Department, and I with the support of the Robert Wood Johnson Foundation. I I I

88 I Society of Per±natal Obstetricians I Annual Meeting San Antonio, Texas February, 1982

I POSSIBLE FETAL ALCOHOL EFFECTS ON NEUROBEHAVIORAL DEVELOPMENT: A PILOT PROSPECTIVE STUDY WITH METHODOLOGIC IMPLICATIONS Nancy L. Golden, M.D., Robert J. Sokol, M.D., Sara Debanne, Ph.D., Sheldon 1. I Miller, M.D., Susan Mattier, M.S.S.A and Sidney Bottoms, M.D. (Departments of Obstetrics and Gynecology, Biometry, Pediatrics and Psychiatry and the Per±- natal Clinical Research Center, Cleveland Metropolitan General Hospital/Case I Western Reserve Universit~ Abnormal neurobehavioral development of the offspring in association with heavy alcohol use during pregnancy has been reported in studies of animals and hum- I ans. Though studies in humans have not been uniformly well controlled, they have suggested that i) both motor and cognitive development are retarded, 2) the former more than the latter, and 3) that the severity of neurobehavioral abnormality is re- I lated to the severity of physical abnormality in the alcohol affected offspring. To test these hypotheses, 12 infa~nts whose mothers had been identified prospectively during pregnancy as alcohol abusers and who had abnormal physical findings in the nursery consistent with "possible fetal alcohol effects" (Study Group) were com- I pared with 12 infants delivered during the same period from non-alcohol-abusing pregnancies, matched for gestational age at birth, sex and ethnicity (Control Group). At an average of 12 months postnatally, these 12 matched pairs were examined blindly I for neurobehavioral development using the Bayley Scales, as well as for physical growth and dysmorphologic features. The number of comparisons made, using pared t tests, was strictly limited because of the small sample size. I Study Group ContrOl Grou~ ~<

Psychomotor (P) 89.8 ± 20.2 109.7 ± 11.7 Size (~ ± Weight (Kg) 6+98 ± 2.01 11.48 ± 3.90 74.4 ! 6.3 I Height (am) 67.6 t 8.3 Hesd circumference (em) 41.9 + 2.8 45.9 ± 1.9 .002 Physical abnormaltles ~ t SD--number) 5.5 ± 4.3 0.8 ± 1.0 .003 In the Study Group, 11 of the 12 mothers were smokers, compared with one of 12 I in the Control Group; thus, because of collinearity, the effects of heavy drinking and smoking could not be separated. Also, nine Study Group infants were small for gestational age at birth, compared with two of the Control Group infants. As shown I in the Table, at followup, the Bayley scores of the Study Group averaged 20 points lower than those of the Control Group. Study Group infants were significantly smal- ler and had more physical abnormalities. In the Study Group, Bayley P scores were I not lower than M scores; Bayley scores were unrelated to the number of physcial abnormalities (r = -o17; p, NS) and there was no evidence of catch up growth. Fin- ally, for the entire sample of 24 pregnancies and infants, the Hobel antepartum risk score was significantly related to the total Bayley score at 12 months of age I (r = -.465; p<.025), but when the scores for substance use (alcohol and cigarettes) were removed from the Hobel score, this relationship was no longer significant (r = 0.189) the amount of variance explained having decreased from 21.6% to 3.6%. I These findings suggest i) that a group of infants at high risk for neurobeha- vioral abnormality at one year can be identified in the nursery bssed on a history of maternal alcohol abuse and the presence of physical abnormalities and 2) that maternal substance use (heavy alcohol plus smoking) may have persistent effects on I the infants and account for significant abnormality in infant neurobehavioral de- velopment. However, in order to infer that observed effects on infant development are attributable to maternal alcohol use with an increased level of certainty in I future studies, the current findings suggest that data concerning the volume, pat- ter and timing of maternal alcohol intake and careful control for maternal smoking I and intrauterine growth retardation will be necessary.

89 Society of Perinatal Obstetricians Annual Meeting I San Antonio, Texas February, 1982 I I

ABSTRACT I

SURVEY OF ULTRASOUND SERVICES IN HOSPITALS WITH PERINATOLOGISTS Author: John W. Goldkrand, M.D., Director of Perinatal Medicine I Sinai Hospital of Detroit 134 questionnaires were sent to the members of the Society of Perinatal Obste- I tricians regarding ultrasound services in their hospitals. 80 responses (59.7%) were obtained and used for this survey. The respondents were from a university hospital: 75% of the time, private hospital: 23.75% and military: 1.25%. In I

17 (21.3%), ultrasound was done solely in the obstetrics department, while in an additional 48 hospitals (60%), it was performed In both radiology and obstetrics. I Therefore, 81.3% of hospltals have some ultrasound facility located~within the ob- stetrics department. The interpretation of ultrasound findings followed a pattern I similar to the location of ultrasound facility. The billing for ultrasound devia- ted from the above proportions only in the fact that in 1/3 of the hospitals, I billing was only through radiology. Approximately 77% of the hospitals responding have realtlme ultrasound available in labor and delivery 24 hours a day and have residents performlng examinations. Approximately 1/3 of the hospitals’ outpatient I referrals for ultrasound are to the OB department, while an additional 1/3, they are both to obstetrics and radiology. The responding physicians found that their I ultrasound accuracy was excellent: 52%, and good: 38.75%. Comments by respon- dents strongly supported the locatlon of ultrasound within the obstetrics department. I In those hospitals with ultrasound in radiology, even with excellent results, a num- ber expressed similar findings. The overall conclusion is that current ultrasono- I graphic service is, to a large extent, being provided by the departments of obstetrics in those hospitals having perlnatologists. Satisfaction and accuracy appear to be h~gh. I I I I 90 I Society of Perinatal Obstetricians Annual Meeting San Antonio, Texas February, 1982

I

I MATERNAL TEMPERATURE CHANGES IN LABOR

R.C. Goodlin, M.D. and 3. Chapin, M.D. (Departments of OB/GYN and Anesthesia, I University of Nebraska Medical Center, Omaha, Nebraska) Temperatures were recorded from ~0 pregnant women at term in labor and during the immediate post partum period. Recording sites include maternal rectum, I vaginal fornix, inferior aspect of breast, axilla, mouth and ear (tympanic). In parturients with adequate pain relief, (with epidural anesthesia), there was a 0.# to 1.~ C degree rise in temperature which was maintained through the immediate post I partum period. In those without significant pain relief, the ~atern~a~ temperatures decreased especially in the terminal aspect .o~ labor ~rom 1 to 1.$ C, but in the immediate post partum period there was a .1 to 2.2 C rise in temperature. The I amount of decline in maternal temperature in those without significant pain relief appeared to be related to the degree of the mothers hyperventilation and sweating. The immediate newborn’s rectal temperature reflects the maternal vaginal and rectal temperature, and therefore is usually lower in infants born to hypervent- I ilating and perspiring mothers.

In three cases of fetal distress related to partial abruptio placentae in late labor I there were fetal tachycardia and significantly higher maternal vaginal and rectal temperatures and subsequent higher newborn rectal temperatures, The newborn UA pH values were below 7.22. It is postulated that such cases of fetal tachycardia represent fetal hyperthermia due to inadequate placental mechanisms for fetal I heat transfer. I I I I I I I I 91 Society of Per±natal Obstetricians Annual Meeting San Antonio, Texas I February, 1982

’AVOIDING IATROGENIC PREMATURITY IN ELECTIVE REPEAT CESAREAN BIRTH: A ROLE I FOR AMNIOTIC FLUID PHOSPHATIDYLGLYCEROL (AF PG)? Thomas L. Gross, M.D., Robert J. Sokol, M.D., Margaret V. Wilson, Paul M. Kuhnert, Ph.D. and Melinda S. Kwong, M.D. (Departments of Obstetrics and Gynecology, Pedia- I trics and the Per±natal Clinical Research Center, Cleveland Metropolitan General Hospital/Case Western Reserve University) Amniocentesis and determination of the lecithin/sphingomyelin ratio (L/S) prior I to elective repeat cesarean is an accepted method of avoiding hyaline membrane d~- ease (HMD), but other less severe neonatal complications of preterm delivery might occur nonetheless. PG appears in amniotic fluid at a later gestational age ~han a mature L/S. In order to determine whether AF PG may be better than theL/Salone I in avoiding iatrogenic prematurity after elective repeat cesarean, 25 neonatal com- plications related to prenatal delivery were evaluated prospectively in 107 uncom- plicated pregnancies, in which the L/S obtained within 72 hours of cesarean deli- I very was mature (>2). Gravidas were managed based on the L/S and blind to AF PG results; HMD and transient tachypnea of the newborn were diagnosed on strict clin- ical and radiologic criteria by a single neonatologist, blind to all AF results. I Obstetric estimates of gestational age were based on historical and ultrasound c~- teria, pediatric estimates were based on modified Dubowitz examination of the neo- nate. Differences between the 20 pregnancies with negative AF PG and the other 87 I in which AF PG was positive (>2%) were tested by ~2 analyses and t tests as appro- priate, a p < .05 was considered significant.

L/S > 2:1 PG < 2% PG ~ 2% I (n " 20) (n - 87) Obstetric estimate gestatlonal age ~± SO weeks) 38.2 ± 2.0 39.1 ± 1.2 NS Birthwelght (~ ± $D grams) 3080 ± 539 3259 ± 415 Ng

Neonatal complications Admission to NICD 25% 5% .005 I

Physiologic Jaundice 100% 61% .0001 Maximal serum btltrubln ([ ± SD mg/dl) 11.2 ± 2.2 9.3 ± 2.0 .01

Transient tachypnea 35% 8% .01 02 admxnistered > 6 hours 15% 0% .005 Arterial blood gases obtained 15% 0% .005 I Chest \ ray obtained 35% 11% .01 Intravenous llne placed 10% 0% .Ol

Pediatric estimate gesta~ional age (~ ± Sb weeks) 37.4 ! 1.9 39.~ ± 1.4 .001 Delivered prcterm (<38 "ped£atrlc" weeks) 40% 5% .00001 As shown in the Table, even though the obstetric estimates of gestational age I and infant birthweights in the two groups of pregnancies with positive L/S were not different, the PG negative group was significantly more likely to be admitted to the Neonatal Intensive Care Unit and to have excess of complications and related I procedures attributable to preterm delivery. In the PG negative group, the pedia- tric estimate of gestational age was 0.8 weeks less than the obstetric estimate (p<.05). PG negative infants were born nearly two weeks earlier than PG positive I infants; indeed, based on the pediatric estimate of gestational age, eight of 20 infants in the PG negative group were inadvertently delivered prematurely, i.e., before full term. The key finding of this study is that neonates delivered by elective repeat I cesarean with a positive L/S, but negative AF PG are at increased risk for iatro- genic preterm delivery. Although no tragic complications, such as neonatal mortab ity or HMD occurred in this series in which the L/S alone was used to document fe- I tal pulmonary maturity, it appears that neonatal complications could be further re- duced by awaiting appearance of AF PG before elective repeat cesarean. In this series, AF PG was superior to both the best obstetric estimate of gestational age I and a positive L/S as an indicator that full term had been reached, i.e., that complications related to "mild" prematurity would not occur. Thus, the results of this study suggest that in patients for whom amniocentesis prior to elective re- peat cesarean is planned, AF PG should be determined and delivery deferred unless I it is positive. 92 I Society of Perinatal Obstetricians I Annual Meeting San Antonio, Texas I February, 1982 AMNIOTIC FLUID PHOSPHOLIPIDS AND RISK FOR TRANSIENT TACHYPNEA OF THE NEWBORN Thomas L. Gross, M.D. Robert J. Sokol, M.D., Margaret V. Wilson, Paul M. Kuhnert, I Ph.D., Melinda Kwong, M.D. and Victor Hirsch, B.S. (Department of Obstetrics and Gynecology and Pediatrics and the Perinatal Clinical Research Center, Cleveland Metropolitan General Hospital/Case Western Reserve ~iversity) I Transient tachypnea of the newborn (TTN) has not been previously considered to be an important neonatal complication. However, we have found an increase in neo- natal morbidity in infants with TTN including significant increases in Neonatal I Intensive Care Unit admissions, umbilical artery catheterization, prolonged oxygen therapy and prolonged hospital stay. Previous studies have been unclear as to which perinatal factors are associated with TTN. Some studies have found the I disease occurs only at term gestation while others have reported prematurity is a factor. In the present study 12 perinatal factors that have previously been relat- ed to TTN were compared in a group of 55 neonates developing TTN and a group of 355 newborns in which no respiratory disease developed. In all pregnancies an amnio- I centesis to evaluate fetal lung maturity was performed within 7 days of delivery. Obstetric estimate of gestational age was based on historical and ultrasound cri- teria, pediatric estimate was based on modified Dubowitz examination of tlne neonate I Hyaline membrane disease (HMD) and TTN were diagnosed by one neonatologist using standard X-ray and clinical criteria. HMD and other neonatal problems known to cause tachypnea were excluded. Univariate differences between the two groups were I examined by X2 analysis and stepwise discriminant analysis was used to test the multivariate relationships. TTN (~5) No TTN (355) p <

Pediatric Gestational Age < 38 wks. 49% 24% .0001 I Amniotic Fluid PG 44% 79% .000001 ~ Diabetes Mellitus 22% 18% NS Cesarean section 58% 53% NS General Anesthesia 27% 18% NS One min. Apgar < 7 35% 15% .0006 I M~le infant 62% ~B% NB As shown in the table, prematurity, low Apgar score and absent amniotic fluid phosphatidylglycerol (PG) were followed, by an increase in TTN. Amniotic fluid I PG was less common in the owerall TTNigroup and was also significantly less common in the TTN patients at term gestation. The seven perinatal factors with the low- est p values shown in the table were subjected to stepwise discriminant analysis. In the multivariate setting only factors related to prematurity (low gestational I age and absent amniotic fluid PG) and asphyxia were found to contribute signifi- cantly to the classification of TTN. Pulmonary irmnaturity and low Apgar were re- lated significantly with a p <.001. A number of previously reported factors are I not risks once gestational age is controlled for. These findings suggest that fun maturation may be a factor in TTN. As HMD decreases, TTN will likely increase in importance as a cause of neo- I natal morbidity. In spite of this, most fetal maturity studies still exclude these patients from consideration. This is likely related to the fact that even though retained lung fluid is felt to be a causative factor the final etiology remains I obscure. In the present study the relationship with mild fetal pulmonary immatur- ity is contrary to many previous reports and suggests that increased research into I this disease is justified. I I 93 Society of Perinatal Obstetricians Annual Meeting I San Antonio, Texas February, 1982 I BIPARIETAL DIAMETER AND PREMATURE RUPTURE OF THE MEMBRANES: ERRORS IN ESTIMATING GESTATIONAL AGE Philip Halvorsen, M.D., Ivan E. Zador, Ph.D. and Robert J. Sokol, M.D., Department I of Obstetrics and Gynecology and the Perinatal Clinical Research Center, Cleveland’ Metropolitan General Hospital/Case Western Reserve University The accuracy of the clinician’s estimate of gestational age (GA) has been re- I ported to affect the management of preterm labor and, hence, the survival chances of the very low birthweight infant. The clinician’s estimate may, in turn, be in- fluenced by his/her realtime sonographic measurement of the fetal biparietal dia- I meter (BPD). The experience on our clinical service suggested that the BPD might not be reflecting the GA of the fetus accurately in preterm pregnancies complica~ by premature rupture of the membranes (PROM). Our purpose in this study was to evaluate the effect of PROM on the relationship between the sonographically meas- I ured BPD and the true GA of the fetus. Of 2510 consecutive pregnancies for which the BPD was obtained on sonographic examination at or beyond 20 weeks’ gestation, 122 (4.9%) were complicated by PROM I and 2388 were not. PROM was documented both clinically (fluid leakage, positive fern and Nitrazine tests) and sonographically. For pregnancies with and without PROM, the relationship, if any, between BPD and GA at the time of examination was I determined by regression analysis. GA was based on modified Dubowitz examination of the neonate in the nursery. The regression equations obtained were then com- pared by F test. Because of the potential clinical importance of this problem in early preterm labor, as a final step, the analysis was repeated including only I pregnancies of < 30 weeks. Correlation Number Re~ression Equation Coefficlent ALL PATIENTS I PROM 122 GA=0.290 BPD ÷ 10.53 .83 .0001 NO PROM 2388 GA=0.292 BPD ÷ 9.05 .89 .000! pREGNANCIES ! 30 weeks PROM 24 0A=0.155 BPD + 18.25 .25 NB NO PROM 820 CA=0.225 BPD + 11.7! .64 .0001 For the whole series, the regression lines, as shown in the Table, were found I to be significantly different (F = 17.2, p < .Ol)--although the slopes are the same, in the presence of PROM the BPD underestimates the true GA of the fetus by 1.5 weeks. For pregnancies at < 30 weeks, the regressions also differ, since the I BPD does not relate significantly to GA in the presence of PROM. These results were not accounted for by differences in fetal growth, there being no significant differences in the distributions of birthweight percentiles between pregnancies I with and without PROM. The results of this study indicate that at a given GA, the sonographically measured BPD is smaller than expected in the presence of PROM. It may be specula- ted that this might result from fetal compression in the absence of amniotic flu~; i the fetal head may be narrowed and lengthened in these circumstances. If, in the presence of PROM, the clinician were to use the measured BPD to estimate GA, he/she would be led to helieve that the pregnancy was 1.5 weeks less far along than was I actually the case, leading to less than optimal management. Thus, these findings have two important clinical implications, i) They suggest that beyond the early third trimester, a more accurate estimate of the true fetal GA can be obtained in I the presence of PROM by adding 1.5 weeks to the estimate obtained from the measured BPD. 2) If the membranes have ruptured in the critical late second or early third :trimester, it appears that the BPD cannot be used to predict gestational age re- liably. Management decisions for the very low weight fetus would p=obably be bet- I ter based on other criteria. Further studies of antenatal assessment of fetal viability, i.e., chance for survival, might lead to improved pregnancy outcomes for this very high risk group. I

