Search

OBJECTIVE: The goal of this study was to create a computational model of the pregnant occupant of a motor vehicle to predict fetal outcome in crashes. STUDY DESIGN: A finite element uterine model of a 7-month pregnant woman was created and integrated into a multibody human model. Unrestrained, three-point belt, and three-point belt plus airbag tests were simulated at speeds that ranged from 13 to 55 km per hour. RESULTS: Peak uterine strain, as determined by the model, correlated well with the risk of fetal death, as determined by investigations of car crashes. The strain in the uterine wall exceeded the limits of the tissue in simulations of no restraint at 35 km per hour and three-point belt tests at 45 and 55 km per hour. The safest restraint for the pregnant driver is the combination three-point belt and airbag. CONCLUSION: The model is a good first step toward the prediction of the risk of fetal death and verified experimental findings that note the importance of proper restraint use for the pregnant occupant.

Our purposes were (1) to compare the safety of transabdominal and transcervical chorionic villus sampling with the use of a consistent technique at one center and (2) to determine whether the training of fellows can be accomplished without an increase in the loss rate.We performed a retrospective comparison of transabdominal and transcervical chorionic villus sampling loss rates from procedures performed by three principal operators between 1984 and 1992. The type of procedure was chosen by the operator at the time of the procedure on the basis of placental location.Procedures 1 through 2573 were performed solely by transcervical chorionic villus sampling and had an overall fetal loss rate of 5.12%. With the addition of transabdominal chorionic villus sampling the overall fetal loss rate dropped to 3.07% (p0.0001). Three and one half years after the start of transabdominal chorionic villus sampling (about 1300 transabdominal chorionic villus sampling procedures), the transabdominal chorionic villus sampling loss rate was significantly better than the transcervical loss rate (p = 0.035), and the difference widened steadily after that. During the same time period seven fellows performed 716 procedures for a fetal loss rate among fellows of 2.72%.(1) Under optimal circumstances (one center, large numbers, few operators, consistent technique, operator choice of best approach), transabdominal chorionic villus sampling may be inherently safer than transcervical chorionic villus sampling. (2) The addition of transabdominal chorionic villus sampling decreases overall chorionic villus sampling loss rates. (3) Although the number of procedures performed by fellows is small, it appears that with close supervision by experienced operators successful training of fellows can be accomplished without adverse effects on loss rates.

Our purpose was to determine acute and persistent psychologic impacts of multifetal pregnancy reductions and patients' ability to cope with fetal loss while simultaneously bonding to surviving infants.The first 100 women to undergo a multifetal reduction were invited to participate in a retrospective telephone study assessing their emotional reactions and attitudes toward multifetal reduction. The semistructured interview elicited demographic and obstetric data and contained scales used in previous studies of reproductive loss, which assessed repetitive thoughts about reduced fetuses, catastrophic fears, and lingering depressive feelings.More than 65% of the sample recalled acute feelings of emotional pain, stress, and fear during the reduction procedure. Mourning for the lost fetuses was reported by 70% of women, but most grieved for only 1 month. Thoughts about reduced fetuses occurred moderately frequently after the reduction but rarely at follow-up. Persistent depressive symptoms were mild, although moderately severe levels of sadness and guilt continued for many. Nonetheless, 93% would make the same decision again. Emotional reactions of patients who miscarried differed little. The small subsample who continued to be most affected were younger (p0.02), were more religious (p0.003), and had viewed the multifetal pregnancy on ultrasonography more often (p0.009).Multifetal reductions, although highly stressful psychologically, are well tolerated. Sadness and guilt may persist, especially for an identifiable subgroup. Normal maternal bonding and achievement of parenthood goals facilitate grief resolution. The large majority were reconciled to the termination of some fetuses to perserve the lives of a remaining few.

Prior studies have identified a correlation between the rate of fetal loss (subsequent to chorionic villus sampling) and the operator's level of experience. However, centers performing only modest numbers of procedures during the initial phase of their programs have reported loss rates similar to those of the more active diagnostic units. Our personal experience would suggest that a "learning curve" for chorionic villus sampling does exist but that fetal loss may be an insensitive end point with which to evaluate the impact of cumulative performance. In an attempt to quantify the learning curve that we have appreciated subjectively, a detailed analysis of our initial experience with chorionic villus sampling was undertaken. Between May 1988 and August 1989, a total of 185 procedures were accomplished consecutively by one operator and form the basis for this analysis. Transcervical (n = 82) and transabdominal (n = 103) techniques were used for posterior and anterior-fundal placental locations, respectively. Three pregnancy losses occurred and insufficient material for analysis was retrieved in five patients. We observed a significant reduction in the required number of placental aspirations during the study interval (p less than 0.001). When analyzed separately, consecutive performances of the transabdominal technique demonstrated a significant reduction in the mean number of placental passes (p less than 0.00001) along with more efficient sampling (increased sample weight/aspiration attempt; p less than 0.01). Although the fetal loss rate is a critical measure of safety and may directly be related to operator experience, other measures of expertise (e.g., single-pass success rate) may be more appropriate indicators of competence and may be useful to centers wishing to initiate their own chorionic villus sampling programs.

