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A study was conducted to assess the percentage of individual placental mass that is associated with fetal survival in twin-twin transfusion syndrome after selective photocoagulation of communicating vessels. The findings contribute to the understanding of normal and pathologic monochorionic twin gestations, in the counseling of patients, and potentially to the improvement of surgical treatment of twin-twin transfusion syndrome.

Laser photocoagulation may be more effective than amniocentesis in treating twin-twin transfusion syndrome, especially in the third trimester of pregnancy. This was the conclusion of a study of 173 women pregnant with twins whose babies were affected by this condition. Twin-twin transfusion syndrome occurs when a blood vessel malformation allows one twin to receive more blood at the expense of the other twin.

In the first trimester of pregnancy, patients with untreated endocervical gonococcal infection are at increased risk for endometritis after elective abortion or chorionic villus sampling. Neisseria gonorrhoeae infection is the [...]

Using a laser to destroy blood vessels between twin fetuses can spare the life of one fetus when the other one has intrauterine growth retardation. If the smaller twin dies, it can adversely affect the bigger twin by taking its blood supply.

Doctors describe the prenatal treatment of two fetuses with an obstructed urinary tract. The technique they describe should only be used if conventional surgical techniques fail.

Injecting platelets and cryoprecipitate into the amniotic sac can seal fetal membranes that rupture prematurely. The exact location of the rupture is not important and the technique is relatively simple.

Byline: Ruben A. Quintero, Walter J. Morales, Mary Allen, Patricia W. Bornick, Jorge Arroyo, German LeParc Keywords: Premature rupture of membranes; amniocentesis; fetoscopy; endoscopic fetal surgery; platelets; cryoprecipitate; wound healing Abstract: Objective: Our aim was to describe the treatment of iatrogenic previable premature rupture of membranes with the intra-amniotic injection of platelets and cryoprecipitate (amniopatch). Study Design: Patients with iatrogenic previable premature rupture of membranes and without evidence of intra-amniotic infection underwent transabdominal intra-amniotic injection of platelets and cryoprecipitate through a 22-gauge needle. The study was approved by the Institutional Review Board of St Joseph's Hospital in Tampa, Florida, and all patients gave written informed consent. Results: Seven patients with iatrogenic preterm premature rupture of membranes underwent placement of an amniopatch. Membrane sealing was verifiable in 6 of 7 patients. Three patients had iatrogenic preterm premature rupture of membranes after operative fetoscopy, 3 cases were after genetic amniocentesis, and 1 was after diagnostic fetoscopy. Three pregnancies progressed well, with restoration of the amniotic fluid volume and no further leakage. Two patients had unexplained fetal death despite successful sealing. One case of bladder outlet obstruction had no further leakage, but oligohydramnios persisted and did not allow unequivocal documentation of sealing. One patient miscarried from twin-twin transfusion, but the amniotic cavity was sealed. Conclusions: Iatrogenic preterm premature rupture of membranes can be treated effectively with an amniopatch. The technique is simple and does not require knowledge of the exact location of the defect. Unexpected fetal death from the procedure may be attributable to vasoactive effects of platelets or indigo carmine. Although the appropriate dose of platelets and cryoprecipitate needs to be established, the amniopatch may mean that iatrogenic preterm premature rupture of membranes no longer needs to be considered a devastating complication of pregnancy. (Am J Obstet Gynecol 1999;181:744-9.) Author Affiliation: Tampa, Florida Article History: Received 2 February 1999; Revised 21 April 1999; Accepted 21 May 1999 Article Note: (footnote) [star] From the Florida Institute for Fetal Diagnosis and Therapy, St Joseph Women's Hospital,a and Florida Blood Services, University of South Florida.b , [star][star] Reprint requests: Ruben A. Quintero, MD, 13601 Bruce B. Downs Blvd, Suite 160, Tampa, FL 33613., a 0002-9378/99 $8.00 + 0 6/1/100248

Many strains of group B Streptococcus are becoming resistant to erythromycin. This antibiotic is used to treat these kinds of infections during childbirth so the baby is not infected. Eighteen of 100 strains tested were resistant to erythromycin in 1998 compared to only 1 or 85 strains in the 1980s.

It may not be necessary to reduce a triplet or quadruplet pregnancy to a twin pregnancy. In study of 53 women with a triplet or quadruplet pregnancy, prolonged hospitalization and early delivery were common, but otherwise the mother and baby did very well. Their outcomes were similar to women who had reduced and non-reduced twin pregnancies.