94 Society of Perinatal Obstetricians I Annual Meeting San Antonio, Texas I February, 1982

I A DOUBLE-BLIND TRIAL OF 17 ~ HYDROXYPROGESTERONE CAPROATE IN THE ACTIVE DUTY MILITARY PREGNANCY J.C. Hauth, M.D., L.C. Gilstrap, III, M.D., A.L. Brekken, M.D., I J. Hauth, B.So (Department of Obstetrics and Gynecology, Wilford Hall USAF Medical Center, Lackland Air Force Base, I Texas)

That active duty pregnant women are at increased risk for I low birth weight infants and a higher perinatal mortality rate was confirmed in a prospective, double-blind study to test the efficacy of 17 ~ hydroxyprogesterone (17~OH-P) in I preventing these complications. Entry into the protocol was between 16 and 20 weeks. There were three groups: a) 80 patients who received (17~OH-P), I b) 88 patients who received the placebo and c) 78 patients who declined the protocol. These groups were similar for parity, previous abortion, race, cigarette smoking, and I marital status. 17~OH-P Placebo Declined I #8o #88 .... #78 Infant <2500 gm (6) 7.5% (8) 9.1% (9) 11,5% I Perinatal Mortality (3) 3,8% (3) 3.4% (2) 2.6% There was no significant difference between these three groups with regard to pregnancy outcome and complications.

I However, the active duty population had a significantly worse outcome with regard to perinatal mortality (p=.001) and infants <2500 gms (p<.01) when compared to our dependent I population. Thus, the active duty pregnancy is at increased risk of an I adverse outcome but that risk was not altered by prolonged 17~OH-P therapy or antenatal care in a high risk clinic I staffed by specialists in Maternal-Fetal Medicine. I I I i 95 Society of Perinatal Obstetricians Annual Meeting San Antonio, Texas February, 1982

FETAL LIMB MEASUREMENTS AS INDICATORS OF INTRAUTERINE GROWTH I Robert H. Hayashi, M.D., Julian C. Schink, B.A., Dora Cavazos, L.V.N. (Depart- ment of Obstetrics and Gynecology, The University of Texas Health Science Center at San Antonio, Texas.) I

Ultrasound measurements of fetal limbs as indicators of fetal development has previously been described by Queenan, 1980 and reported to SPO last year by I his group. Normative data throughout gestation has not been published yet.

We report our normative data on 255 measurements of fetal femur lengths (FFL), I obtained by real-time ultrasonography (Toshiba SAL-20A, 3.5 mHz) between 16 to 40 weeks, and collected in a cross-sectional manner. The data was obtained by one person (DC) who was practiced and confident in obtaining a I satisfactory fetal femur image before entering the data. Electronic calipers with imm readout were used for measurements. All subjects were Mexican- Americans, and had a singleton gestation, normal prenatal course and the birth- weight was within two standard deviation for gestational age for our own I population.

Linear regression analysis of these data were as follows: I

i. FFL vs. Gestational Weeks. N R S intercept signif. 255 0.88019 0.19290 -0.67618 <.001 I 2. FFL vs. BPD 255 0.88767 0.77731 -0.78753 <.001

These data suggest that FFL and BPD measurements may improve gestational age I assessment much the way a second ultrasound exam does. (We are currently evaluating neonatal thigh measurements in correlation to I weight. We hope to present our preliminary data by 2/82.) I I I I I I 96 I Society of Perinatal Obstetricians I Annual Meeting San Antonio, Texas I February, 1982 EFFECT OF DIETARY FIBER ON GLUCOSE TOLERANCE IN PREGNANCY

G.O. Herman, M. D., S.G. Gabbe, M. D., A.W. Cohen, M. D., S.S.Schwartz, M.D., I Department of Obstetrics and Gynecology, Jerrold R. Golding Division of Fetal Medicine, Hospital of the University of Pennsylvania, 3400 Spruce I Street, Philadelphia, PA 19104 Normalization of maternal blood sugar is essential for good fetal outcome in pregnancies complicated by diabetes mellitus. In the gestational dia- I betic, this goal is approached using a diet which eliminates concentrated carbohydrates while providing adequate calories and protein. Failures of such dietary therapy do occur, however. Deterioration of maternal glucose tolerance with the eventual need for insulin therapy, as well as, physical I and biochemical abnormalities in the newborn child such as macrosomia and hypoglycemia are still observed.

I In non-pregnant patients, an alternative diet based on the ingestion of large amounts of soluble dietary fiber has been shown to have substantial hypoglycemic properties. The mechanism for the improved glucose tolerance is not fully understood but apparently relates to the fiber temporarily I "trapping" glucose in thegut with its subsequent gradual release into the circulation. Because gastrointestinal physiology is substantially altered in pregnancy, it is not known if a high fiber diet would be useful in preg- I nancy.

Paired oral glucose tolerance tests (GTT) were performed during the third I trimester of pregnancy. Normal pregnant women (n=14) and gestational diabetics (n=4) were first given a standard i00 gram oral GTT, and plasma levels of glucose and insulin were determined in the fasting state and 60, 120, and 180 minutes after ingestion of the glucose load. Several days later, I a second GTT was done. In this test, glucose was combined with 15 grams of guar gum, a purified soluble dietary fiber. Improved glucose tolerance was documented in all but one patient. Guar gum produced a significant I reduction in mean plasma glucose levels at 1 hour (p<.005), 2 hours (p<.005), and 3 hours (p<.005), and each of the four gestational diabetics tested I showed a normal glucose tolerance curve. The soluble dietary fiber, guar gum, did limit the post-challenge rise of plasma glucose in pregnant subjects. Furthermore, the improvement in glucose tolerance in gestational diabetics is sufficient to suggest potential clin- I ical value for dietary fiber in the treatment of this disorder. I I I I I 97 Society of Perinatal Obstetricians An~ual Meeting San Antonio, Texas I February, 1982 I

DOES IN-UTERO TRANSPORT IMPROVE SURVIVAL OF VERY LOW BIRTHWEIGHT INFANTS?

D.E. Hickok, M.D.,M.P.H., K.K. Shy, M.D.,M.P.H., D.A. Luthy, M.D., T.S. I Inui, M.D. (Departments o[Obstetrics and Gynecology and Internal Medicine, University of Washington, Seattle, Washington) I In-utero transport of infants expected to require neonatal intensive care has been advocated as a method to improve survival. We examined the efficacy of this practice by reviewing records of 225 very low I birthweight (VLBW, 700-1500 grams) infants born in King County, Washington over a three year time period 1977-1979. To reduce possible bias resul- ting from selective referral, a population-based ascertainment of cases was accomplished by reviewing birth records in all thirteen I community hospitals with obstetrical facilities and the one tertiary referral center. 112 VLBW infants were born in community hospitals; 95 were transported as neonates to the tertiary center, and 18 remained in I their community hospitals. The mortality of all VLBW infants was 39%. Differences in mortality I rates between maternal transports and community-born infants were adjus- ted for maternal pregnancy and delivery complications, infant birthweight, gestational age and sex. Maternal transport was associated with 16% im- provement in survival (95% CI = 5% - 27%). Although cesarean section, I fetal monitoring and use of labor-inhibiting agents were utilized more frequently at the tertiary center, none of these factors explained the observed risk difference. I

We conclude: l) maternal transport reduced mortality in VLBW infants; 2) only 50% of VLBW infants had the benefit of maternal transport; and I 3) greater effort should be placed in the development of regional systems for the in-utero transport of infants who may be expected to require intensive care. I I I I I I I 98 I Society of Perinatal Obstetricians I Annual Meeting San Antonio, Texas I February, 1982 I TH~ RELIABILITY OF FETAL ACID-BASE DETErmINATIONS FORTHJ~ PREDICTION OF NORMAL APGAR SCORES: A RFAPPRAISAL USING THE 5 MINUT~ SCORE

J0 M. Hutson, M. D., Eo T. Bowe, M. D. and R. H. Petrie, M. D. (Section of I Perinatal Obstetrics, Division of Perinatal Medicine, College of Physicians and Surgeons of Columbia University, New York, New York) I Fetal surveillance by assessment of fetal acid-base status is relied upon by many clinicians and investigators for fetal management and prediction of neonatal outcome. This methodology is usually combined with fetal heart rate monitoring to define the limits of the safety of labor continuation I and to establish the point of appropriate intervention to avoid damage to the fetus from acidosis. To a considerable extent the reliability of this form of fetal surveillance is based on a 1970 study which assessed intrapart- I umacid-base status in 355 fetuses using fetal capillary blood for deter- mination of pH as the only fetal surveillance system. The use of pH alone without associated electronic monitoringmakes this study essentially ir- I reproducible today. There was a lack of correlation betweenpH and the 1 minute Apgar score in 18% of cases. In that study 10.4% of the fetuses had normal pH values (>7.20)_ but were I depressed at 1 minute (Apgar score of <6), i.e. "false normals." Reexam- ination of the data from this group in-relat-i~n to the 5 minute Apgar score decreases the incidence of "false normals" from 10.4% to approximately I 1.7%. The mechanism for this shift most probably relates to vagal stimu- lationwhichmay occur during delivery and vigorous resuscitation result- ing in depression at 1 minute but recovery by 5 minutes. This 5 minute I finding is clinically significant as a measure of the reliability of an accepted normal pH value obtained by fetal capillary blood sampling to be a reassuring indicator of fetal well-being. In the original study 7.4% of the fetuses had abnormal pH values (<7.20) and were vigorous at 1 min- I ute (Apgar score >6), i.e. "false abnormals." Independent evaluation re- veals that this group most probably results from fetal respiratory acid- osis which is corrected by respiratory el"~mination of CO~ resulting in a I good Apgarscore. "False abnormal" pH values may be clari[ied by fetal cap- illary blood measurement of base excess thus differentiating metabolic and respiratory etiologies of the acidosis and enabling the clinician to I avoid unnecessary surgical intervention for delivery. Another etiologic factor, maternal acidosis, can be assessed by comparison of fetal and mat- ernal base excess values. These 1 minute data based on the acid-base de- I penden’~ variable cannot be reexamined retrospectively. The 5minuteApgar score has been shown to be a more dependable predictor of long term neonatal outcome and lack of neurological impairment than the I 1 minute score. The reexamination of the original 1 minute acid-base/ Apgar score dat~~ which resulted in a better association between a normal fetal acid-base value and a good 5 minute Apgar score allows this method of fetal surveillance to be depended upon as an even more reliable indica- I tor of fetal well-being. I I 99 Society of Perinatal Obstetricians Annual Meeting San Antonio, Texas I February, 1982

REGIONAL SKIN PERFUSION DURING PREGNANCY I M. Katz, M.D. and J.M. Roberts, M.D. (Department of Obstetrics, Gynaecology and Reproductive Sciences, University of California, San Francisco, CA 94143) In the past, indirect methods of estimating skin blood flow (SBF) indicated that I SBF increases linearly throughout pregnancy. Recent direct measurements of SBF in the finger pad, using a photo-electric flow sensing probe have shown that the in- creased perfusion of this vascular bed occurs only between the 20th and 30th weeks I ~f gestation. Using the same methods the following study was undertaken to docu- nent the pregnancy associated changes in skin perfusion in six different body cegions. I Ten healthy patients with normal pregnancies had each of five blood flow measur- ments at 16-18, 24-26, 32-34, 38-41 gestational weeks and a final one at 6-8 weeks ?ostpartum. Blood flow was measured (PPG-13, MedasonicsR, VasculabR) in the fol- lowing six regions: index finger pad, forearm, forehead, face, calf and toe. The I cesults are expressed as previously described by mm of Pulse Wave Amplitude (PWA), (Katz, et al, Am. J. Obstet. Gynecol. 137:30, 1980). the results indicate that skin perfusion during pregnancy is maximal at the finger I ?ad; followed in order by the face, forehead, forearm, toe and calf. Significant increases in skin perfusion occurred during pregnancy in all regions except the to~ ~nd calf, and returned to non-pregnant values at 6-8 weeks postpartum. The pattern )f increase in blood flow was different in different regions. While finger pad I ~nd face SBF increased only during the second trimester, forehead-SBF increased ~radually throughout gestation and forearm-SBF was significantly elevated only at term (see Figure). I [he results of this study suggest that skin anterioles in various body regions have Jifferent sensitivity to neural and humoral flow regulators during pregnancy. Documentation of skin perfusion changes or alterations in skin vascular response to I ~arious stimuli in normal and abnormal pregnancies may provide a new useful clini- cal tool for assessment of the gravid patient. I FOREARM FOREHEAD I (mm) ~ I INDEX FINGER FACE 40-

~ 14 30

PWA (mm) zo

Io

I I I I I o 16ol8 24-~’6:54-’:~6 TERM PP 16-18 24-26 34-:56 TERM PP WEEKS GESTATION I

Skin Blood Flow during pregnancy and postpartum (P.P.) expressed in mm of pulse I wave amplitude (PWA). *P~0.05 vs. previous measurement **~0.05 vs. control. Shaded area = normal non-pregnant control range. (Mean ± SD) I