Maternal, fetal, and neonatal results and complications were analyzed after 923 genetic amniocenteses. Maternal age of 35 years and beyond was associated with a 2.0% risk of fetal trisomy 21 and a 3.0% risk of all major chromosome abnormalities. Comparable rates for women aged 40 and beyond were 4.8% and 7.2%. Neural tube defects were detected in 0.15% of procedures done for maternal age and 3.4% of those done for a previous involved child. The risk of spontaneous abortion as a result of amniocentesis was 0.2% to 1.4%. Mahogany or green fluid was associated with a 29% rate of fetal loss. Unexplained midtrimester elevations of maternal serum α-fetoprotein were associated with a 38% risk of a subsequent low-birth weight infant. The only neonatal complication associated with amniocentesis was an apparent marked increase in the incidence of lower-extremity orthopedic abnormalities.

Between 1979 and 1984, 2136 midtrimester genetic amniocenteses were performed by a single physician at the University of California (Davis) Medical Center. The medical records were reviewed for maternal age, amniocentesis indication, ultrasound findings, location of placenta, location of the needle insertion (transplacental versus nontransplacental), color of the amniotic fluid, results of prenatal testing, complications of procedure, and pregnancy outcome. Follow-up data were available for 88% of the pregnancies. There were 38 miscarriages (1.9%),18 stillbirths (0.9%), and four neonatal deaths (0.2%), resulting in a total postprocedural loss rate of 3.1%. Miscarriage within 2 weeks of amniocentesis occurred in only 0.4% of procedures (seven of 1918). No significant difference in pregnancy outcome was noted between transplacental and nontransplacental amniocentesis. Greenish brown discolored amniotic fluid was found in 3.6% of procedures (76 of 2136). In this group there was a 14.5% fetal loss rate with an overall 22.4% adverse outcome.

1. 1. A total of 360 viable pregnancies in diabetic patients from 1932 to the present are reviewed. 2. 2. The viable fetal loss in the earlier series (1932 to 1949) was 22 per cent and in the current series (1950 to date) was 8.7 per cent. 3. 3. The method of management responsible for this improvement is presented. 4. 4. The patient with an abnormal glucose tolerance curve during pregnancy should be treated as a diabetic. 5. 5. Further education and cooperation of patients are necessary to improve fetal salvage in the diabetic. 6. 6. In the uncomplicated case, termination of pregnancy more than 28 days prior to the estimated date of labor will result in an increased fetal mortality.

An increase in early fetal deaths and perinatal mortality was observed in a prospective study of 763 cases of maternal rubella in New York City from 1957 to 1964, inclusive. The increase appeared to be limited to cases with onset in the first trimester. Spontaneous fetal deaths accounted for 18.3 per cent of the total fetal loss following rubella. An additional 81.7 per cent were due to artificial termination of labor for therapeutic reasons. The combined fetal loss from spontaneous deaths and induced abortions was 73.6 per cent of cases reported in the first three months of gestation. There was no evidence of an increase in virulence of infection in the extensive epidemic of rubella in 1964 as measured by fetal mortality following maternal disease in recent years.

1. 1. There were 110 cases of prolapsed cord studied. 2. 2. Etiological factors, methods of treatment, and results are discussed. 3. 3. Corrected infant salvage (over 2,500 grams) is 87.5 per cent in this series; that is, a fetal loss of 12.5 per cent.

A review of diabetic pregnancies taken from private hospitals over a ten-year period has been presented. An attempt has been made to discover deficiencies that caused fetal loss and to out-line possible methods to overcome them. Better results in fetal salvage are possible in the hands of physicians in private practice, but more effort must be made to achieve a standardized pattern of management.

Among 1,108 patients with obstetric histories complicated by fetal wastage, 217 (19.6 per cent) were found to have both the complement fixation test and the intradermal test positive for toxoplasmosis. The presence or absence of one or more of 15 other factors, regarded as possible causes of fetal wastage, are examined in these 217 cases of suspected toxoplasmosis in an effort to determine the probable contribution of toxoplasmosis, alone or in association, to the production of fetal loss.

