Intrapartum Treatment Research Articles

Intrapartum airway management for giant fetal neck masses: The EXIT (ex utero intrapartum treatment) procedure

OBJECTIVE: Our goal was to review our experience with the EXIT (ex utero intrapartum treatment) procedure in the management of five cases with life-threatening fetal neck masses. STUDY DESIGN: We present a retrospective review of prenatal presentation and course, diagnostic accuracy of imaging studies, intraoperative management, complications, and outcomes. RESULTS: Polyhydramnios was the initial presenting symptom in three of five fetuses with a mean gestational age of 25 ± 6 weeks. Preterm labor occurred in two patients. Fetal magnetic resonance imaging provided accurate diagnosis in all four cases whereas conventional ultrasonography led to the diagnosis in four of five cases. The mean duration of EXIT was 28 ± 22 minutes. The mean venous cord blood gas values were pH 7.22 ± 0.05, P co 2 61 ± 11 mm Hg, and P o 2 42 ± 8 mm Hg. In four of five cases an airway was successfully secured. CONCLUSIONS: The EXIT procedure provides up to 1 hour of good uteroplacental support and is the procedure of choice to secure an airway in the fetus with a giant neck mass. (Am J Obstet Gynecol 1997;177:870-4.)

Compliance with voluntary prenatal HIV testing in a large health maintenance organization (HMO).

Results of a recent national clinical trial show that maternal-to-fetal transfer of HIV can be decreased threefold by prenatal, intrapartum, and neonatal treatment. The question is whether to make prenatal HIV testing compulsory or to encourage voluntary testing. Kaiser Permanente Northern California (KPNC), which has 2.5 million members, is part of a large health maintenance organization (HMO). In 1994, KPNC cared for 32,700 prenatal patients; 16,500 (50%) agreed to voluntary HIV testing. Compliance with testing ranged from 0% to 92% among the 31 KPNC locations. A study done by telephone survey identified three main factors favoring success of voluntary HIV screening: the ease and accessibility of HIV testing, a designated educator, and the presence of a registered nurse on the counseling team. In 1995, following feedback to the 31 facilities of the 1994 results, compliance rose to 19,800 of 31,300 prenatal patients (63%). KPNC, by encouraging counseled voluntary screening and following known positive cases, hopes to identify, track, and offer treatment options to all HIV-positive prenatal patients.

Anesthetic Management of Cesarean Delivery Complicated by Ex Utero Intrapartum Treatment of the Fetus

Anesthetic Management of Cesarean Delivery Complicated by Ex Utero Intrapartum Treatment of the Fetus

Selective intrapartum anti-bioprophylaxy of group B streptococci infection of neonates: a prospective study in 2454 subsequent deliveries

Objective: To investigate the efficacy of a selective intrapartum prophylaxy of group B streptococci (GBS) infection of the neonates. Study design: A prospective protocol of universal antepartum screening of GBS and selective intrapartum treatment from the 1st February 1994 to the 31st December 1995, on 2454 subsequent deliveries was designed. Our policy included: (1) antepartum screening as soon as possible after 28 weeks by a single vaginal and perianal sample for culture; (2) intrapartum recognition of one condition of high risk of fetal contamination during labor (these conditions included: a temperature of 38°C during labor, rupture of membranes for more than 12 h or prolonged labor for more than 12 h with rupture of membranes, prematurity, twins, maternal diabetes, previous pregnancy with GBS infection of the neonate); and (3) intrapartum anti-bioprophylaxy (amoxicillin) for women with positive screening during pregnancy and one condition of high risk of fetal contamination during labor. We studied the outcome of neonates during this period to look for immediate GBS severe infection of the neonates in the form of bacteraemia or meningitis and compared the results with the rate of neonatal infection before this protocol ( 4,5 1000 live births in 1993). Results: We noted that 11% of pregnant women were carriers, 25% of which led to antibiotic chemoprophylaxis during the labor. We noticed four cases of neonatal bacteraemia of GBS. One case arose from the group of carriers (but no condition of risk of fetal contamination during the labor and no chemoprophylaxy). The three other cases were from women with a negative antepartum screening. There was no case of meningitis and all four babies were in good health at day 10 of life. Comparing with results prior to the study, we noticed that the rate of neonatal bacteraemia dropped from 4.5 to 1.6 per 1000 livebirths ( P < 0.0001). Conclusion: This protocol of intrapartum anti-bioprophylaxy significantly decreases the rate of GBS neonatal sepsis. We propose to improve the efficacy of this prevention program, especially with regard to the method of antepartum screening of pregnant women colonized with GBS.