100 Society of Perinatal Obstetricians I Annual Meeting San Antonio, Texas I February, 1982 LONGTERM PELVIC FOLLOWUP OF MOTHERS OF VAGINALLY DELIVERED MACROSOMIC INFANTS: A PROSPECTIVE RANDOMIZED CLINICAL TRIAL (RCT) OF EPISIOTOMY USING THE TYROLEAN STRESS I TEST (TST) RE Laxed, M.D., UR Loose, M.D., RU Inne, Ph.D., IM Tense, B.S., GR Cheatham, Jr., M.D. and RJ Sokol, M.D. (Department of Ob/Gyn, Division of Perineology, Mt. St. I Elsewhere Medical Center and School of Musical Medicine, East Hutzaplutz, N. J.) Episiotomy is believed by many clinicians not only to protect the perineum from laceration, but also to lead to improved longterm pelvic support. However, no RCT’s I of episiotomy and later pelvic support have been published. One reason for this lack of appropriate studies may be the difficulty of quantitating the degree of pelvic relaxation in the laboratory. To solve this problem, a recently rediscov- I ered method, the TST, first reported in 1850 (Rogers and Hammerstein, 1958) was adopted for this study. It seems that a monk, one Gregor Mendel, seven years after taking his vows, became interested in the process of fertilization while investi- gating variegation of peas. Working diligently one evening in the laboratory, I demonstrating Mendelian dominance with one of the sisters, who was in an unusual position, they were happened upon by the Abbot. As might be anticipated, Mendel was startled and emitted an intense yedel. An echo was appreciated by Mendel, but i not by the Abbot. Although the hills came alive with the sound of music, Mendel was relegated for the next 15 years to preparing pea soup. The sister in question was reported to have later become a Mother Superior. I For the current study, the TST was performed with the patient in the dorsal lithotomy position; a weighted speculum was gently placed in the vagina. The mean and deviated investigator then yodeled towards the introitus. If an echo was ap- preciated, the test was considered positive. Depending upon the number of rever- I berations, the test was graded i+ to 4+. A I+ test was taken to indicate mild pel- vic relaxation and 2+ and 3+ to indicate moderate and severe pelvic relaxation, With a 4+ test, Grofe’s "Grand Canyon Suite" could be heard in its entirety. I To test the hypothesis that episiotomy preserves pelvic support, 50 uninformed gravidas, delivered at random, consented to weekly followup over a 20 year period. One-half were compared for their response to the TST. Of 5 patients with 4+ TST’s, 8 had had gestational diabetes, as well as precipitate (recorded in the study as I unplanned homelike) deliveries. Of 20 patients without 4+ TST’s, all had devoted significant others (p < .01). The results of this study of episiotomy though c~earcut (pun intended), were I found to be confounded by ethnicity. Of the 5 patients with 4+ TST’s, 2 were from Philadelphia, one was a Native American, one was British aud the last, of Italian descent. For the patients from Philadelphia, a ringing sound, rather than yodelin~ I was found to be most appropriate. The expected bell-shaped curve was obtained for these patients. For the Native American, the reliability of the test was improved by the investigator’s smoking one cigarette precisely i00 millimeters in length. While an auditory response was not obtained from this patient, a visual interpre- I tation of the patterns of smoke provided a clear end point for the test. No res- ponse was obtained from the British subject due, apparently, to the "Lost Chord" phenomenon. Finally, for the patient of Italian descent, the Callas Modification I was developed. In this version of the test, the investigator, rather than yodelinl sang a coloratura aria. If a duet, trio, quartet, quintet or sextet were to be appreciated, the test would be considered to be positive at the Grade II through I Grade VI level, as with heart murmurs. In this case, the resulting choral effects were well reviewed in "Opera News." In conclusion, this study suggests that until yodeling is made a part of all medical school curricula, preferably under the aegis of the Department of Ob/Gyn, I this valuable test will not be used with the frequency (and amplitude) which it so richly deserves. This abstract clearly indicates that some perinatologists will I read anything on paper. I01 I I FETOMATERNAL BLEEDING FOLLOWING DIAGNOSTIC AMNIOCENTESIS

A.S. Lele, M.D., P.J. Carmody, Ph.D., M. Hurd, R.N. and J.A. O’Leary, M.D. I (Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, State University of New York at Buffalo)

The frequency of diagnostic amniocentesis is increasing, especially in regional I perinatal centers. The following project was undertaken to study (I) the incidence of Fetomaternal (FM) bleeding associated with amniocentesis (2) the relationship of such bleeding to location of the placenta and (3) to evaluate I the sensitivity of techniques of modified Kleihauer, Betke (K.B.) staining and maternal serum alpha-fetoprotein (AFP) levels for detection of FM bleeding associated with amniocentesis. i An ultrasound scan was performed immediately before amniocentesis. Blood samples for K.Bo staining and AFP were drawn before and i0 to 15 minutes after amniocentesis. One hundred and seven patients underwent iii amniocentesis I attempts. Ninety-five patients had genetic amniocentesis, 21 patients had fetal maturity studies and four patients had amniocentesis for Rh sensitization follow-up. In 75% of patients with anterior placenta and in 89.4% of patients I with posterior placenta, clear amniotic fluid was obtained. Incidence of blood stained or bloody fluid was 8.76% in posterior placenta. Incidence of bloody or blood stained fluid was significantly higher, 23.72% in anterior placents (p = 0.05). I

Two patients were diagnosed to have FM bleeding by K.B. staining. A difference of 5 fetal cells/50 low power fields was taken to be indicative of FM bleeding. I Eight patients were diagnosed to have FM bleeding by AFP technique. A 40% rise in postamniocentesis maternal serum sample, over preamniocentesis sample was taken to be indicative of FM bleeding. AFP assay was found to be a more I sensitive method for diagnosis by FM bleeding (p = .01).

The incidence of fetal complications, i.e., fetal death in eight patients with I FM bleeding was 16.6% and in 89 patients without FM bleeding was 1.1%. Occur- rence of FM bleeding was associated with increased risk of fetal death (p = 0.02).

All Rh negative non-sensitized patients were given 300 pgm of anti Rh immuno- I ~lobulin. None of these patients including one patient with amniocentesis associated FM bleeding’showed evidence of sensitization at the end of pregnancy.I Use of AFP levels to identify patients at risk of sensitization following I amniocentesis is proposed, if routine prophylactic postamniocentesis anti Rh immunoglobulin is not offered to non-sensitized patients. I I I I 102 I Society of Perinatal Obstetricians Annual Meeting San Antonio, Texas February, 1982

I PYELONEPHRITIS IN PREGNANCY: A PROSPECTIVE RANDOMIZED CONTROLLED TRIAL EVALUATING SUPPRESSIVE THERAPY WITH NITROFURANTOIN IN PREVENTING RECURRENT I DISEASE R.R. Lenke, M.D., J.P. VanDorsten, M.D. and B.S. Schifrin, M.D., Saint Francis Hospital and Medical Center, Hartford, Connecticut and Los Angeles I County/USC Medical Center, Los Angeles, California The efficacy of suppressive therapy in preventing recurrent disease was prospectively evaluated in 200 women whose pregnancies were complicated I by pyelonephritis. The incidences of recurrent pyelonephritis in the nitrofurantoin and control groups were 7% and 8% respectively. The results cast doubt on the need for suppressive therapy, and instead dramatized the I beneficial effects of close surveillance with cultures.

We also redefined the amount of bacteriuria necessary for a "significant" culture. Patients with Gram negative bacilluria of~10.5 col/ml had an I appreciable risk (>30%) of subsequently maintaining a positive culture or developing pyelonephritis. The prompt treatment of Gram negative bacilluria, regardless of colony count, appeared to be a critical factor I in preventing recurrent disease. I I I I I I I I I

103 Society of Perinatal Obstetricians Annual Meeting San Antonio, Texas February, 1982

ELASTIN IN THE UTERINE CERVIX I P.D. Leppert,*M.D., S. Keller, Ph.D., M. Clark and I. Mandl, Ph.D. (Departments of Obstetrics and Gynecology and Pediatrics and Pathology, Columbia University College of Physicians and Surgeons, New York, NY) I To. account for the dilatation and effacement of the cervix during parturition a high degree of extensibility and elastic recoil is essential. This functional requirement can be met by the unique connective tissue protein elastin which we I have demonstrated to be present in human, monkey and sheep cervices. The levels determined by biochemical analysis based on the content of the characteristic crosslinking amino acid markers desmosine and isodesmosine were comparable to I those found in other soft tissues such as skin and lung. In normal sub- jects the proportions of elastin in the total connective tissue remained stable at 1.54-1.57% in the non-pregnant human cervix and at various stages of gesta- tion. Slightly lower proportions of 0.9% were determined during labor at term I in a multipara who underwent cesarean section hysterectomy. However, it cannot be ruled out that this deviation is due to increased levels of collagen rather than decreased levels of elastin. Both cycling and non-cycling monkey cervices I contained somewhat higher proportions of 1.7~2.5% elastin. Similar results were obtained on analysis of sheep cervices, with little difference between non- pregnant animals, ewes at 109 through 133 days gestation and 7 or 8 days post- I partum.

A qualitative difference between the elastin extracted from non-pregnant and pregnant cervices of human or adolescent sheep origin is suggested by the i presence in non-pregnant cervices only of an unusual lysine derived crosslink, distinct from desmosine, isodesmosine and other known amino acids. Significant differences in the organization of the fibrillar network and amino acid compo- ! sition appear to be characteristic of the incompetent human cervix. Although mature crosslinked elastin could be detected there was a decrease in the relative number of crosslinks. These observations indicate that elastin plays a major I role in the dilatation of the cervix and may be implicated in the clinical outcome of pregnancies.

Associate Member of the Society of Perinatal Obstetricians I I I I I I

104 Society of Perinatal Obstetricians I Annual Meeting San Antonio, Texas I February, 1982 EFFECT OF HEXOPRENALINE ON UTERO-PLACENTAL BLOOD FLOW I Jeffrey Lipshitz, M.B.Ch.B., Robert A. Ahokas, Ph.D., Karen Broyles, B.S. and Garland D. Anderson, M.D. (Department of Obstetrics and Gynecology, Division of Maternal/Fetal Medicine, The University of Tennessee College of Medicine, I Memphis, Tennessee)

A placebo controlled, double-blind trial was performed on 13 Sprague-Dawley rats I on day 14 of gestation to study the effects of hexoprenaline on the distribution of cardiac output (CO). Catheters were placed under ether anesthesia and the animals allowed to recover for three hours. Baseline values of CO and blood flow I to the uterus, placenta, ovary, vagina, kidney, spleen, heart and lungs were obtained using radioactive labelled 15 ~ microspheres (113Sn or 153Gd). An intra- venous bolus of hexoprenaline (0.5 ~g/kg = 0.27 ml/kg) or placebo was administered and immediately followed by a 30 minute infusion of hexoprenaline (0.I ~g/kg/min) I or placebo. Maternal heart rate and blood pressure was continuously recorded. Upon completion of the infusion the alternate microspheres were injected.

I The placebo had no effect on any of the parameters. (See Table) Hexoprenaline produced a maternal tachycardia and decrease in blood pressure. Cardiac output was unaffected. Blood flow and CO to the myometrium, ovaries, vagina, spleen, I heart and lungs was unaltered. A decrease in % CO and blood flow to the kidney was noted. Percent cardiac output and blood flow to the placentas was markedly increased (229% and 198% respectively).

I It is possible that the effect of hexoprenaline on the placental blood flow was to reverse the "stress effects" of surgery. This has potential application in I certain clinical situations to reverse a decrease in utero-placental blood flow. Before Drug After Drug Treatment I Hexoprenaline (N=7) Placebo (N=6) Hexoprenaline Placebo P-Value I Cardiovascular Cardiac output lOOg 32,42 ± 4.93 26.90 ± 4.57 30.90 ± 6.89 31.06 ± 4.66 .96 .04" Heart rate 396.9 + 72.3 365.0 4- 24.3 424.6 ± 41.7 374.7 ± 32.4 .01" I Mean BP (mm Hg) 97.7 ± 22.9 108.2 ± 13.4 82.7 ± 19.5 115.3 ± 18.8 Systolic BP 129.0 ± 25.0 138.2 -+ 15.5 117.8 ± 28.1 144.7 ± 21.6 .08

Diastolic BP 79.1 ± 20.4 88.3 + 14.8 64.1 ± 18.6 96.0 ± 15.8 .007"

I II Blood Flow/l.O 9 tissue 6.00 ± 1.06 4.89 ± 1.35 4.54 ± 1.73 5.34 ± 1.31 .37 Kidney (.005)**

Uterus .558 ± 1.74 .466 ± .191 .556 ± .125 .529 ± .188 .76 I .075 ± .037 .05" .049 ± .028 .065 ± .053 .146 ± .071 Placenta (.004)**

III Cardiac Output I 14.01 ± 2.59 15.68 ± 4.98 10.90 ± 3.52 14.54 ± 3.23 .O8 Kidney (.01)**

Uterus 1.27 ± .39 1.26 ± .67 1.34 ± .31 1.18 ± ,26 .34 Placenta ,141 ± .066 .193 ± .128 .465 ± .197 .224 ± .118 .02 I (.001)**

*Significant difference between hexoprenaline and placebo (Students t-test) **Significant change within hexoprenaline group (paired t-test) I ± Standard Deviation

I05 :\nnu,’~l >k,,,rin~ Snn Antoni¢ , "l’ext~s February, ~982 I

EXPERIENCE WITH PRENATAL DIAGNOSIS OF THE TAR SYNDROME I

David A. Luthy, M.D. and Edith Cheng, M.S. (Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington 98195 I (206) 543-3714)

Thrombocytopenia with absent radius (TAR) syndrome is an autosomal recessive disorder in which congenital hypoproliferative thrombocytopenia I and absent radii are constant features. Our experience with prenatal diagnos~s of the TAR syndrome is reviewed. Eight pregnancies at risk for this disorder were examined utilizing indirect fetal visualization. I The pregnancies were examined at 18 to 22 weeks gestation. There were five unaffected and three affected fetuses. The diagnosis was correct in all cases. The first seven cases were examined using fetal radiography I to visualize the presence or absence of the fetal radius to indicate an unaffected or affected fetus. In our most recent case, an affected fetus was detected utilizing a high resolution sector scanner (ATL) with a 5 mHx transducer. In this case, the fetal hand was observed to be at I right angles to the fetal forearm. Th~s was the first indication of an affected fetus. After fetal sedation, a deformed ulna was visualized and the fetal radius was not visualized, indicating an affected I fetus. .Examination of the fetus post-abortion revealed that the brachioradialis inserted at the base of the thumb and that this was partially responsible for the abnormal position of the fetal hand. I Accurate diagnosis of the TAR syndrome is available through indirect fetal visualization. With the new generation of high resolution sector scanners, this diagnosis can now be made by ultrasound. I I I I I I I I I 106 I Society of Perinatal Obstetricians I Annual Meeting San Antonio, Texas I February, 1982 AMNIOTIC FLUID PHOSPHOLIPID PROFILE IN FETUSES AT RISK F.G. Mariona, M.D., Department of Obstetrics and Gynecology, Division of Maternal I Fetal Medicine, Hugh Yee, Ph.D., M.J. Espy, M.D., Department of Obstetrics and Gynecology, J.D. Artiss, Ph.D., Department of Pathology, B. Jackson, B.S., I Department of Pathology (Hutzel Hospital/Wayne State University, Detroit, MI) The critical role for the accurate determination of fetal lung maturation is generally accepted. The widely used L/S ratio has proven its predictive I accuracy.with a low false positive rate of 5% for values greater than 2. How- ever, for L/S values less than 2, the false negative rate is about 58%, so that undue prolongation of a pregnancy may result that may increase the risk for the fetus. A number of factors may be responsible for this high false I negative rate. Chief among these are the great variety of modified analytical procedures differing from that of Gluck and the lack of agreement concerning the processing of the amniotic fluid for analysis. Oulton and other investi- I gators have demonstrated that centrifugation beyond 140 x g used in the initial preparatory step will remove substantial quantities of phospholipid material. Losses will also occur from the use of an acetone precipitation step. We have completed a thorough investigation of several of the analytical variables I during the initial phase of our study. Our findings have been utilized for the development of quantitative methods for the total phospholipid (as phos- phorus)(TPP) and lecithin (LT) concentrations of amniotic fluid. The TPP I method can be summarized as follows: (i) extraction of 1 ml of fresh uncentri- fuged amniotic fluid with 2:1 chloroform-methanol (2) evaporation of the solvents (3) digestion of the residue with sulfuric-perchloric acids containing I vanadium pentoxide (4) dilution of the digest and (5) removal of an aliquot for phosphate quantitation with molybdate and stannous chloride-hydrazine sulfate. The LT method consists of: (i) extraction of 1 ml of fresh uncentri fuged amniotic fluid with 2:1 chloroform-methanol (2) passage of the solvents I through a column of calcium hydroxy phosphate to remove all phospholipids except lecithin and sphingomyelin (3) evaporation of the solvents (4) selective hydrolysis of the lecithin with periodate-sulfuric acid to release inorganic I phosphate (5) dilution and (6) removal of an aliquot for phosphate quantitation. Note that both methods may be standardized against a weighed amount of inorganic I phosphate or lecithin. Phase II of the study consisted in the concomitant determination of TPP lecithin sphingomyelin and LT on amniotic fluid samples obtained in pregnant patients I between 30 and 40 weeks gestation, to retrospectively establish the normogram. Phase III of the study involved the prospective utilization of TPP and LT for the management of high risk pregnant patients at Hutzel Hospital/Wayne State I University Division of Maternal Fetal Medicine