1. 1. One hundred eighty-six consecutive cases of transverse presentation at Charity Hospital, New Orleans, La., are analyzed. 2. 2. The factors producing the high fetal and maternal mortality are emphasized. 3. 3. Two factors seem essential from a study of this series in the possible lowering of maternal and fetal mortality: 3.1. (a) An early diagnosis of the malpresentation present, and 3.2. (b) The more frequent use of cesarean section in early labor in these cases. 4. 4. Transverse presentation, although occurring about one-half as frequently as placenta previa, produced a much higher fetal loss than the latter in this series. In fact, the fetal loss is only exceeded by the loss associated with rupture of the uterus. Any obstetric abnormality producing a 67.6 per cent fetal loss and a 9.6 per cent maternal death rate over a period of years deserves the most serious consideration.

Summary Surgical induction of labor is not without risk to the mother, and should not be lightly undertaken. It has, I believe, an important place in the treatment of postmaturity, anyhow in primigra vidas; it can reduce the fetal loss, also the incidence of difficult labor in this class of case. Induction has no place, I believe, in the treatment of disproportion in primigravidas, and almost no place in multiparas. In pre-eclamptic toxemia, induction has an established place, in the interests of both the mother and the baby, but under certain circumstances cesarean section should be undertaken. Of all the risks in surgical induction of labor, prolapsed cord is the most worrying, and if the head is above the brim the incidence is high. These days, most of us I think would undertake cesarean section if this accident happens, but even so it is not always possible to recognize the condition in time to save the child. It will be interesting for me to learn how far the use of Pitocin drips has added, if at all, to the safety of surgical induction in the classes of ease discussed. Although I have had relatively little experience with it. J would hesitate to use it in postmaturity or in pre-eclamptic toxemia on account of increasing the already present risk of anoxia in the child.

The 54 cases of abruptio placentae occurring in 18,202 deliveries have been studied. In the 15 cases of the mild group, interference was almost always unnecessary and their chief importance was the fetal loss due to prematurity and asphyxia. In the 31 cases of moderate severity with 34 babies, the fetal mortality was 64.7 per cent. Five cesarean sections were done, the remainder being delivered through the normal passages. Of the eight severe cases, three were treated by immediate cesarean section, four were successfully treated by conservative treatment and one was saved by combined treatment. All babies were dead when treatment was started. There was no maternal mortality in the total series. Total fetal mortality was 58.6 per cent.

The gravity of the complication of rupture of the uterus to the mother and the consequences to the fetus still provides an important subject for discussion in the world literature. Although the incidence varies between countries and centers, a study of statistics presents facts and insight into the problem and hammers the ways and means to reduce the gravity. The present study includes 104 patients with uterine rupture admitted, studied, and treated in the Maternity Hospital, Amman. A maternal mortality rate of 36.5 per cent and fetal loss of 80.7 per cent is explained according to the causes of uterine rupture.

Summary Effects of therapy, antibody titer, and pregnancy history on pregnancy outcome were evaluated in pregnancies of women with antiphospholipid antibody. Prior fetal death and a high antiphospholipid antibody titer (> 40 IgG phospholipid units) contributed independently, in an additive manner, to current fetal loss. Twenty-one pregnancies occurred in asymptomatic women who had both prior fetal death and a high IgG antiphospholipid antibody titer. In this very high-risk group, 9 of 11 (82%) of pregnancies treated with prednisone, 10 to 60 mg/day, ended in fetal death, compared with 5 of 10 (50%) not treated with prednisone ( p ≈ 0.01, life-table analysis). Of pregnancies treated with aspirin, 80 mg/day, 9 of 14 (64%) treated and 5 of 7 (71%) not treated with prednisone had a fetal death (difference not significant). Prednisone does not improve, and may worsen, current fetal outcome in asymptomatic pregnant women with a high antiphospholipid antibody titer and prior fetal death. (Am J Obstet Gynecol 1989;160:439-43.)

A total of 12,084 patients participated in a maternal serum α-fetoprotein (AFP) screening program in central North Carolina between July 1, 1978, and June 30, 1982. Fifteen open neural tube defects were detected and three others were missed, resulting in a detection rate of 83%. With a cutoff of 2.5 times the normal median, 3.7% of patients screened had a single maternal serum AFP elevation, 2.1% had two successive elevations, and 1.2% became candidates for amniocentesis. Of those patients offered amniocentesis, one in 10 was found to have a fetus with a neural tube defect. No normal fetuses have been aborted. Patients with maternal serum AFP elevations were shown to have a substantially increased risk of fetal loss. Low maternal serum AFP levels were also a significant finding and led to recognition of less advanced gestational age, fetal death, or molar pregnancy in a number of cases.