PRETERM LABOR AND PRETERM PREMATURE RUPTURE OF THE MEMBRANES: Diagnosis and Management

Preterm delivery due to preterm labor and pPROM is responsible for most infant morbidity and mortality in the United States. The patient who presents with suspicious symptoms should undergo a thorough evaluation to confirm the diagnosis of either entity and identify a treatable cause. Determination of gestational age, fetal well-being, and the presence of intrauterine infection is a crucial step in subsequent management. Corticosteroid therapy has been demonstrated to be one of the most effective antenatal interventions to reduce infant morbidity and should be administered to patients with preterm labor, if feasible, when fetal pulmonary maturity is absent or undocumented. We recommend a similar protocol regarding gravidas with pPROM remote from term but recognize the need for further study in this area. Acute tocolytic therapy has been demonstrated to offer short-term benefit to enhance corticosteroid effect. However, all of the available tocolytic agents carry significant risks to the mother and fetus. As such, administration of these agents should be given only when the potential benefits outweigh the risks of administration. Evaluation for fetal pulmonary maturity and intrauterine infection, in concert with evaluation of gestational age-dependent risks of prematurity, may be helpful in determining whether tocolysis should be attempted. Adjunctive antibiotic administration has not been shown to reduce maternal or infant morbidity in the face of preterm labor. However, such treatment offers a reduction of chorioamnionitis, prolongation of latency, and a possible reduction of neonatal infectious and gestational age-dependent morbidity in the setting of pPROM remote from term. Finally, current guidelines recommend the administration of intrapartum GBS prophylaxis when preterm birth or prolonged membrane rupture is anticipated if GBS carrier status is unknown or positive. Intrapartum treatment with intravenous penicillin or ampicillin is appropriate.

Impact of Maternal Group B Streptococcal Screening on Pediatric Management in Full-Term Newborns

Background: The American Academy of Pediatrics strategy to prevent early-onset neonatal sepsis with group B streptococcus (GBS) relies on maternal antepartum GBS cultures, while the American College of Obstetrics and Gynecology strategy does not. Objective: To evaluate the impact of the 2 strategies on the care of asymptomatic full-term newborns. Design/Setting: Self-administered survey mailed to a national random sample of US pediatricians who were members of the American Academy of Pediatrics. Participants: A total of 461 members of the American Academy of Pediatrics who routinely care for newborns. Main Outcome Measure: Self-report of diagnostic and treatment strategies for asymptomatic full-term new-borns who were born under different clinical scenarios. Maternal risk factors, antepartum maternal GBS screening status, and maternal treatment with intrapartum antibiotics were varied across the scenarios. Results: Pediatricians treating asymptomatic full-term newborns born to risk factor–negative mothers reported ordering tests (63.3% in GBS-positive cases vs 6.7% with GBS unknown;P=.001) and antibiotics (21.5% in GBS-positive cases vs 0.9% with GBS unknown;P=.001) more frequently when presented with a positive maternal GBS screening result. Maternal intrapartum treatment had little impact on pediatric practice when risk factors were absent. In risk factor–positive mothers, pediatricians reported an increase in their antibiotic usage in response to a positive maternal GBS screen (61.8% in GBS-positive cases vs 36.9% with GBS unknown;P=.001). In risk factor–positive mothers with unknown results of GBS screening, use of intrapartum antibiotics increased the number of pediatricians who reported that they would prescribe antibiotic therapy. Conclusions: Obstetrical strategies to decrease the risk of neonatal GBS sepsis increase pediatric services provided to full-term healthy newborns. This increase in services by pediatric practices is likely to be greater with the screening-based strategy recommended by the American Academy of Pediatrics. Arch Pediatr Adolesc Med. 1996;150:802-808

Operating on placental support: The ex utero intrapartum treatment procedure

While treating eight fetuses with predictable airway obstruction, the authors developed a systematic approach, the ex utero intrapartum treatment procedure, to secure the airway during delivery. Six patients had their trachea plugged or clipped in utero for treatment of congenital diaphragmatic hernia, and two patients had prenatally diagnosed cystic hygroma of the neck and oropharynx. The ex utero intrapartum treatment procedure was performed by using high doses of inhaled halogenated agents to facilitate uterine relaxation during cesarean section, securing the fetal airway while feto-placental circulation remained intact, and then dividing the umbilical cord. A variety of procedures were performed during the ex utero intrapartum treatment procedure including bronchoscopy, orotracheal intubation, tracheostomy, tracheostomy with retrograde orotracheal intubation, tracheoplasty, removal of internal tracheal plug, removal of external tracheal clip, central line placement, and instillation of surfactant. There were minimal maternal or fetal complications during the procedure. This approach requires the coordinated efforts of pediatric surgeons, obstetricians, anesthesiologists, sonographers, and neonatologists. The combination of intensive maternal-fetal monitoring, cesarean section with maximal uterine relaxation, and maintenance of intact feto-placental circulation provides a controlled environment for securing the airway in babies with prenatally diagnosed airway obstruction.