Byline: Walter J. Morales, Sonja S. Dickey, Patricia Bornick, Daniel V. Lim Keywords: Group B Streptococcus; antibiotic resistance; Centers for Disease Control and Prevention protocol Abstract: Objective: Intrapartum chemoprophylaxis has resulted in a significant reduction of group B Streptococcus neonatal infection. For penicillin-allergic patients, clindamycin or erythromycin is the recommended antibiotic. The purpose of this study was to establish any pattern of antibiotic resistance of group B streptococcal clinical isolates over the past 15 years. Study Design: Group B streptococcal isolates obtained from the lower genital tract were tested for sensitivity to ampicillin, penicillin, clindamycin, and erythromycin. The sensitivity of 100 group B streptococcal isolates retrieved in the period 1997-1998 was compared with that of 85 group B streptococcal isolates from 1980-1993. Results: From 1980-1993 group B streptococcal isolates were available for testing for antibiotic resistance along with 100 isolates from a second study period 1997-1998. Of the 100 group B streptococcal isolates from 1997-1998, 18 were resistant to erythromycin, of which 5 were also resistant to clindamycin, as compared with 1 of the 85 isolates from 1980-1993 that was resistant to erythromycin (P < .001). All the isolates were sensitive to ampicillin and penicillin. All 18 resistant strains from 1997-1998 were found to be sensitive to cephalothin. Conclusion: Over the past 18 years there has been increased in vitro resistance of group B streptococci to both clindamycin and erythromycin. If other studies confirm these findings, modifications to the current Centers for Disease Control and Prevention recommendations may be necessary. (Am J Obstet Gynecol 1999;181:310-4.) Article Note: (footnote) [star] From the Florida Perinatal Associates, the Department of Biology, University of South Florida, and St Joseph's Women's Hospital., [star][star] Reprint requests: Walter J. Morales, MD, Florida Perinatal Associates, 13601 Bruce B. Downs Blvd, #160, Tampa, FL 33613., a 0002-9378/99 $8.00 + 0 6/6/99906

Byline: Jeffrey L. Angel, Craig S. Kalter, Walter J. Morales, Connie Rasmussen, Linda Caron Keywords: Multiple gestation; fetal reduction; assisted reproductive techniques Abstract: Objective: The purpose of this study was to determine the factors that must be considered for appropriate counseling of patients with high-order multiple gestations. Study Design: A retrospective chart review was carried out from all high-order multiple gestations that were managed by a single perinatology group from February 1993-June 1998. Twin pregnancies that did not result from fetal reduction procedures were used as a control group. Results: Clinical outcome data were analyzed from 9 quadruplet, 25 triplet, 19 reduced twin, and 24 nonreduced twin pregnancies. Women with quadruplet pregnancies were admitted more frequently at an early gestational age, the infants were delivered earlier, and the maternal and neonatal hospital days were longer than for triplet and reduced and nonreduced twin gestations. Triplet pregnancies had an earlier gestational age at delivery (32.3 vs 34.2 weeks), a higher incidence of preterm labor (87% vs 68%), and a higher percentage of neonatal intensive care unit admissions (94% vs 59%) than reduced twin gestations. Reduced twins were hospitalized longer (16.4 vs 9.8 days), were delivered earlier (34.2 vs 36.2 weeks), had a higher incidence of preterm labor (68% vs 29%), and had a greater percentage of neonatal intensive care unit admissions (59% vs 21%), a greater percentage of birth weight Article Note: (footnote) [star] From the Florida Perinatal Associates., [star][star] Reprints not available from the authors., a 0002-9378/99 $8.00 + 0 6/6/99904

An endoscopic probe inserted into the uterus through the abdominal wall shows that spontaneous premature rupture of the fetal membranes often occurs close to the opening between the uterus and cervix. This was the conclusion of a study that used this technique on four women with premature rupture of membranes, three of which were spontaneous and one which was presumably caused by amniocentesis. In the three spontaneous cases, the rupture was always close to the cervical opening, but this was not true in the woman who received amniocentesis. The rupture was closed for up to three days by a technique called aminopatch.