Lowered maternal serum alpha-fetoprotein was retrospectively investigated in 20,000 patients who underwent prenatal maternal serum alpha-fetoprotein screening. Two hundred thirty-two patients were initially evaluated as having maternal serum alpha-fetoprotein levels less than 0.25 multiple of the normal median. Correction factors, such as incorrect estimation of gestational age, reduced to 180 the number of patients with low alpha-fetoprotein. In this target group, patients with known pregnancy outcomes sustained a fetal loss in 38% of the cases. It appears that significantly low maternal serum alpha-fetoprotein is associated with a dramatic increase in second-trimester fetal wastage.

Four pregnancies managed with erythrocyte membrane oral therapy because of severe Rh disease are presented. Reduction in anti-(D) production was the goal of the study. A patient was classified as having severe Rh immunization if there was a history of fetal loss due to erythroblastosis fetalis prior to 26 weeks.

The prophylactic administration of diethylstilbestrol in pregnancy to prevent those accidents associated with progesterone deficiency was introduced in 1946 by Smith, Smith, and Hurwitz. 1 The success of this treatment in preventing abortion, 2 reducing the incidence and severity of late pregnancy complications, and increasing fetal salvage 3, 4 has led to its continued and extensive use in this hospital. Previously reported clinical studies indicated that the newborn infants of stilbestrol-treated mothers exhibited no deleterious effects from the Smith and Smith regime. In fact, weights and lengths of infants born prematurely to stilbestrol-treated mothers exceeded those expected at their gestational age, 3, 4 a finding presumably related to the reduced fetal loss observed. Because all of these data covered only the prenatal and immediately postnatal periods, the present study of postnatal development was undertaken.

A total 226 diabetic women who had 357 pregnancies during the years 1938 to 1966 are reviewed. The perinatal mortality rate (12.3 per cent) is similar to other reported series. The most important factor in assessing fetal loss is poor control of the diabetes. Suggestions for improving the classification of pregnant diabetic women and 6 points for improving perinatal mortality are made.

Serial serum human placental lactogen (S-HPL) determinations were done in early pregnancy on 85 high-risk cases. Normal S-HPL values with a normal ultrasonogram had a 94.8 per cent successful outcome of pregnancy. Low S-HPL values were often accompanied by an abnormal or equivocal ultrasonogram (29.6 per cent). The fetal loss in patients with low S-HPL values and a normal ultrasonogram was 36.8 per cent.

A series of 864 women are being followed subsequent to amputation of the cervix. Of 193 women who were menstruating at the time of operation, 20 have conceived, 17 inadvertently, and 3 deliberately since, in these 3, the cervix was excised in the management of secondary infertility. There were 2 abortions in the first trimester, one fetal loss secondary to cervical incompetence in the second trimester, and 18 healthy babies resulting from vaginal delivery at term. It is concluded that excision biopsy of the cervix by a modified Sturmdorft amputation technique does not increase the hazard during future childbearing.

I N 1952, Dailey and Ijenson’ reviewed the ]itel*ature an(l rel)()l*ted :! 1 additional cases of hyperthyroidism complicating pregnancy. They ~n~lu&~l t,hat hyperthyroidism has no adverse effects on a well-established preg11ancy ; that the course of a toxic goiter is not altered appreciably 1)~ pregnancy ; and that there is a slight increase in fetal loss during pregnancy. Although medica. management will control this complication, these authors recommend operation as the procedure of choice. Vit,h these concepts in mind the management of thyrotoxicosis a.ppears to be relatively simple. This is true certa,inly for the patient seen early in the course of pregnancy with mild or moderate hyperthyroidism. Subtotal thyroidectorny following adequate medical preparation can usually be a.ccomplisheci without difficulty during the second and early third trimesters. Occasionally, however, one may be confronted with uncontrolled severe thyrotoxicosis in a patient late in pregnancy. Sufficient time may not be available to prepare these patients adequately for surgery, necessitating medical management alone. We have recently ohsc~~~ed a patient admitted to the hospital in labor who presented such severe maternal c*onlplications due t,o thyrotosicosis that they seem worthy of report,.

1.1. A case of spina bifida occulta with aplasia of the lower sacrum and coccyx and probable myelocele is reported. 2.2. Problems in the obstetrical management of this type of case are discussed which may become more common as more of these patients reach adult life in the modern antibiotic era. Careful management will decrease fetal loss and maternal morbidity.