A predictive value model was established that demonstrated that TPP has a specificity of 96% and lecithin of 94% with a false negative rate of 2.4% I in fetuses at high risk in our population. A true negative of 95.3% indicated I a predictive value of 97.5%. I

107 i San Antonio, Texas I PREGNANCY ALTERED GLUCOSE TOLERANCE IN NONHUMAN PRIMATES (MACACA FASCICULARIS) I P.J. Meis, M.D., J.R. Kaplan, Ph.D., J.C. Rose, Ph.D. (Departments of Obstetrics and Gynecology, Physiology and Comparative Medicine, Bowman Gray School of Medicine, Winston-Salem, N.C.) I

Although nonhuman primates have been used as animal models for manipulations of carbohydrate metabolism in pregnancy, little normative data are available I about effects of pregnancy on carbohydrate metabolism in a nonhuman primate species. To obtain information about the effects of pregnancy on glucose tolerance, we performed 136 intravenous glucose tolerance tests longitudinally I before and during pregnancy in a group of clinically heal~,hy cynomolgus monkeys (macaca fascicularis). All tests were performed under ketamine anesthesia (15 mg/kg) using an intravenous glucose bolus of 0.75 gm/kg. Blood was drawn prior to and at 5, i0, 20, 30, and 60 minutes after glucose I injection. The glucose clearance rate (k~ was calculated from log glucose values. Comparisons were made using one way analysis of variance and Scheffe’s test. I Nonpregnant ist Trimester 2nd Trimester 3rd Trimester I Fasting Glucose 68.2 ~ 2.67 59.6 + 2.23 59.2 + 3.69 59.5 + 2.56 k 3.47 ~ .19 4.06 + .17 3.72 + .17 3.01 + .19" I *p <0.05 compared with ist trimester I

These data indicate a significant reduction in glucose clearance rate over the course of pregnancy in a nonhuman primate species. This diminishment of glucose tolerance is similar to longitudinal studies performed in pregnant I women and suggests that this primate species may be a useful animal model to study metabolic alterations related to pregnancy. I I I I I I 108 i Society of Perinatal Obstetricians I Annual Meeting San Antonio, Texas ! February, 1982 SHORT TERM FHR VARIABILITY CORRELATION WITH F~IR REACTIVITY IN THE ANTEPARTUM FETUS I M. Nageotte, M.D., A.G. Freeman, W. Dorchester, B.S., and R.K. Freeman, M.D. (Women’s Hospital, Memorial Hospital Medical Center of Long Beach and Univ. of Ca. at Irvime, 0range, Ca.

! Two hundred and thirty six antepartum fetal heart rate studies were performed on 188 patients utilizing abdominal fetal electrocardiogram technique. Quantitation of short term variability was determined. Fifty percent of beat to beat interval I differences ranged between plus or minus one beat per minute and ninety nine per- cent of the interval differences were less than plus or minus 7.6 beats per minute. I Due to fetal-maternal electrocardiogram coincidence and other artifacts the actual number of true consecutive beat to beat intervals measured averaged 37 percent + 24% (2 standard deviations).

I No correlation could be found with gestational age or birth weight but post date pregnancy had significantly higher variability than did non-post date pregnancies (p~0.5). Because of an insufficient number of positive oxytocin challenge tests, I no statement can be made with respect to short term variability and test result. However, there was a trend towards reduced variability with a positive oxytocin challenge test.

I There was no significant correlation between the short term variability and the ratio of late decelerations to the total number of contractions. The presence of I variable decelerations also could not be correlated with short term variability. Fetal heart rate acceleration has been considered a function of heart rate varia- bility in antepartum heart rate testing. For this reason, the number of acceler- I ations per minute was correlated with various measures of short term variability. The most significant correlation was found between the percent of time that aversg~ Ishort term interval differences were less than 0.6 beats per minute (r=0.285). Other significant correlations were found with the total mean beat to beat inter- I val differences (r=0.210) and the ratio of positive to negative beat to beat in- terval differences (r=0.287). The least,but still significant correlation, was ! found with the differential index (r=0.143) Phis preliminary data shows a significant correlation between manually quantitated IFHR reactivity (accelerations/minute) and various measures of short term variabil- I ity measured from abdominal FECG interval differences. I I I I

109 Society of Perinatal Obstetricians Annual Meeting San Antonio, Texas ! February, 1982 ! CLINICAL SIGNIFICANCE OF LOW PLACENTAL IMPLANTATION ! E.R. Newton, M.D., V.A. Barss, M.D., C.L. Cetrulo, M.D. (Department of Obstetrics and Gynecology. Division of Perinatoiogy). St. Margaret’s Hospital for Women. Tufts University School of Medicine Affiliated H~spitals, Boston, MA. !

The advent of the use of ultrasound in the second trimester for dating and ! genetic amniocentesis have identified 5.3% of patients having low implantation. Ninety percent of these convert to normal implantation by term. (Rizos, et al Am J Obstet Gynecol 133: 287, 1979). Despite conversion to normal implantation, at least one author suggests an increase in maternal morbidity. Ballas S, et al ! (Obstet Gynecol 54 (I) July 1979) noted of 123 patients with low implantation, 20 had cesarean sections for bleeding. The current study is designed to evaluate the effects on maternal and infant welfare of low placental ! implantation defined by ultrasound. All ultrasounds performed at St. Margaret’s Hospital between October 1980 ! and September 1981 are reviewed. The charts of those with low implantation are reviewed and will be compared to matched controls of patients with normal implantation. The preliminary results of the first 74 patients with low implantations are as follows: 41 had previous damage to the uterus including ! primarily D&C’s and cesarean sections. Antenata! complications included: 8 patients with premature rupture of membranes, 7 patients with premature labor, 23 patients with third trimester bleeding, 12 patients with abruption, I patient ! with an intrauterine fetal death, 11 patients with anemia, 2 patients with intrauterine growth retardation, and I patient with fetal to maternal bleed. Intrapartum complications included: 21 patients with primary cesarean sections- 10 for bleeding or abruption and I for previa. Two patients had cesarean ! hysterectomy, and 7 mothers required transfusion. InfNnt complications are: 15 premature infants, 12 infants had low I minute and/or 5 minute Apgars, and 4 infants had perinatal deaths. !

The authors conclude from prelimina~7 results that despite only one patient with placenta previa at delivery, low implantation defined by I ultrasound forbodes multiple perinatal problems. The final results wil! be presented at the meeting. I I I I I ii0 i Society of Per±natal Obstetricians Annual Meeting I San Antonio, Texas February, 1982 I EFFECTS OF CEPHALIC 0D~RESSION IN THE FETAL

I W.F. O’Brien, L(DR, MC, USNR, S.E. Davis, CAPT, MC, USPHS, M~. Grissom, L(DR, MSC, USN and R .R. F~g, CAPT, USA (Department of Obstetrics and Gynecology, Uniformed Services University School of Medicine and Nuclear Sciences Division, I AFRRI, Bethesda, Md .) ~he physiologic effects of fetal cephalic compression (C~ are incompletely understood. We studied these effects in near tem (125-130 d) fetal lambs. I Pulse rate, aortic compression, blood gases, cardiac and cerebral blood flow, and regional cerebral distribution were monitored during and following compression at 200 tort. CCwas associated with a fall in pHand PO2 accom- I panied by a rise in base excess. Initital br~dycardia was followed by sus- tained tachycardia. Mean aortic pressure rose rapidly during the period of compression and persisted throughout the period of observation. Total I cerebral blood flow fell markedly during CCand this fall was most marked in the cortex with relative sparing of the brainstem. Ooronary blood flow was unchanged. We conclude that CCin the fetal lamb is accompanied by I marked changes in cerebral blood flow and cardiovascular homeostasis.

I (ml/min/lO0 g, X + S~) I OBGAN BASELINE 0DMPRESSION SIGNIFI Q~CE (DRTEX 140 ± 18 21 ± 15 <0 ~I I SUBOORTEK 152 ± 20 25 ± 17 <0 ~)i CERE~,LUM 163 ± 26 30 ± 21 <0 ~I I BRAINST~ 148 ± 24 35 ± 20 <0 ~31 I HEART 220 ± 35 213 +- 36 N .S. I I I I I I iii Society of i)erinat;ll Obs{~etrlclans Annual Meeting San Antonio, Texas I February, 1982 I I

EFFECTS OF SWINE INFLUENZA VACCINATION ON MATERNAL HEALTH AND PREGNANCY OUTCOME I

Paul L. Ogburn, Jr., M.D., F.AoC.O.G., Amos S. Deinard, M.D. (Department of Obstetrics and Gynecology and Department of Pediatrics, University I of Minnesota Hospitals, Minneapolis, Minnesota)

A prospective study compared pregnancies in women who received Influenza A/NJ8/76 (Infa/NJ) vaccination with those in women who did not. No I significant differences in the rates of maternal, fetal, or neonatal complications were seen in these two groups. I Infa/NJ may have been the virus causing the 1918 pandemic which killed 500,000 Americans. Maternal mortality at this time may have reached 27% of women with influenza and 50% of women with influenza pneumonia. I A significant drop in births in Minnesota was seen during this outbreak and may be related to increased maternal death rates. In 1957-1958, Asian influenza accounted for more maternal deaths than any other cause (20% of all maternal deaths) in Minnesota. I

The Department of Health, Education, and Welfare decided to offer Infa/NJ vaccine to pregnant patients because of presumed safety of the I vaccine and possible increased risk of influenza to pregnancy. 189 patients who elected irm~unization before or during their preg- I nancies were compared with 517 patients who elected not to be immunized. Reactions to immunizations occured in less than 3% of patients and included myalgia, headache, fever, malaise, chills, and cough. No uillain-Barre syndromes were seen. I

Pregnancy outcomes are tabulated below: IMMUNIZED NON-IMMUNIZED I TOTAL PATIENTS 189 517 Spontaneous Abortions 2 6 I Still births 1 1 Premature infants 18 55 Neonatal deaths 2 8 Congenital anomalies 19 67 I Abnormalities seen at 8 weeks of life 15 70 Apgar less than 7 at 1 minute 24 65 I at 5 minutes 6 17 Neurologically abnormal at 8 weeks 2 7 I I 112 I Society of Perinatal Obstetricians I Annual Meeting San Antonio, Texas I February, 1982 NORYd~L ULTRASONIC FETAL WEIGHT CURVE

I W.J. Ott, M.D., S. Doyle, R.N. (Department of Ob Gyn, Division of Perinatology, St. Louis University, and Department of OB GYN, I Division of Maternal-Fetal Medicine Washington University, St. Louis, M0) A combined prospective and retrospective study of normal fetal growth was I undertaken using ultrasound measurements from 186 normal obstetrical patients who had no obstetrical or medical complications and denied exposure to cigarette smoking, alcohol, or other drugs. They delivered normal AGA neonates at 38 thru I 41 weeks gestational age.

Fetal weight was calculated from biparietal diameter (BPD) and abdominal circumference (AC) values using a modified formula of Hobbins et al (personal I communication): log birth weight = -1.7492 + 0.166 BPD + 0.046 AC - 2.646 (BPD X AC) / i000. Mean weight of all infants delivered was 3,374.2 + 346.6 grams (Mean I + S.D. ). The ultrasonic weight curve was smoothed by dividing it into three splines: (A) 15 thru 24 weeks, (B) 25 thru 34 weeks, and (C) 35 thru 40 weeks. Figure 1 I illustrates this.curve. The best fit for each spline was: (A) y = ii. 39e"±l>x (r = .9249) (B) y = -4088 + 196_.6x (r = .9946) I (C) y = l134.6e-028x (r = .9249) Examination of the ultrasonic weight curve suggests three areas for further evaluation: NORMAL ULTII~x?~U~N~_W.EIOHTCURVE I (1)Weight values after 28 weeks of gestation are higher than standard fetal weight curves I and therefore actual fetal weight in the third I trimester may be greater than previously )ublished curves indicate. 2) There appears to be a fetal growth spurt | ,t 34 to 35 weeks gestation. I 3) There may be a more drastic decreasease in .he fetal growth rate than previous curves ~ I / I , ~l I of weight the r,~i~’at~, or an actual Io:~:~ ~n ~ I .ast 3 to 4 weeks of gestation. Though the study’was not designed to _ liagnose intrauterine growth retardation I IUGR) or acceleration (IUGA) ultrasonically ~alculated weights from 75 SGA and 105 LGA infants were plotted against the ultrasonic I weight curve. After 30 weeks gestation the sensitivity of the smoothed ultrasonic weight curve for the diagnosis of IUGR was 76.3% and I for the diagnosis of IUGA was 56.4%, with an overall specificity of 83.1%. I I 113 Society of Perinatal Obstetricians Annual Meeting San Antonio, Texas I February, 1982 I

MANAGEMENT OF THE TINY FETUS AND NEONATE

W.J. Ott, M.D., W.J. Keenan, M.D. (Department of Ob Gyn, Division of Perinatology, and Department of Pediatrics, Division of Neona- tology, St. Louis University, St. Louis, Missouri).

Advances in antenatal screening, intrapartum management, and neonatal care have all contributed to a significant improvement in perinatal mortality, espe- cially in low birth weight infants.

Prevention of premature delivery is a most desirable goal, but in many situations this is not possible or advisable. If delivery is immanent a decision must be made about the management of the small fetus in order to obtain an optimal neonatal outcome. For the last three years we have been utilizing as the keystone in the management of the small fetus an accurate~estimation of fetal weight by ultrasonic means (0tt WJ: Obstet Gynecol 57: 758, 1981). In those fetuses esti- mated to weigh between 750 and 1250 grams, the mother is offered a cesarean section delivery regardless of fetal presentation.

The overall neonatal survival rates (per i00) at our institution in infants weighing less than 2500 grams is listed below and compared to survival rates in the state of New York during the year 1957:

WEIGHT (grams) NEW YOR~ - 1957 SLU - 1978 to 1981 I

500 - 999 5.5 24.4 i000 - 1499 43.1 74.6 I 1500 - 1999 81.7 88.0 2000 - 2499 95.8 94.3 From January i, 1978 through December 31, 1980 there were 39 infants delivered I ~n the St. Louis University/St. Mary’s Health Center service that weighed between ~50 and 1250 grams. Nineteen of these infants were delivered by cesarean section ~nd sixteen (84.2%) survived. Twenty of the infants delivered vaginally and twelve I 60%) survived. There was an equal distribution of breech presentation in each iroup, and none of the fetuses received steroids to accelerate lung maturation.