Byline: Ruben A. Quintero, Walter J. Morales, Craig S. Kalter, Mary Allen, Gustavo Mendoza, Jeffrey L. Angel, Roberto Romero Keywords: Premature rupture of membranes; preterm labor; fetoscopy; amniocentesis Abstract: OBJECTIVE: Our purpose was to describe the endoscopic characteristics of the site of rupture in vivo in patients with spontaneous premature rupture of membranes. STUDY DESIGN: Patients with preterm premature rupture of membranes between 16 and 26 weeks of gestation, without evidence of intra-amniotic infection, and with a normal karyotype underwent transabdominal endoscopic examination of the amniotic cavity. Subsequently, an amniopatch of a combination of platelets and cryoprecipitate to seal the membrane defect was administered. The study was approved by the Institutional Review Board of St. Joseph's Hospital in Tampa, Florida, and all patients gave written informed consent. RESULTS: Four patients underwent endoscopic examination and amniopatch administration; three had spontaneous preterm premature rupture of membranes, and in the other the membranes ruptured after an early amniocentesis. The location of the site of rupture was over the internal os in the 3 cases with spontaneous preterm premature rupture of membranes. This area was normal in the patient with iatrogenic preterm premature rupture of membranes. The longer the time between preterm premature rupture of membranes and fetoscopy, the larger and less defined was the site of rupture. The amniopatch restored amniotic integrity for a maximum of 72 hours. CONCLUSIONS: This is the first in vivo endoscopic visualization of the site of spontaneous rupture of membranes from within the uterine cavity. The defect is located over the internal cervical os in patients with spontaneous preterm premature rupture of membranes. There appear to be time-related changes in the morphologic characteristics of the site of rupture. Endoscopic visualization of the site of rupture has the potential for improving our understanding of spontaneous preterm premature rupture of membranes and in the development of possible therapeutic alternatives. (Am J Obstet Gynecol 1998;179:71-6.) Author Affiliation: Tampa, Florida Article History: Received 12 March 1998; Accepted 12 May 1998 Article Note: (footnote) [star] From the Florida Institute for Fetal Diagnosis and Therapy, St. Joseph's Women's Hospital. Dr. Romero participated in this study as a private citizen, without any affiliation to the institutions with which he holds appointments., [star][star] Reprint requests: Ruben A. Quintero, MD, 13601 Bruce B. Downs Blvd, Suite 160, Tampa, FL 33613., a 0002-9378/98 $5.00 + 0 6/1/91594

Treating vaginal bacterial infections with metronidazole reduced the number of preterm births in women with a history of a prior preterm birth. Prior preterm birth is the leading risk for preterm birth in a subsequent pregnancy. Bacterial vaginosis also has a strong association with preterm birth. Eighty women with a prior preterm birth were screened for bacterial vaginosis at between 13 and 20 weeks gestation. Women with a positive test result were assigned randomly to either oral metronidazole therapy or a placebo (vitamin C tablet). The treated group was less likely to be admitted to the hospital for preterm labor (27% versus 78%), to have a preterm birth (18% versus 39%), to have an infant weighing less than 2500 g (14% versus 33%), and to have premature rupture of membranes (5% versus 33%).

Oral nifedipine may be as effective as intravenous magnesium sulfate for the treatment of premature labor. Among 80 women with premature labor at between 20 and 34 weeks of pregnancy, 39 were treated with oral nifedipine and 41 were treated with intravenous magnesium sulfate. No significant difference was found between the two groups of patients in the time until contractions stopped. Delivery was delayed at least two days in a similar proportion of patients from each group. The incidence of recurrent labor was also similar for the two groups. Thirteen percent of the women treated with nifedipine developed side effects, compared with 31% of the women treated with magnesium sulfate. None of the women in the nifedipine group had to discontinue treatment as a result of severe side effects, compared with 10% of those in the magnesium sulfate group.

Indomethacin appears to be as effective as magnesium sulphate in suppressing premature labor. In a study of 101 patients who went into labor at

A significant number of newborns may survive after premature rupture of fetal membranes at 25 weeks or less of gestation. Fetuses less than 25 weeks old are not considered viable. A study examined the pregnancy outcome in 97 mothers admitted to the hospital for premature rupture of membranes at 25 weeks of gestation or less. Twenty-four mothers were diagnosed with amnionitis, or inflammation of the amniotic membrane surrounding the fetus. Nineteen infants were stillborn, 39 infants died after birth and 39 infants (40%) survived. Five percent of the infants were suffering from incomplete development of their lungs and none were suffering from any orthopedic deformities. Infants who survived had a higher birth weight and a more advanced gestational age than those who did not survive. Sixty-three percent of the infants who survived were developmentally normal at the time of their first birthday.

Researchers used a collagen graft to seal ruptured fetal membranes in a pregnant woman with premature rupture of membranes. The membranes were sealed at 17 weeks and although they broke again 14 days later, she successfully carried the fetus to 30.5 weeks.

Postpartum endomyometritis is an inflammation and swelling of the muscle wall inside the uterus caused by a bacterial infection following vaginal delivery of a pregnancy. As the infection may be due to more than one organism, combination antibiotic therapy has been recommended. To determine the effectiveness of antibiotic combination treatment, 109 patients with endomyometritis were given a short course of clindamycin and tobramycin antibiotics. The patients were given the medication until the fever and signs of the disease were gone. Three groups were given the combination for either 24 hours, 48 hours or 48 hours followed by another 7 days of treatment with augmentin, another antibiotic, until the symptoms were gone. The short term treatment group offered the most effective results, both in terms of outcome and cost.