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To compare the safety and efficacy of intravaginal misoprostol to oxytocin for the induction of labor in twin gestations.All twin gestations that underwent induction of labor with misoprostol or oxytocin during a 4-year period were identified from the Mount Sinai obstetrical database. Only twinsor = 34 weeks with a vertex presenting twin A were included. Labor and delivery characteristics, maternal complications and neonatal outcomes were compared between the two groups.Of 134 patients with twins, 57 initially received misoprostol and 77 received oxytocin. These groups had similar demographics, but women who received misoprostol had less cervical dilation (0.8 vs. 2.2 cm, p0.0001) and were less likely to be multiparous (19% vs. 44%, p = 0.003). There was a shorter length of induction to delivery (7.8 hours vs. 15.1 hours, p = 0.001) and a trend toward a lower cesarean section rate (16.9% vs. 31.6%, p = 0.06) in the oxytocin-only group. There were no cases of uterine rupture or maternal mortality in this series. There were no significant differences in neonatal outcomes between the two groups, but the sample size was underpowered to detect significant differences between the groups.Misoprostol and oxytocin both appear to be safe and efficacious for use in inductions of labor in twins in this limited retrospective investigation. The safety of these agents with regard to neonatal outcomes should be confirmed by larger studies.

We have reviewed the prenatal diagnosis and management of abnormalities in the urologic system. Urologic anomalies may be caused by embryologic aberrations, genetic disease, or a nonrandom association with other structural abnormalities. There is a wide range of prognoses, depending on the cause and the impact of the anomaly on the production of amniotic fluid. Management focuses on obtaining an accurate prenatal diagnosis, providing appropriate counseling, and ensuring the proper surveillance or treatment before and after birth.

Objective: The purpose of this study was to determine the rates of obstetric hemorrhage and maternal mortality in women who are Jehovah's Witnesses and to evaluate a protocol that uses erythropoietin to optimize the red blood cell mass before delivery. Study Design: Obstetric outcomes were described for all of the women who were Jehovah's Witnesses and who delivered at Mount Sinai Medical Center during an 11-year period. The risk of maternal death was compared with our general obstetric population during this interval. Results: A total of 332 women who were Jehovah's Witnesses had 391 deliveries. An obstetric hemorrhage was experienced in 6% of this population. There were 2 maternal deaths among the women who were Jehovah's Witnesses, for a rate of 512 maternal deaths per 100,000 live births versus 12 maternal deaths per 100,000 live births (risk ratio, 44; 95% CI, 9-211). Erythropoietin was associated with a nonsignificant increase in hematocrit level. Conclusion: Women who are Jehovah's Witnesses are at a 44-fold increased risk of maternal death, which is due to obstetric hemorrhage. Patients should be counseled about this risk of death, and obstetric hemorrhage should be aggressively treated, including a rapid decision to proceed to hysterectomy when indicated. (Am J Obstet Gynecol 2001;185: 893-5.)

We sought to test the hypothesis that apoptosis is a method of remodeling in second-trimester fetal heart development. We also hypothesized that hearts from fetuses with Down syndrome would have different levels of apoptosis than would control hearts, associated with their abnormal heart development.We obtained hearts from fetuses between 14 and 23 weeks' gestation with Down syndrome without anomalies (n = 10) and with the atrioventricular canal defect (n = 5). These hearts were compared with control hearts without anomalies (n = 5). Hearts were subjected to in situ end-labeling of deoxyribonucleic acid to test for evidence of apoptosis. The apoptotic indices were compared by anatomic location.Apoptotic nuclei were observed in each anatomic location in every category. The apoptotic indices were significantly lower in the atrial myocardial tissues of fetuses with Down syndrome than in control preparations (P.05). The apoptotic index did not differ significantly in the atrial septum, ventricular myocardium, or ventricular septum.Apoptosis occurs in human fetal hearts during the second trimester. The different levels observed in our study suggest a different remodeling process in hearts of fetuses with Down syndrome than in hearts of control fetuses. Further study is needed to determine whether the different level of apoptosis associated with Down syndrome is due to the abnormal karyotype or to the presence of an anomaly.

Hemolysis, elevated liver enzymes, and low platelet (HELLP) syndrome is a form of severe preeclampsia that threatens the gravida and her fetus. In this report, the diagnostic criteria and maternal and fetal risks of HELLP are defined. Prompt recognition and treatment in tertiary centers is emphasized, because the prognosis can be adversely affected by delayed or less than optimal diagnosis and treatment. Management guidelines are offered for treating this disorder. The potential roles of corticosteroids, plasmapheresis, and expectant management are critically evaluated. Subsequent pregnancy outcome, contraception, and preventative strategies are considered.Hemolysis, elevated liver enzymes, and low platelet (HELLP) syndrome is a form of severe preeclampsia which threatens the health and life of both pregnant women and their fetuses. Primary and consulting obstetricians therefore need to know how to recognize and treat the condition. The diagnostic criteria and maternal and fetal risks of HELLP are defined, with stress upon the prompt recognition and treatment of the condition in tertiary centers, because prognosis can be adversely affected by delayed or suboptimal diagnosis and treatment. Management guidelines are offered for treating the disorder, and the potential roles of corticosteroids, plasmapheresis, and expectant management are critically evaluated. Moreover, subsequent pregnancy outcome, contraception, and preventative strategies are considered.

Objective: To determine in obstetric malpractice cases the incidence of adverse events (AE), defined in the litigation literature as an injury caused by medical management, and to determine the proportion of cases that would meet no-fault criteria.Methods: In a retrospective cohort design, all neonatal outcome claims (n = 47) occurring between January 1992 and December 1993 were reviewed from carriers in Massachusetts, Colorado, and Utah. Two obstetricians determined whether an AE occurred, as defined above. The cases were then reevaluated according to Swedish Compensatory Event (SCE) criteria, which compensate AEs due to avoidable or substandard care, and to Florida Neurological Injury Compensation Association (NICA) criteria, which compensate neurologic injury following peripartum oxygen deprivation or mechanical injury.Results: An AE occurred in only 23/47 claims, representing 49% (95% CI 34-64%). SCE criteria were met in all 23 of the cases with an AE. NICA criteria were met in 9/23, or 39% (95% CI 19-61%), of the cases with an AE. Neither SCE nor NICA criteria were satisfied in any of the 24 cases without an AE. There were strong relationships between an occurrence of an adverse event and fulfilling criteria for SCE (P