Though not statistically significant we feel that this approach to the man- I ~gement of the tiny fetus is an appropriate one, and with further experience and reater numbers this trend in improved survival will prove to be statistically ~ignificant. I I I I 114 I Society of Perinatal Obstetricians Annual Meeting I San Antonio, Texas February, 1982 l The Low Birthweight Baby: a Clinical Study PelatingCord Blood Gases and Neonatal Complications to Outcome. l Richard p. Perkins, M.D.,Division of Maternal-Fetal Medicine, U. New Mexico. A detailed assessment of the neonatal courses of 78 babies with birth- weights under 2000g is presented. Included are 51 babies with BW <1500g. Cord I blood gas analysis was obtained on each and compared to initial neonatal values obtained in the ICU, including assessment of differential changes over time. Neonatal adverse events were noted and the influences of these upon outcome were I explored, including CAT scan evidence of intracranial hemorrhage (ICH). The latter was sought among 32 infants with BW ~ 1500g by an on-going protocol (Dr. L.-A. Papile). Mild to severe ICH was found in 11/32. In the study, 14/78 had BW <1000g with a 50% survival; 37/78 had BW i000- I 1499g with an 87% survival; and 27/78 were 1500g or more with a uniform survival. Gestational-age (GA)-related survivals were: <28 weeks= 50%; 28-30 weeks=73%; 31-33 weeks= 91%; and >33 weeks= 90%. SGA babies (20.5% of the total) showed a I 33.3% mortality, while AGA babies had only a 14.8% mortality (p=0.06). Half of those who died w~re SGA. Significant associations (p~0.05) were noted with mortality by BW, GA, RDS, I HMD, late metabolic acidosis (IMA), DIC, and air leaks. BW and GA correlated with one- and five-minute Apgar scores as well as with outcome. Anesthe~sia, cord gases, and mode of delivery were n_~ correlated with Apgars and outcome. Stepwise jacknifed discriminant analysis revealed that BW, NEC, hyperbilirubinemia, LMA, I and air leaks could correctly predict 65/70 outcomes. Among those dying, BW and C~ were not correlated with days of life, but a significant correlation was seen among survivors with lengTj~ of hospitalization. I Significant changes were observed between cord gases and D~onatal values inAPO2(UA/NN) and inApH, ~PO2, ApC02, and abicarb. (U~J/NN). ICH was not statistically associated with single variables such as BW, GA, I SGA, presentation, labor and delivery factors, RDS, HMD, hypotension, hypo- calcemia, Apgar scores, or even ultimate outcome. ICH was found by analysis Of variance to be associated with A pH (UA/NN)/roT but not with other cord/neonatal gas ~/alues or differential changes. Those babies with the most serious bleeds I had a significantly higher mean UV pO2 than those with mild hemorrhage (33.75 vs. 21.83 torr) but neither varied with those with no hemorrhage(25.43). Ste~wise l discriminant analysis of 31 ot!~r variables failed to turn up any association These studies may bear little relation to those utilizing ultrasound for I identification of patients with ICH. I I I I I 115 Society of Perinatal Obstetricians Annual Meeting San Antonio, Texas I February, 1982 I REVERSAL OF PREVIOUSLY IRREVERSIBLE FETAL PATHOPHYSIOLOGY. Robert E. Petres, M.D., Dwight P. Cruikshank, M.D., Fay O. Redwine, M.D. Department of Obstetrics and Gynecology, Medical College of Virginia, I Virginia Commonwealth University, Richmond, Virginia.

Diagnostic ultrasound is revolutionizing fetal medicine. Previously undiagnosable fetal conditions are now being diagnosed at earlier and I earlier stages of pregnancy. This development demands the evolution of active management plans to improve pregnancy outcome. Two cases recently managed with ultrasound diagnosis and intrauterine therapy illustrate I these principles. A 29 year old white female, gravida 2, para O, was referred for ultra- I sound examination at 26 weeks because of the clinical signs and symptoms of acute polyhydramnios. Ultrasound examination confirmed polyhydramnios and revealed a 70mm left flank cyst in the fetus thought to represent an obstructed left kidney. The cyst filled the left side of the abdomen from I the perineum to the diaphragm. Fetal renal cystocentesis was carried out once. The hydramnios disappeared in one week and the patient went on to deliver a normal-appearing male at 38 weeks gestation. Neonatal IVP I revealed ~ non-functioning left kidney.

A 26 year old white female, gravida 2, para I, was referred for ultra- sound at 36 weeks because of the clinical signs and symptoms of acute poly- I hydramnios. Ultrasound revealed bilateral collapse of the fetal lungs with hydrothoraces. This was thought to represent chylothorax. Transabdominal fetal thoracentesis produced 175 ml of clear yellow fluid. The right lung I was completely reexpanded following the procedure, but the fluid reaccumu- lated overnight with subsequent collapse of the lung. One week later, when the patient went into labor, a right-sided thoracentesis was repeated on I the fetus. The baby breathed spontaneously after delivery, and’chest x-ray revealed a fully expanded right lung. The left lung was re-expanded in the NICU with placement of chest tubes. After 5 days the tubes were removed, and the baby was discharged on the seventh day with no sequelae. I

Both cases demonstrate life threatening fetal conditions which were reversed in utero. In both instances fetal homeostatic mechanisms for I amniotic fluid volume were upset. -In the first instance this disruption was corrected remote from term by a single decompression. Fortunately in the second case, where reversal of the deranged control mechanism could l not be maintained, the baby was mature enough for delivery. However, the second procedure on this infant insured its ability to breath immediately after birth. These cases demonstrate that active intrauterine intervention in a number of fetal conditions may improve pregnancy outcome. I I I I 116 I Society of Perinatal Obstetricians I Annual Meeting San Antonio, Texas I February, 1982

I REAL TIME ULTRASOUND IN ASSESSMENT OF FETAl_ PULMONIC MATURITY R.A. Petrucha, M.D., S.H. Golde, M.U. and L.D. Platt, M.D., (Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, LAC/USC I Medical Center and USC School of Medicine, Los Angeles, Ca.)

I Ultrasound examination of the placenta and measurement of the biparietal diameter (BPD) offer a non-invasive method of assessing fetal maturity. The ultrasound patterns seen as the placenta develops through gestation are mainly dependent on the degree of calcification - the "mature" placenta I lobules, thus giving the appearance of bright echogenic rings on the ultra- sound exam. This pattern has been suggested as a marker of pulmonary matu- rity in the fetus. The BPD has also been recently examined as a potential I marker of fetal pulmonary maturity. To study the correlation of pulmonary maturity with the ultrasonic placental architecture and the BPD, amniocentesis results from I00 non-diabetic flra- vidas were correlated with the ultrasound findings. Eight-five placentas I did not have a pattern consistent with the ultrasonically mature placenta. Of these cases, 78 amniocentesis yi.elded L/S ratios of greater than 2, and 7 had L/S ratios of less than 2. Of the 15 gravidas with placentas of a I mature ultrasound pattern, all had L/S ratios of greater than 2. There were 40 BPD’s of 9.2 and greater, all of which were associated with mature L/S ratios. Of the 60 exams with BPD’s of less than 9.2 cm., 7 had L/S ratios I of less than 2. The largest BPD associated with an immature L/S ratio was 9.1 cm. Based on the constant finding of a mature pulmonary profile with an ultrasonic placental pattern of maturity, a prospective study was undertaken. From July I 1980 to September 1981, every gravida referred for amniocentesis has been first scanned for placenta pattern and BPD. If the ultrasound examination is consistent with a mature placental pattern or with a BPD of greater than 9.2 I cms., the patient is delivered without amniocentesis. Thus far 123 babies have been delivered by these criterion. No baby has developed respiratory distress syndrome thus far. I Ultrasound criteria of fetal maturity appears to be an accurate, useful pre- dictor of pulmonamy maturity. I I I I I

117 Society of Perinatal Obstetricians Annual Meeting San Antonio, Texas I February, 1982 I THE NONSTRESS TEST: THE FALSE NEGATIVE TEST

J.P. Phelan, Cdr MC USNR, A.D. Cromartie, Lt MC, USNR, C.V. Smith, Lt, MC USNR (Department of Obstetrics and Gynecology, Naval Regional Medical Center, I Portsmouth, Virginia 23708)

The nonstress test (NST) has been shown to be a reliable technique for the I evaluation of fetal status. As a rule, a reactive NST, as opposed to a nonreactive NST, has been associated with a good pregnancy outcome. Nontheless, fetal demise has followed a reactive test. Because of the uncommon occurrence I of a false negative NST, a retrospective investigation of the 2226 patients who had undergone 4500 NST’s was undertaken. Of these high risk pregnancies, 1564 women delivered within 7 days of a reactive NST and had 4 fetal deaths (0.26%). The presumed etiology for the 4 deaths was cord accident - 3 and I abruptio placentae - I. As with the false negativecontraction stress test, the false negative NST appears to be associated with cord accidents, congenital anomalies, and abruptio placentae. Even though a reactive NST is associated I with a low incidence of fetal demise, close attention to the presence of fetal heart rate deceleration on the NST may be helpful in identifying those patients at risk for a cord accident; and, theoretically, in reducing the incidence of I fetal death. Even with that finding, certain unavoidable situations can befall a fetus soon after a reactive NST; and, at present, no test of fetal well-being offers complete reassurance. ! ! I I I I I I I ! 118 i Annt,,l[ Me t iiig San Antonio’, Texas I February, ]982 I SEVERE PREECLAMPSIA I: PERIPARTUM HEMODYNAMIC OBSERVATIONS J.P. Phelan, Cdr MC, USN, D.A. Yurth, Lcdr, MC, USN (Department of Obstetrics and Gynecology and Department ofAnesthesiology, Naval Regional Medical Center, I Portsmouth, Virginia 23708) Several investigators have recently described the cardiovascular dynamics assoc- iated with severe preeclampsia (SP), and have suggested that Swan-Ganz catheteriza- tion is clinically useful and justifiable in these patients.1,3," As a corroborativ~ I endeavor, the peripartum hemodynamic patterns oflOpatients ~ 14 with severe preeclampsia were investigated. .~I~. " I ~ith human use committee approval and after informed consent. ~m each participant was studied with radial and pulmonary arter- :_-" ial catheterization. Cardiac outputs (CO) were determined ~,- using thermodilution. Hemodynamic data was obtained immed- ~ I iately following line placement, during active labor, and postpartum. ~,,~ ~, ...... ,, I At the time of line placement, CO and systemic vascular re- sistances (SVR) for our study ~roup were 9.3-+1.3 liters/min and 1042 + 160 dyne x sec x cm-~, respectively. Comparing data-

I SVR was found. While CO and SVR are inversely related, the disparity in CO and SVR would suggest that hemodynamically, SP has a variable expressi’on, and that these differences are _ I ~ost likely related to the severity of theSP. These findings also suggest that patients with SP should not be classified ’° under one diagnostic umbrella. WEDC~ pR£SSURE ImmHgl I Hyperdynamic ventricular function was characteristic of most of our patients. "Normal" ventricular function (VF) for the patient with SP appears to be in the hyperdynamic zone (Hz). For example, initial mean VF (Fig. 2) was found to be in Hz (+). Postpartum, the majority of patients exhibited cardiac failure as evidence~ I by a decline in VF (I~,). This was associated with an increase in pulmonary wedge and central venous pressures suggesting acute volume overlaod. Approximately one I hour postpartum (~), mean VF had returned to the Hz border. hese findings suggest that one of the goals in the clinical management of the ~atient with SP should be to reduce cardiac work. Therefore, therapy in these patients should be individualized and be based on the hemodynamic findings. For I example, current practice has been to limit fluids in the SP. This would appear to be most beneficial in those cases with a high CO and low SVR. In contrast, the low CO - high SVR patient, would appear to benefit primarily from a reduction in I afterload." Subsequent therapy would be based on hemodynamic findings. During the time where "autotransfusion" occurs, fluid volumes should be limited so as to pre- vent acute volume overload. I In conclusion, Swan-Ganz catheterization and cardiac output data were most useful in the monitoring of those patients with the diagnosis of SP. As suggested by are- view, SP appears to be a continuum which ranges from a comparatively high CO-low I SVR system to a low CO-high SVR one. VF in these patients appears to operate at different "normal" VF zone than the nonpregnant patient. Therefore, in the evalua- tion of the patient with SP, a hemodynamic profile would be helpful in order to determine the "phase" of her SP and the status of her VF. As a result, one could I theoretically direct therapy in a more precise.fashion. 1) Rafferty & Berkowitz: AJOG 138:263, 1980; 2) Current_investigation; I 31Benedetti et al: AJOG 136:465, 1980; 4~ Strauss et al: OB/GYN 55:170, 1980. 119 I Society of Perinatal Obstetricians Annual Meeting San Antonio, Texas I February, 1982 I SONOGRAPHICALLY DIAGNOSED OLIGOHYDRAMNIOS: CAN IT DETECT INTRAUTERINE GROWTH RETARDATION (IUGR)? Elliot H. Philipson, M.D. and Robert J. Sokol, M.D. (Department of Obstetrics and I Gynecology and the Perinatal Clinical Research Center, Cleveland Metropolitan General Hospital/Case Western Reserve University) IUGR is a major source of perinatal morbidity and mortality. Detecting this I complication before birth remains problematic, indicating a need for improved ante- natal laboratory assessment. Oligohydramnios, long known to be associated with IUGR, can be diagnosed sonographically and has been reported to be highly sensi- tive and reliable in detecting IUGR in carefully prescreened patients. Our purpose I in this study was to evaluate the clinical usefulness of sonographically diagnosed oligohydramnios in predicting the birth of small-for-gestational-age (SGA = <10th percentile weight for gestational age) infants on a large obstetric service. I During a 13 month period, 2989 consecutive ultrasound examinations were per- formed for 2453 antepartum gravidas with viable singleton pregnancies and intact ~embranes at less than 42 weeks’ gestation. Among these 2453, oligohydramnios was I diagnosed in 96 (3.9%) at an average of 33 weeks’ gestation (Study Group). Com- pared with 96 pregnancies with the same biparietal diameters on ultrasound examin- ation, but with normal amniotic fluid volumes (Control Group), Study Group mothers ~ere younger and of lower gravidity, although their medical/obstetric risk scores I ~ere not different from those of the Control Group. Study Group infants were of similar gestational age at birth, but had significantly lower birthweights andbirt[ ~eight percentiles than did comparison infants. Of 96 study infants, 38 (40%) were I BGA, compared with 6 (6%) in the Control Group. Of the 44 SGA births, 38 were pre- ceded by sonographically diagnosed oligohydramnios (p<.O001). Of the 96 patients ~ith oligohydramnios, 49 had more than one ultrasound examination. When oligohy- I ~ramnios was present once, but other ultrasound examinations revealed normal amnio- ~ic fluid volumes, nine (28%) of 32 births were SGA; when oligohydramnios was pre- ~ent on two examinations, six (43%) of 14 were SGA; and when oligohydramnios was )resent on three examinations, three (100%) of three births were SGA. I These results provide the first published etimate of which the investigators Lre aware, of the frequency of oligohydramnios in a large population sample. It is ~ot a common complication of pregnancy, occurring in less than four percent of pa- I tients examined sonographically in this series. In addition, the current results :onfirm the association of oligohydramnios with IUGR, as indicated by the birth of ~n SGA infant, but clearly indicate that oligohydramnios cannot be a sensitive I )redictor of SGA birth. Even with perfect association, oligohydramnios could occur in a maximum of 40% of pregnancies complicated by IUGR (four of 10%). Indeed, if ~Ii patients on a service were screened and 10% of births were SGA, it would be ex- pected that four in I0 cases with oligohydramnios would result in SGA births (40% I ~rue positive rate, i.e., predictive value of an abnormal test), but that only 16% ~f SGA births would be preceded by sonographically diagnosed oligohydramnios (16% ~ensitivity). Eighty-four percent of the cases would be missed--statistical sig- I nificance does not assure predictive value. We conclude from this analysis that while the presence of oligohydramnios ~hould increase the clinician’s index of suspicion for IUGR ~nd may indicate repeat [itrasound examination and careful followup, routine sonographic screening to dete~ I loligohydramnios is not warranted. Evaluation of oligohydramnios in combination with other clinical risk factors and laboratory tests for IUGR is needed. I I 120 I Society of Perinatal Obstetricians Annual Meeting I San Antonio, Texas February, 1982 I A PROSPECTIVE TRIAL OF BIOPHYSICAL PROFILE VERSUS THE NONSTRESS TEST IN THE I MANAGEMENT OF HIGH RISK PATIENTS L.D. Platt, G.So Eglinton, R.H. Paul, P. Broussard, M. Trujillo, K. Walla (Department of Obstetrics and Gynecology, Los Angeles County/University of Southern California Medical Center, Women’s Hospital, 1240 North llission Road, I Los Angeles, California 90033)

he use of real time B-scan as an adjunct in the assessment of fetal condition I has received increased attention since the first report from our medical center. In that report 260 high risk pregnancies were monitored at Women’s Hospital at the USC Medical Center utilizing both real time B-scan and a standard fetal moniton I Fetal breathing movement, fetal movements, fetal tone and amniotic fluid volume were combined with the nonstress test into a biophysical profile (BP) of five fetal parameters. Each variable was assigned a score of two when normal and zero when abnormal. A relationship was shown between the profile score and pregnancy I outcome. Subsequent to this report Manning, et al demonstrated the usefulness of the same scheme in 1,184 high risk patients. In their study, perinatal mortality was significantly lower than when compared to a non-randomized historical control I group. Schifrin, et al utilizing a similar technique with real time B-scan, con- cluded that these parameters were more predictive of abnormal outcome than was the abnormal CST result. They were unable to demonstrate a statistical difference between any or all of the real time B-scan parameters as compared to the nonstress I test when normal. However, none of these studies was carried out in a prospective randomized control fashion. Therefore, we designed this prospective randomized study to compare the outcome of patients managed with the nonstress test to the I outcome of those managed with the biophysical profile. The outcome data of 218 patients have been reviewed for this analysis. Measures of outcome for the study were five minute Apgar score, birth weight small for gestational age, fetal dis- I tress in labor and perinatal mortality. Many patients had more than one test per- formed, but only the test performed within.one week of delivery was included in the data analysis. One hundred eleven patients managed with the biophysical pro- file had a score of I0; three of these patients had abnormal outcomes. Eleven I patients had a BP score of 8; three of these patients had abnormal outcomes. There were no patients with a score of 6 or 4. The only patient with a score of two had an abnormal outcoce. In the group managed by the nonstress test scheme, I one hundred two patients had a reactive nonstress test, of these, eight had abnormal outcomes. Of the six patients with nonreactive nonstress tests, all infants were normal. The predictive value of a normal biophysical profile (score of 8 or I greater) as compared to a normal nonstress test (reactive) was not significantly different(chi square, p>0.05). These preliminary data suggest that the biophys- ical profile is a sensitive indicator of fetal well being but probably not superior I to the nonstress test when reactive I I I

121 Society of Perinatal Obstetricians Annual Meeting San Antonio, Texas I February, 1982 I SONOGRAPHIC EVIDENCE OF HYDRAMNIOS AND DETECTION OF ASSOCIATED FETAL ANOMALIES R. William Quinlan, M.D., A.C. Cruz, M.D. and M. Martin, R.N. (Department of I Obstetrics and Gynecology, Division of Maternal/Fetal Medicine, University of Florida College of Medicine, Gainesville, Florida)

Hydramnios has in the past been defined clinically or by invasive dilutional I techniques. Present ultrasound technology allows for a noninvasive quantifi- cation of amniotic fluid volume and the diagnosis of hydramnios during pregnancy. I During the one year period from September 1980 through September 1981, 21 preg- nancies were detected in which ultrasound evidence of hydramnios was present, an incidence during this period of 0.4%. For purposes of this study, hydramnios I was diagnosed when the total intrauterine volume exceeded the volume expected for gestation by one standard deviation in the absence of fetal macrosomia or multiple gestation.

The duration of the pregnancy at the time of diagnosis of hydramnios ranged be- tween 25 and 40 weeks gestation. Using standard technique, the total intra- uterine volume was measured to be between 4,680 and 7,750cc3. Of the 12 preg- I nancies with confirmed hydramnios, 9 (75%) had fetal anomalies detected on ultrasound examination. These anomalies included duodenal atresia, hydrocephaly, hydrothorax, nonimmunologic hydrops fetalis, omphalocele, hydranencephaly and anencephaly; all anomalies which have been clinically associated with hydramnios. I The ultrasonographic appearance of these anomalies will be illustrated. 4 of the 9 detected fetal anomalies were considered incompatible with extrauterine survival. In 3 of the 12 pregnancies with hydramnios, no anomalies were detected I by ultrasound examination. 2 of these infants were normal at birth and 1 was born with a tracheo-esophageal fistula, i0 of the 12 infants expired. 1 of the infants expired secondary to complications of prematurity and all 9 of the in- I fants with ultrasonographically detected fetal anomalies expired. 3 of the infants with know~ anomalies delivered vaginally. In all instances, these anom- alies were considered inconsistent with life. The remaining 6 were delivered by cesarean section; in 4 of these the indication for cesarean section was fetal I distress during labor, i of these 4 infants had diagnosis of a fetal anomaly incompatible with extrauterine survival. In all instances where anomalies were diagnosed by ultrasound, these abnormalities were confirmed at autopsy. I

Ultrasonic examination during a pregnancy complicated by hydramnios allows for both the detection and quantification of the amount of polyhydramnios in a non- I invasive manner. In this small series, the presence of hydramnios was associated with a high incidence of major fetal anomalies (83%); the majority of which could be detected by intensive ultrasound examination of the fetus. Increasing sophis- tication of ultrasound imaging permits more and more detailed evaluation of the I fetus in utero. In this one year’s experience of sonographic evaluation of the fetus in the pregnancy complicated by hydramnios, ultrasound appears to be accur- ate in detecting major fetal anomalies and appears to be of use in predicting I neonatal outcome and ultrasound investigation of hydramnios should be encouraged to modify obstetrical management in these complicated pregnancies. I I 122 i Society of Perinatal Obstetricians I Annual Meeting San Antonio, Texas I February, 1982 PARENTERAL HYPERALIMENTATION FOR FETAL GROWTH IN TWO CASES OF PANCREATITIS IN I PREGNANCY Anne RaunRaunio, M.D., Prasanta C. Chandra, M.D., and Harbhajan Chawla, M.D. DepartmentsDepartmen of Obstetrics and Gynecology and Pediatrics, Hahnemann Medical I CollegeCol lege & Hospital, Philadelphia, PA. Pregnancies~regnanci complicated by both pancreatitis and severe maternal malnutrition are~re at dodouble risk for poor outcome. Two cases are presented where total I parenteral)arentera nutrition (TPN) was used with good results. In each case, 2 to 3 liters/day of a solution of dextrose 250g./I, amino acids 8.5%, and appropriate electrolytes,electrolyt s, mineral,m and vitamin supplementation was used. Intralipid 500- I I000 ml everyev ry 1 to 3 days was added. Electrolytes, glucose, urine ketones, and trace elemelements nt.. were monitored and remained in the normal range. I Case #I. C.O. A 27 year old white female, P I-0-0-I, with a history of chronic pancreatitis, wasw admitted at 28 weeks gestation with abdominal pain, vomiting, and weight loss.Io~ s Serum amylase initially was 170 i.u. (normal <300), but rose to 2,055 i.u. aand remained elevated until after delivery. Hematology and I chemistry ~an~panels 1 were normal. After 2 weeks of standard pancreatitis therapy, weight loss c(ncontinued, hypoalbuminemia was seen, and hyperalimentation was begun. After 3 weeks oof treatment, the patient demanded delivery and an L/S ratio of I 2.7/I was obt~obtained. i A primary cesarean section at 33 weeks resulted in a living femaleemale infant wweighing 1480 grams (25th percentile). The child is currently 2 years old aland d developmentally normal. I Case #2.0.S. A 25 year old Hispanic female P I-0-I-I, with a history of intestinal by- pass surgery for obesity, was admitted at I 24 weeks gestation with epigastric pain and Low No~m~ vomiting. Serum amylase was 425 i.u. Ultra- sound examination confirmed her gestational age. The patient improved and was dis- 0 S (Patient #2) I charged. At 28 weeks, symptoms unresponsive to conservative treatment recurred, and parenteral nutrition (TPN) was begun. (See ~~ I Table). The patient requested discharge at 32 weeks, but returned in I0 days with weight loss. Ultrasound showed slowing of I the rate of biparietal growth and a drop in the total intrauterine volume for gesta- 300 (Nor ma~l tional age. Hyperalimentation was restarted and continued until a mature L/S was I obtained at 36"weeks. Induction resulted in the vaginal delivery of a 2835 gram male

Geslahonal Age (wks) infant, 50th percentile by weight for age, I in good condition.

These cases show the effectiveness of parenteral hyperalimentation in supporting I adequate fetal growth during pregnancy. In the second case, its use apparently reversed a trend toward growth retardation in the fetus (on the basis of I sequential scans), and resulted in the birth of a A.G.A. baby.

123 Society of Perinatal Obstetricians Annual Meeting I San Antonio, Texas February, 1982 I CHRONIC CARRIAGE OF GROUP B STREPTOCOCCI (GBS) THROUGH SEO.U~NTIAL ~REGNANC!ES. I Joan A. Regan, M.D., Jane O’Neill, ~.N. and L.S.James, M.D., Section of Neonatology, Division of Perinatal Medicine, Colle~e of Physicians and Surgeons, Columbia University, New York City. (Sponsored by Roy H. Petrie, M.D~ I During the past 5 years we have prospectively screened)12,000 patients at the time of delivery for colonization with GBSo 12.4% of parturients have had cervical cultures positive for GBS. I

Fifty-eight patients who were GBS positive during their initial pregnancy in our study have been followed through 2 or more subsequent ~re~naneies in the course of our ongoing study. Among these gravidae 20 (35%) have been colon- I ized with GBS during each subsequent pregnancy.

Thus, the risk of GBS co!onization among gravidae known to be colonized in I a prior pregnancy is significantly greater than that in the total population. I I I I I ! I I I I I 124 I Society of Perinatal Obstetricians I Annual Meeting San Antonio, Texas I February, 1982 Subendocardial Ischemia During Beta-Mimetic Tocolysis For Preterm Labor

I N. Reynolds, M.D., I. Golditch, M.D., J. Schroeder, M.D., J. Wachtel, M.D. and K. Ueland, M.D. (Department of Gynecology and Obstetrics and Medicine, Division of Cardiology, Stanford University Medical Center and The Department of Obstetric; I and Gynecology San Francisco ~iser-Permanente Medical Center).

Tocolysis with beta-mimetic agents has the potential to cause serious cardio- I vascular side effects, and these agents must be used with caution and careful hemodynamic monitoring.

Six cases are presented of women with substernal chest pain and electrocardio- I graphic changes consistent with myocardial ischemia. Four patients received intravenous ritodrine, one oral ritodrine, and one subcutaneous terbutaline. This experience suggests that major cardiovascular complications of beta-mimetic I therapy occur more frequently than previously recognized.

The hemodynamic responses to pregnancy and sympathomimetic therapy are similar in I many respects. Both cause: i) an increase in cardiac output; 2) an increase in heart rate; 3) an augmented stroke volume; 4) an increase in myocardial contract- ility; 5) a decrease in diastolic blood pressure; 6) a decline in systemic vascu- lar resistance; 7) an increase in plasma volume and 8) a decrease in hemoglobin I concentration. Additionally, both increase myocardial oxygen consumption which is further increased by labor. The net effect is a reduction in coronary perfu- sion and oxygen supply to the myocardium (decreased diastolic pressure time index I - DPTI, and decreased oxygen carrying capacity of the blood (lower levels of hemoglobin) on the one hand, and an increase in myocardial oxygen demand on the I other (the most significant factor being tachycardia). EKG evidence of subendocardial ischemia was found in each instance. This seems logical as the subendocardium is more susceptible to ischemia than the outer half of the myocardium not only because of the unique anatomy of the blood vessels I supplying the region but also because of the higher intramyocardial systolic pressure generated in the inner half of the ventricle.

I Suggested therapy for this serious complication of tocolytic therapy include: i) discontinuation of the drug; 2) oxygen; 3) analgesia; 4) nitrates and 5) I propranolol. It is recommended that betamimetic drugs should be used in the treatment of preterm labor only when the diagnosis is clearly established and by a practitionel who can competently diagnose and treat the cardiovascular complications that are I frequently encountered. In typical post treatment cases, left axis deviation with ST segment depression was noted in leads I and V2 through V6. I I I

125 Society of Perinatal Obstetricians Annual Meeting I San Antonio, Texas February, 1982 I I ESTIMATION OF FETAL NEIGHT IN PREMATURE LABOR BY COMBINED BIPARIETAL DIAMETER AND ABDOMINAL CIRCUMFERENCE

Rivera-Alsina, Manuel E., Saldana, Luis, and Arias, Juan I University of Texas Health Science Center at Houston,,-Division of Maternal-Fetal Medicine I Sonographic estimates of fetal weight using abdominal circumference and biparietal diameter (BPD) was measured in 50 patients admitted in premature labor from 26 weeks to 34 weeks of gestation. Neonatal survival is related to birth weight. Our Neonatal Intensive Care Unit has a survival rate of 87.6% I in the 701-1000 gram birth weight category. Aggressive management seems justified if the fetal birth weight exceeds 700 grams. I Fifty ultrasonic profiles were performed with an ADR Real-Time Scanner, calibrated to the velocity of sound tissue of 1540 meter per second, a trans- ducer of 3.5 MHz was used. All scans and measurements were performed I by the authors. Polaroid prints were made of all the scans and measured with standard calipers by Real-Time scans. BPD was measured at the level of the Thalamus (Arrow BPD). The measurements were taken from the outer to the inner table of the skull. The abdomen was measured at the level of the stomach I and/or umbilical vein. Measurements were taken from the outer border of the spine to the outer border of the anterior abdominal wall (DI), and a second measurement was made perpendicular to this (D2). I

The formula used for the abdominal circumference was DI + D2 divided by 2 x 3.14. Using the tables by Warsof et al, we estimated the fetal weight by I aligning the values of the BPD to the abdominal circumference. The mean standard deviation (SD) yielded by this formula is 106 g/kg. of actual weight.

The mean estimated fetal weight was 1421.6 grams with a SD : 85 g/kg. This I represents a slightly increased accuracy than that reported originally for this formula by Warsof. The actual mean birth weight was 1491.5 grams. In all instances ultrasonographically estimated fetal weight was below the actual I birth weight. The fetal weight was estimated in 6 sets of twins. In all instances this I estimated fetal weight fell within the SD of the calculation for singletons.

Based on our findings it would appear that the formula is underestimating the fetal weight. Aggressive management could be justified where the I sonographically estimated fetal weight exceeds 650 grams. This policy must be individualized depending on the neonatal survival rate for each neonatal intensive care unit. I I I

126 I Society of Perinatal Obstetricians I Annual Meeting San Antonio, Texas ! February, 1982 I Comparison of Five Methods for Prediction of Fetal Weight in Utero with Real-Time Ultrasound

! M.B. Sampson, M.D., AoM. Tomasi, M.D., J.L. Thomason, M.D., B.A. Work, Jr., M.D., Department of Obstetrics and Gynecology, University of Illinois School of Medicine, Chicago, Illinois 60612 I Five methods described below were used to prospectively measure fetal weight in utero with a 3.5 M~z linear array transducer. Cranial and abdominal parameters were measured in 32 infants whose gestational ages ranged from 28 to 42 weeks. All infants were live born without congenital anomaly and were between the lOth and 90th percentile by I weight for gestational age. 13 of the women underwent repeat Cesarean section, ii were pre-eclamptic or hypertensive and 7 had premature rupture of the membranes or premature labor, i0 infants were premature. All measurements were made within 72 hours of delivery. I Previously, Campbell showed that abdominal circumference measured in utero (Ac) correlates better with fetal weight than does biparietal diameter measurement (BPD). (Clin. Perinatol. 1:567, 1974; Br. J. Obstet. Gynecol. 82:689, 1975). Using multifactorial regression I analysis Birnholtz was able to calculate weight from summed volume components (Ultrasonic Imaging 2:135, 1980). Warsof has shown that Ac is the single parameter that correlates best with weight whereas an algorithm using both BPD and Ac gave the best estimate of fetal weight in utero. (Am. J. Obstet. Gynecol. 128:881, 1977) The above I studies were done with contact B-scanner, but Clement has shown that measurement of Ac with a real-time linear scanner compares favorably with B-scan despite inferior lateral resolution (J. Clin. Ultrasound 9:1, 1981). I In this study BPD was measured with electronic calipers and photographed for later measurement of other parameters. Fetal spines were identified and consecutive cross-sectional scans perpendicular to the long axis were obtained by moving the transducer until the umbilical vein under the liver or a stomach bubble was identified. I A 3:1 plaroid reduction was obtained, poorly defined segements less than one centimeter were inked in and Ac was measured with a map reader and also by approximating the abdominal circumference with an ellipse, it/2 (major + minor axis). These axes and other cephalic and abdominal I diameters were measured with a mapreader and weights were calculated from the authors’ tables and formulae. Regression equations for actual versus calculated weights are shown below in Table I.

TABLE I: ACTUAL (W) vs CALCULATED WEIGHT i9 grams (We) i SD (g) r source parameter regression equation BPD, Ac (map reader) Wc=I.00W - 40 150 0.99 Warsof’s table BPD, Ac (ellipse) Wc=O.90W - 160 150 0.91 " " I 0.90 Birnholtz equation BPD, OFC, AD W =0.79W + 430 200<2500g e 340>2500g Ac(map) W =0.76 + 500 160<2500g 9.87 Campbell’s table i c 340>2500g BPD W =770BPD - 4100 450 0.77 Present study c Warsof’s tahle using two parameters gave the best results, with a mapreader improving accuracy. Neither measurement of Ac alone nor I Birnholtz’ approximation of the fetal abdomen and head by spheres correlated as well as Warsof’s two parameter regression equation which is weighted toward Ac, reflecting liver size and indirectly weight. I I i 127 Annual Meeting San Antonio, Texas February, 1982 I I A COMPARISON OF NORMATIVE FEMUR LENGTH DATA FROM SEVERAL SOURCES AND THE PRENATAL ULTRASONIC DIAGNOSIS OF OSTEOGENESIS IMPERFECTA AT 19 WEEKS J.W. Seeds, M.D. and R.C. Cefalo, M.D. (Division of Maternal and Fetal Medicine, I Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill) Monitoring of several parameters of fetal growth and development is now pos- I sible with serial ultrasound examinations. The measurement of fetal limb lengths and the definition of normal growth patterns has enabled the prenatal diagnosis of certain forms of dwarfism. It is essential that accepted norma- I tive data be broadly and accurately derived and study bias minimized. Hobbins, in 1977, published an ultrasonically derived femur nomogram, but wide confidence limits has made clinical usage difficult. Queenan, et al, in 1980, and Jeanty, et al, in 1981, published well designed ultrasonic studies of the normal growth I of fetal limbs related to gestational age. Inconsistancies between the data of these two studies, though, suggested that more work was needed to further elu- cidate the normal relationship between limb length and gestational age. This I study was, therefore, undertaken to gather data regarding fetal limb growth in clinically normal pregnancies of established gestational age, from 14 weeks to term. In addition, a pregnancy at risk for the delivery of an infant with osteogenesis imperfecta was followed and at 19 weeks the correct diagnosis of I an affected fetus made. 504 ultrasonic measurements were made including biparietal diameter, femur, humerus, tibia/fibula, and radius/ulna complexes. These were made with linear I array realtime equipment utilizing a 3.5 mhz transducer, freeze-frame and elec- tronic calipers. Linear regression analysis related each of the five categories of measure to gestational age (menstrual). Both Jeanty and Queenan have shown, I as does present data, that linear regression analysis is reasonable prior to 28 weeks gestation. BPD was found to have the best correlation (Table i) and to give the most accurate prediction of gestational age (smallest Standard Error). These data are compared with those of Queenan and Jeanty (Table 2) and I a composite mean constructed. Its usefulness will be discussed. The "at risk" pregnancy occurred in a 23 year old G P She was evaluated at i0, 15, and 19 weeks. A crown rump length at i0 wee~s2 1 01" was consistent with menstrual dates. I At 15 weeks, limb lengths were measured and found to be normal, but the femur image was noted to be irregular. At 19 weeks, both length and shape were ab- normal, with both femurs severely bowed and measuring only 19mm. Significant I asymmetry was also noted between the humeri and femurs, and among the tibia/ fibula complexes. An affected fetus was diagnosed and this was confirmed following termination. Pictures and radiographs will be shown. I Table 2 Table 1 COMPARATIVE STUDIES-FEMUR CORRELATION WITH wks mm COMPOSITE GESTATIONAL AGE G.A. SEEDS JEANTY QUEENAN MEAN I 14-27 wks. 14 13 17 18 16 15 16 19 21 19 S.Eo 16 19 22 24 22 I MEASURE (wks.) 17 23 25 26 25 BPD .985 .666 18 26 28 29 28 FEMUR .970 .911 19 29 30 32 31 I HOMERUS .955 1.120 20 32 33 36 34 TIB/FIB .954 1.090 21 35 36 40 36 RAD/ULN .896 1.290 22 38 38 43 39 I 128 Society of Perinatal Obstetricians i Annual Meeting San Antonio, Texas I February, 1982 A CENTRAL ROLE FOR AMNIOCENTESIS AND THE FOAM STABILITY INDEX (FSI) - TEST, IN THE MANAGEMENT OF THE HIGH-RISK, SMALL THIRD- I TRIMESTER FETUS (STF) : A PROSPECTIVE STUDY. G. Sher, M.D., V. K. Knutzen, M.D., and B. E. Statland, M.D.,PH.D. (Department of Obstetrics and Gynecology, University of Nevada I School of Medicine, Reno, Nevada, and Department of Pathology, Boston University School of Medicine, Boston, Massachusetts). I A prospective study was undertaken from January, 1979, to June, 1981, in order to determine whether an aggressive approach to the management of pregnancies associated with the birth of pre- term or low birth weight (LBW) neonates, would impact upon I perinatal mortality statistics. In this study, amniocentesis, with the subsequent performance of the FSI - Test, played a central role in the management of 61 of 77 cases. Given an I FSI value of equal to or greater than 0.47, it was recommended that the STF (thought to weigh less than 2500 grams) be delivered. Cesarean section was the delivery,.~method of choice I in all cases associated with a very - STF (thought to weigh less than 1500 grams), in all cases associated with breech presentation, and in other situations where independent pregnancy complications indicated Ceserean Section. In other I cases, trial labor was allowed. The detection of an FSI value of less than 0.47 ("immature"), in the absence of chorioamnionitis, provided an indication for prolonging I pregnancy with or without the use of tocolytic agents such as Terbutaline or Indomethacin. Indomethacin was only used in cases where the FSI value was less than 0.45, and prior Ter- I butaline therapy had failed to inhibit labor successfully. Such cases also qualified for the selective administration of Betamethasone in an attempt to enhance fetal pulmonary maturity. I In pregnancies associated with the very - STF, a "mature" FSI value almost invariably meant that the fetus was small for gestational a~e (SGA), whereas an "immature" FSI value (less I than 0.47)was consistently associated with an appropriately grown (AGA) fetus. None of the SGA neonates developed the idiopathic respiratory distress syndrome (IRDS), and not a ~single case of IRDS occurred in association with an FSI value I of equal to or greater than 0.47. The overall periantal mortality rate in our prospective study I was 9 per 1,000 (6 out of 666 deliveries), corrected to 3.1 per 1,000 when major congenital abnormalities were excluded. I We believe that the results of this study strongly support a central role for amniocentesis followed by performance of the FSI - Test, in the evaluation and treatment of pregnancies I associated with the high-ris~ STF. I

129 Society of Perinatal Obstetricians Annual Meeting Snn Antonio, Tex~,s i February, 1982 ! THE DIAGNOSTIC VALUE OF THE QUANTITATIVE AMNIOTIC FLUID FOAM STABILITY INDEX (FSl) - TEST FOR PRENATAL FETAL ASSESSMENT. ! G. Sher, M.D., B. E. Statland, M.D., Ph.D., and V. K. Knutzen, M.D. (Department of Obstetrics and Gynecology, University of Nevada School of Medicine, Reno, Nevada, and Boston University Medical School, Department of Pathology, Boston, Massachusetts. I

The most commonly employed tests for the prenatal assessment of fetal pulmonary maturity are the Lecithin/Sphingomyelin (L/S) Ratio Assay, and the simple shake I test. The L/S Ratio, which compares the relative amounts of two phospholipid components in amniotic fluid is costly, requires significant technical expertise. is time-consuming, and lacks uniform reliability in complicated gestations, while the simple shake test, which is easy to perform, and relatively reliable i when "positive" (the presence of foam), has a high incidence of "false-negative" results, i.e. the failure of the idiopathic respiratory distress syndrome (IRDS) to occur in spite of the absence of foam (a "negative" result). I

We performed an in vitro ~D~riment which illustrated that very small adjustments in ethanol volume fractioh"ih final assay mixtures of ethanol and amniotic fluid I could influence the ability to generate stable foam. This observation led to the development of the amniotic fluid Foam Stability Index (FSI) - Test, where we employ graded volumes of 95% ethanol, so that when a known amount of amniotic fluid supernatant is added to each of these volumes, various EVF’s are produced I in the mixtures which are then shaken vigorously. The highest EVF capable of producing stable foam (a "positive" result) is expressed as the FSI value for that sample of amniotic fluid. !

The FSI - Test was analyzed in a total of 323 pregnancies where clear, uncon- taminated amniotic fluid was obtained by transabdominal amniocentesis within I 72 hours of delivery. There were 43 cases of IRDS, 42 of which were associated with FSI values of less than 0.47. In 276 of the 323 cases, the L/S ratio assay was performed concurrently with the FSI - Test. Thirty-five cases of IRDS occurred in this group, 8 of these were associated with L/S ratio values of I greater than 2.0. The risk of IRDS occurring was calculated for three groups of FSI values. Group l - FSI values 0.43 (73%); Group 2 - FSI values of 0.44 - 0.46 (29.2%); Group 3 - FSI values 0.47 (0.35%). Comparable evaluations for I the L/S ratio procedure showed the FSI - Test to be significantly more specific and sensitive than the L/S ratio assay. The improved performance of the FSI - Test was most marked in pregnancies complicated by insulin-dependent diabetes I mellitus and intrauterine growth retardation. We investigated 27 pregnancies associated with small, third-trimester fetuses. The detection of an FSI value of 0.47 or greater enabled us to discriminate between appropriately grown and growth-retarded fetuses, while the L/S ratio did not permit such discrimination. I

We conclude that the FSI - Test has sufficient diagnostic reliability to be considered a method of c,,hoice for the prenatal detection of IRDS, and may also I prove useful in the prenatal diagnosis of intrauterine growth retardation. I I

130 Society of Perinatal Obstetricians Annual Meeting San Antonio, Texas February, 1982

THE EFFECT OF CESAREAN SECTION (CS) AND BIRTH WEIGHT ON THE OUTCOMES OF PREMATURE BREECH PREGNANCIES (7OO-1500 GRAMS) I K.K. Shy, M.D., M.P.H., D.A. Luthy, M.D., D.E. Hickok, M.D., A. Olshan, B.A. (Department of Obstetrics and Gynecology, University of Washington, Seattle, I Washington) Sponsored by D.A. Luthy, M.D. Recent reports indicate that CS may improve survival for premature breech preg- nancies. However, little data are available on the effect of CS on the mortal- I ity of breech pregnancies with birth weights less than 1200 grams. We studied the effect of CS on mortality and 5-minute Apgar scores in a popula- tion-based cohort of 74 singleton breech pregnancies (7OO-1500 grams) delivered I during 1977-1979 at the University Hospital and the 13 community hospitals in King County, WA. Pregnancies with lethal anomalies were excluded. Exposure to CS, mortality, Apgar scores, and potential confounding factors, such as neonatal I transport, birth weight, and pregnancy complications were abstracted from the mothers’ and infants’ charts. (However, in our data set, no factor actually confounded the relationships between CS and outcomes.) Results were expressed I in terms of relative risk (RR): the ratio of rate of mortality with CS to the rate of mortality with vaginal delivery.

Overall, 58% (43/74) of breech pregnancies had CS’s; 40% (30/74) of infants I died. At birth weights 700-12,OO grams, the perinatal mortality rate associated with CS was 65% (13/20) and with vaginal delivery 65% (17/26)(p>0.48). At 1201- 1500 grams, the perinatal mortality rate associated with CS was 13% (3/23) and I with vaginal delivery 40% (2/5)(p0.48) at 700-1200 grams and 0.33 (p0.44); I the mean length of the first stage of labor before CS was 33 hours below 1200 grams and 39 hours above 12OO grams (p>0.6). I We conclude that with birth weights 700-1200 grams, CS has a negligible effect on outcomes. At 1201-1500 grams, these data suggest an association between CS and reduction in perinatal mortality by a factor of 0.33; but the association’s strength is limited by few vaginal deliveries. Summarization of the effects of I CS across these low birth weight categories erroneously implies a uniform effect that is "statistically significant" (p

131 Society of Perinatal Obstetricians Annual Meeting I San Antonio, Texas February, 1982 I LATE ONSET POST-PARTUM ECLAMPSIA

Baha M. Sibai, M.D., Thomas N. Abdella, M.D., and Garland D. Anderson, M.D. (Divi- ! sion of Maternal/Fetal Medicine, Department of Obstetrics and Gynecology, Univer- sity of Tennessee College of Medicine, Memphis, Tennessee) I Late onset post-partum eclampsia is ~efined as the occurence of eclamptic convul- sions more than 48 hours after delivery. The purpose of this prospective clinical study was to describe our recent experience with this syndrome and to define its incidence in our obstetrical population. I

From August 1977 through October 1981 there were 29,058 deliveries at E.H. Crump Women’s Hospital. During this time period, there were 106 documented cases of I eclampsia, of which 33 occurred after delivery. Fifteen of these 33 cases ful- filled the criteria for true, late-onset post-partum eclampsia. I Pregnancy induced hypertension was diagnosed prior to the onset of convulsions in ii patients, all of whom received intravenous MgSO4 post-partum. The mean duration of pre-convulsion, post-delivery MgS~4 therapy was 32.0 hours (range I 24-72 hours). Two of these women were receivlng MgSO4 at the time of their eclamptic seizure. Headaches and visual disturbances were reported by all 15 patients prior to the onset of convulsions. I Physical and laboratory findings immediately after the convulsions were clearly consistent with eclampsia. All patients had elevated blood pr4ssure (diastolic 90-130 mmHg) and documented hyperuricemia. Thirteen of the 15 had hyperreflexia I with sustained clonus. Nine°patients had proteinuria and eight patients had marked edema. Following the intravenous administration of MgS04~ all patients had~ a resolution of the hyperreflexia and a marked diuresis. All patients were normo- tensive on follow-up and none had subsequent convulsions. Neurologic and meta- I bolic studies were obtained to rule-out other causes of convulsions. Twelve patients had post-seizure electroencephalograms (EEG). Six patients had evidence of diffuse encephalopathy consistent with eclampsia. The remaining six patients I had normal EEG tracings. CT-scan, lumber puncture, skull roentgenograms, and arteriograms were performed on several patients, but no abnormalities were found. I Although post-partum eclampsia usually develops during the first 48 hours after delivery, a significant number of cases occur between 3 and Ii days postpartum. These cases represent true eclampsia and should be treated accordingly. Preven- tion of late post-partum eclampsia is difficult because the onset is characteris- I tically abrupt, with few warning signs or symptoms. Further study is needed to determine if the incidence of late post-partum eclampsia can be reduced by pro- longation of MgSO4 therapy in selected patients. I

TABLE I: onset of eclamptic convulsion number of cases (%) i

antepartum 55 (51,9%)

intrapartum 18 (17.0%) I postpartum 33 (31.1%) I

132 I Society of Perinatal Obstetricians I Annual Meeting San Antonio, Texas I February, 1982 MONTHLY VARIATIONS IN PREGNANCY INFECTION, BLEEDING AND ADVERSE PERINATAL OUTCOME: I THE COITUS HYPOTHESIS NOT SUPPORTED Robert J. Sokol, M.D., Victor Hirsch, B.S. and Lawrence Chik, Ph.D. (Department of Obstetrics and Gynecology and the Perinatal Clinical Research Center, Cleveland I Metropolitan General Hospital/Case Western Reserve University) Maternal behavior, if a risk to the fetus, is of particular importance because avoidance could lead to improved pregnancy outcome. There is marked disagreement I in the literature concerning a possible relationship between maternal sexual ac- tivity and adverse perinatal outcome. Based on an observed concomitant variation in the monthly frequecies of coitus, amnionitis, abruptio placenta and perinatal mortality, with a peak in springtime in data from the Collaborative Perinatal I Project, it has been inferred that coitus in late pregnancy is dangerous to the fetus.1 To attempt to replicate and extend these findings, records for 19,635 con- secutive singleton births, which occurred at a single institution over a six year I period ending in 1980, were examined for 15 factors,--seven prenatal problems re- lated to infection and bleeding and eight measures of perinatal morbidity and mortality; variables directly reflecting maternal sexual activity were not avail- I able in this database. No significant trends in monthly frequencies of amnionitis, abruptio placenta or perinatal mortality were identified (Goodness-of-fit X2) and the monthly fre- I quencies of these factors were not significantly elevated in the spring. More- over, the frequencies of amnionitis and abruptio placenta were not significantly correlated with monthly perinatal mortality rates. The frequencies of maternal pyelonephritis, prolonged premature rupture of the membranes and neonatal death I were found to be significantly elevated in October, as were the frequencies of’ premature rupture of the membranes and antibiotic administration to neonates in i January (p<.05). These findings do not support the hypothesis that coitus is a risk for adverse perinatal outcome and suggest that time trends in prenatal events should be in- terpreted cautiously. Advice to all couples to avoid sexual activity in late I pregnancy may be unwarranted and would probably be unheeded. I I. Naeye RL: Seasonal variations in coitus and other risk factors, and the I outcome of pregnancy. Early Hum Develop 4:61, 1980. I I I I

I 133 Society of Perinatal Obstetricians Annual Meeting I San Antonio, Texas February, 1982 I FETAL HEART RATE ACCELERATIONS IN LOW RISK AND DIABETIC PREGNANCIES DURING ACTIVE BEHAVIORAL PERIODS Y. Sorokin, M.D., L.J. Dierker, M.D., L. Chik, Ph.D., L. Kollar, R.N. and I M.G. Rosen, M.D. (Department of Obstetrics and Gynecology, Cleveland Metropolitan General Hospital, Cleveland, Ohio) The nonstress test (NST) is based on the presence of fetal heart rate (FHR) accel- I erations in association with fetal movements (FM). The reactive NST has an excel- lent correlation with good outcome. In this report we present results of monitor- ing FHR and FM in normal and diabetic pregnancies at 36-38 weeks of gestational I age. Our purpose is to compare the duration and amplitude of FHR accelerations in normal and diabetic pregnancies during active behavioral periods. Eleven low risk pregnancies and eight insulin dependent diabetic pregnancies were I monitored at 36-38 weeks of gestational age for two hours each. Gestational age at the time of the study was later confirmed by modified Duhowitz examination of the newborn after delivery. All the low risk patients delivered AGA infants, the I diabetic patients delivered three AGA infants and five LGA infants. The FHR was detected using an abdominal electrocardiogram recorder. FMwere detected using two tocodynamometers placed on the maternal abdomen overlying the upper and lower portions of the fetus and confirmed by maternal perception and/or observer’s nota- I tion. Data were displayed on a four channel recorder using a paper speed of 30 cm/min. I Each one minute segment of recording was determined to be either Active or Quiet based on the following criteria: Quiet - FHR variability < 15 beats per minute (BPM) and FM < 1 second (or no FM). Active - all other one minute segments. FHR and FM were evaluated separately. A behavioral activity, either Active or Quiet, I was said to be present when three consecutive Active or Quiet were observed. A change in behavior was defined as three consecutive epochs consistent with the other type of behavioral activity. Each tracing was evaluated for FHR accelera- I tions during periods of fetal activity. The first ten identifiable FHR acceler- ations (> i0 BPM) associated with identifiable FM were measured for duration, in seconds, and amplitude, in BPM. All tracings were read.blindly. The means and standard deviations (S.Do) were calculated for both the duration and amplitude of I FHR accelerations within each subject as explanatory variables. Discriminant function analysis was performed to compare the characteristics bet- ween groups of diabetic and nondiabetic mothers. The following Table shows the I group means and group S.D. of the within subject means and S.D. of the data.

DURATION (SEC AMPLITUDE (BPM) I GEST. AGE MEAN I S.D. MEANi S.D. DIABETIC 36.63 31.40 12.18 19.81 3.98 NONDIABETIC 3?.64 33.67 33.67 20.84 4.82 I There was no significant difference in the FHR acceleration duration and amplitude between the two groups. Within the study sample, the diabetic group had a signi- ficantly lower mean gestational age and 5 LGA infants. I Using the method of canonical correlation analysis, we attempted to establish the association of gestational age (G.A.) and the presence of LGA infants with FHR acceleration characteristics. The result shows that, while G.A. has the largest I influence on the FHR acceleration characteristics, the association was not statis- tically significant. I

134 I Society of Perinatal Obstetricians Annual Meeting San Antonio, Texas February, 1982

I FETAL SEX DETERMINATION BY REAL TIME ULTRASOUND IN THE THIRD TRIMESTER R.K. Tamura, M.D., R.E. Sabbagha, M.D., R. Depp, M.D., S. Dal Compo RT. R.D.M.S., S.L. Dooley, M.D. and M.L. Socol, M.D. (Sections of Maternal- Fetal Medicine and Diagnostic Ultrasound, Department of Obstetrics and I Gynecology, Prentice Women’s Hospital and Maternity Center, Northwestern University, Chicago, Illinois.)

I Neonatal respiratory distress syndrome (RDS) ranks as a major cause of perinatal mortality and morbidity. Until recently, precise data on the effect of antenatal steroid administration for the prevention of RDS was I lacking, However, the collaborative study of Antenatal Steroid Therapy (Am. J. Obstet. Gynecol. 141:276, 1981) demonstrated that antenatal steroid (dexamethasone) administration decreased the incidence of RDS in non-caucasian, female infants. Since the long term effects, if any, of I steroid therapy have not as yet been elucidated by the collaborative study, the identification of fetal sex prior to the administration of steroids I may permit selective use only in female fetuses at risk for RDS. The prenatal determination of fetal sex by ultrasound examination of the fetal perineal area appears to be most reliable when scrotal or penile echoes are visualized. Accordingly, a prospective study of fetuses between I 24 to 38 weeks gestation (mean= 33.2 weeks) ~ased on menstrual data and sonar biparietal diameter measurements) to determine the accuracy of detect- ing only male fetuses is presented. During a 4 month period, definitive I sex assignment was made in 92 fetuses with real time ultrasound. At birth, 67 males and 25 females were noted. Antenatal sonar sex determination was in error on three occasions (3.3%). However, Table i demonstrates that I fetal sex, particularly male fetuses, can be determined with an acceptable degree of accuracy. I TABLE i REALTIME ULTRASOUND DETERMINATION OF FETAL SEX FETAL SEX BY ULTRASOUND MALE FEMALE

I Male 66 I Female i 23 Total 67 25 I x2= 63.05, p<0.001 For Males X2= 16.0, p<0.O01 For Females

Studies now in progress are intended to further clarify the accuracy of I antenatal sex identification by delineating circumstances in which such determination is not readily possible. I I

135 Society of Perinatal Obstetricians Annual Meeting San Antonio, Texas February, 1982

FOLLOW-UP PREGNANCIES TREATED WITH HYDRATION AND SEDATION FOR THREATENED I PREMATURE lABOR

Guillermo Valenzuela, M.D., Robert Hayashi, M.D., Susan Cline, R.N. (Department I of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, The University of Texas Health Science Center at San Antonio, Texas.) I

It is a well known fact that approximately about 50% of patients who present with threatened premature labor defined as the presence of two or more uterine I contractions in i0 minutes will respond to conservative treatment. At our institution, this conservative treatment consists of hydration (I.V. fluids) and sedation (morphine). Evaluation of retrospective data in 42 patients suggested a high incidence of repeated episodes of threatened premature labor I during the evaluated pregnancy. Because reports are few in the literature, about the outcomes of threatened premature labor, we undertook a prospective study to define: a) need for tocolytic therapy b) time of delivery c) recur- I rence of the complaint d) baby weight and Apgar. We are currently following 200 patients. We have completed data in 133 patients (the rest will be ready for presentation within the next two months). We found that 52% of the 133 patients with completed follow-up data require ~-mimetic drug in their first I visit. Of the remaining 48%, 3/4 went to term and 1/4 delivered a low birth weight (see Table below). Conclusion of our preliminary results indicate that patients reporting to the hospital with threatened premature labor are at I higher risk for low birth weight (LBW) and therefore may benefit of prophylactic measures such as bed rest and/or p.o. tocolytic therapy and in-service education of early recognition of labor and what to do about it. !

133 PATIENTS I

I HYDRATION AND SEDATION I ~\ Tocolytic Therapy I 64 (48%) \3 69 (52%)

dismissed and i/4 of them about half of them delivered I delivered LBWI (one set of LBWI (5 sets of twins, 3 of twins that delivered at term) them delivered at term) I I I 136 I Society of Perinatal Obstetricians Annual Meeting San Antonio, Texas February, 1982

EFFECT OF CAFFEINE ON THE PREGNANT SHEEP - CARDIOVASCULAR AND ACID- I BASE RESPONSES

S.J. Wilson, M.D., J. Ayromlooi, M.D., J. Balkon, Ph.D., D.M. Desiderio, I B.A. and S. Raynis, B.A. (Department of Obstetrics and Gynecology and the Toxicology Laboratory, Long Island Jewish-Hillside Medical Center I and the State University of New York at Stony Brook, School of Medicine) Caffeine citrate in concentrations of 6.96 milligrams per kilogram of combined maternal and fetal weight (low dose group, N = 8) or 69.~6 mg/kg (high dose group, N = 8) was administered intravenously over ten I minutes to ten "steady-state" pregnant sheep. The ewes and their fetuses were monitored for caffeine concentrations, and cardiovascular and acid- base status. Five minutes after the completion of the infusion, maternal I caffeine levels were 5.3 ~ 0.5 ug/ml and 49.7 ± 3.1 ug/ml, respectively, and fetal levels were 3.4 ~ 0.6 ug/ml and 36.9 ± 4.6 ug/ml, respectively. Caffeine was undetectable in both groups of maternal and fetal samples I forty-eight hours after the infusion. Uterine blood flow decreased by ii.5 ± 4.4% (p~0.05) in the low dose group and by I0.6 ± 4.1% (p

137 Society of Perinatal Obstetricians Annual Meeting San Antonio, Texas I February, 1982 -- I ANTEPARTUM HUMAN FETAL CARDIAC TIME INTERVALS: VENTRICULAR FILLING TIME AS A REFLECTOR OF FETA~L HEART RATE VARIABILITY

Robert N. Wolfson, M.D./Ph.D., Ivan E. Zador, Ph.D., and Sasi K. Pillay, Ph.D., I (Department of Obstetrics and Gynecology and the Perinatal Clinical Research Center, Cleveland Metropolitan General Hospital, Cleveland, Ohio) I Decreased fetal heart rate variability during antepartum fetal heart rate monitoring is often associated with an adverse outcome. Interpretation of decreased fetal heart rate variability is complicated by an incomplete under- I standing of its physiologic basis. The fetal cardiac time intervals (FCTI) reflect the electrical and electromechanical properties of the heart. Investi- gations of the FCTI during fetal cardiac arrhythmias have demonstrated that changes in the duration of diastole, occurring with changes in fetal heart rate, I are associated with changes in cardiac function reflected by the FCTI. The FCT! may thus offer a means of understanding the physiologic basis of decreased fetal heart rate variability. I

The ventricular filling time (VFT) is the major cardiac time interval of diastole and corresponds to the filling phase of the cardiac cycle. VFT is measured as the interval between atrioventricular valve opening and closure. I The purpose of this study was to obtain normative data on the relationship of VFT to fetal heart rate and gestational age. I Volunteers were recruited from patients receiving care at Cleveland Metro- politan General Hospital. Patients were studied at eight biweekly intervals from 25 to 40 weeks of gestation. VFT and RR interval (fetal heart rate) were I obtained from the Doppler ultrasound detection of atrioventricular valve acti- vity and the fetal abdominal electrocardiogram respectively. VFT was measured in the course of a reactive non-stress test during episodes devoid of overt fetal activity. Fetal gestational age at the time of study was confirmed with I the modified Dubowitz assessment of pediatric gestational age after birth. A longitudinal study design allowed independent assessment of the correlation of VFT with RR interval and gestational age. Analysis involved the correlation of I VFT with RR interval at each of the eight biweekly intervals of gestational age followed by the Scheffe multiple comparison method to test if these eight independent relationships differed statistically. I Twelve uncomplicated patients were studied. RR interval ranged from 368 to 494 milliseconds and corresponded to the normal fetal heart rate range of 120 to 160 beats/minute. No statistically significant difference in the correla- I tions of VFT with RR interval at each of the eight biweekly intervals of gesta- tional age could be demonstrated. Therefore, VFT and the correlation of VFT with RR interval are independent of gestational age. The correlation of VFT I with RR interval can then be described by a single equation: VFT = 0.70 RR interval - 118. The correlation coefficient is 0.91. In other words, 83 percent of the variance in VFT is attributable to a change in RR interval and I seven tenths of a change in RR interval will be reflected as a change in VFT. Therefore, VFT correlates highly with, and is quite sensitive to, changes in fetal heart rate. The characteristics of the filling phase of the cardiac cycle in the normal versus the hypoxic fetus may yield a better understanding of the I physiologic basis and consequences of decreased fetal heart rate variability. I

138 I Society of Perlnatal Obstetricians Annual Meeting San Antonio, Texas February, 1982

POSSIBLE ROLE OF ULTRASONIC PLACENTAL GRADING IN THE MANAGEMENT OF POST- I TERM PREGNANCIES Sze-Ya Yeh, M.D., Ruth Petrucha, ~I.D., and Lawrence D. Platt, M.D. (Department of Obstetrics and Gynecology, Los Angeles County/University I of Southern California Medical Center, Women’s Hospital, 1240 North Mission Rd., Los Angeles, CA 90033)

I A major issue in the management of post-term pregnancy is the avoidance of development of a dysmature infant with its associated morbidity. In order to evaluate the possible role of ultrasound placental assessment and the detection of the dysmaturity syndrome, a retrospective review was I performed on patients seen and managed in Post-Dates Clinic of LAC/USC Medical Center between July, 1980 and June, 1981. Ultrasonic placental grading was obtained according to the classification of Grannum, et al, I in 106 patients within one week of delivery. The dysmaturity syndrome was determined by a neonatal examination where dry peeling skin, decreased subcutaneous fat, long fingernails, and thick meconium passage were I present. The association between placental grade, the dysmaturity syn- drome and other clinical and biochemical parameters were obtained. In the group of patients with placental grading obtained, 40 patients had a Grade I placenta (37.7%), 35 had a Grade II placenta (33%), and I 31 of these post-dates patients had a Grade III placenta (29.2%1. Dys- mature infants were identified in 22.5% of patients with Grade I placenta, 20% of patients with Grade II placenta, and 48.4% of patients with Grade I III placenta. This incidence of Grade III placenta and dysmature syndrome is statistically significant. In addition to this finding, the occurrence of clinical oligohydramnios was also higher in a group of patients with I Grade III placentas, (22.6% in Grade III vs. 2.5% in Grade I and 5.7% in Grade II). The correlation between gestational age-and grading of the placenta was not significant; however, there was a correlation between the level of plasma unconjugated estriols and the grade of placenta. A signi- I ficantly lower plasma unconjugated estriol was almost uniformly identified with the Grade III placentas as compared to the other two groups. In six of nine patients who had Grade III placenta and decreased amniotic fluid I volume, a dysmature infant was delivered.

In conclusion, these findings suggest the usefulness of ultrasound placental grading and amniotic fluid assessment in the management of pos~-term I pregnancies. When a combination of a Grade III placenta and decreased amniotic fluid volume is identified on ultrasound, termination of pregnancy appears warranted regardless of cervical condition or other biophysical I testing. I I I

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