Exit procedure (Ex utero intrapartum treatment) for giant fetal neck masses

Exit procedure (Ex utero intrapartum treatment) for giant fetal neck masses

Impact of maternal group B streptococcal screening on pediatric management in full-term newborns.

The American Academy of Pediatrics strategy to prevent early-onset neonatal sepsis with group B streptococcus (GBS) relies on maternal antepartum GBS cultures, while the American College of Obstetrics and Gynecology strategy does not. To evaluate the impact of the 2 strategies on the care of asymptomatic full-term newborns. Self-administered survey mailed to a national random sample of US pediatricians who were members of the American Academy of Pediatrics. A total of 461 members of the American Academy of Pediatrics who routinely care for newborns. Self-report of diagnostic and treatment strategies for asymptomatic full-term newborns who were born under different clinical scenarios. Maternal risk factors, antepartum maternal GBS screening status, and maternal treatment with intrapartum antibiotics were varied across the scenarios. Pediatricians treating asymptomatic full-term newborns born to risk factor-negative mothers reported ordering tests (63.3% in GBS-positive cases vs 6.7% with GBS unknown; P = .001) and antibiotics (21.5% in GBS-positive cases vs 0.9% with GBS unknown; P = .001) more frequently when presented with a positive maternal GBS screening result. Maternal intrapartum treatment had little impact on pediatric practice when risk factors were absent. In risk factor-positive mothers, pediatricians reported an increase in their antibiotic usage in response to a positive maternal GBS screen (61.8% in GBS-positive cases vs 36.9% with GBS unknown; P = .001). In risk factor-positive mothers with unknown results of GBS screening, use of intrapartum antibiotics increased the number of pediatricians who reported that they would prescribe antibiotic therapy. Obstetrical strategies to decrease the risk of neonatal GBS sepsis increase pediatric services provided to full-term healthy newborns. This increase in services by pediatric practices is likely to be greater with the screening-based strategy recommended by the American Academy of Pediatrics.

Management of 168 neonates weighing more than 2000 g receiving intrapartum chemoprophylaxis for chorioamnionitis. Evaluation of an early discharge strategy.

To determine whether sequential laboratory and clinical evaluations during the first 3 days of postnatal life can be used to safely limit the duration of antibiotic therapy for term neonates whose mothers received intrapartum antibiotic treatment for intra-amniotic infection (ie, chorioamnionitis). Since postpartum neonatal body fluid cultures can be falsely negative because of transplacental passage of maternal antibiotics, we prospectively followed up 6620 pregnancies for 28 months (December 1991 through March 1994) for the occurrence and treatment of chorioamnionitis. Neonatal antibiotic therapy was initiated and limited to 3 days or continued for 7 days or more in neonates with abnormal laboratory values or clinical signs that were consistent with sepsis on day 3 of postnatal age. Both groups were observed in the hospital for 24 to 48 hours after antibiotics were discontinued. Of the 6620 pregnancies, 158 infants (2.4%) born to 155 mothers received intrapartum antibiotics for chorioamnionitis; 10 additional neonates diagnosed as having chorioamnionitis were transported from other hospitals (N = 168). Because of the absence of signs and negative cultures, 82% (137/168) were treated with antibiotics for 3 days, while 18% (31/168) received 7 days or more of therapy. In 84% of the 3-day group, discharge was accomplished by postnatal day 4 or 5, whereas all of the 7-day or more group were discharged after day 8. Follow-up calls placed 1 month after discharge disclosed no adverse outcomes or hospital readmissions in any of the infants in this survey. Neonates with infection who are born to mothers pretreated with antibiotics for intra-amniotic infection can be reliably identified less than 72 hours after birth and treated appropriately. As 82% of at-risk patients are asymptomatic and have a negative body fluid culture, our data support the position that a full course of antibiotic therapy can be restricted to only those patients with clinical or laboratory signs of sepsis (18%). This will effective reduce the average length of hospital stay for intrapartum-treated neonates by a minimum of 3 to 4 days compared with a commonly used empiric therapy approach of continuing medication for 7 days or more. Perhaps hospital discharge can be further shortened if a 1- to 2-day posttreatment observation period is eliminated for all patients except those with a positive body fluid culture.

Prenatal screening for group B Streptococcus: II. Impact of antepartum screening and prophylaxis on neonatal care

OBJECTIVES: Our purpose was to evaluate the current practice of antimicrobial prophylaxis of preterm and low-birth-weight infants and to determine the impact of intrapartum fever, group B Streptococcus carriage, intrapartum antimicrobial therapy, and duration of membrane rupture on neonatal therapy. STUDY DESIGN: A total of 1356 members of the American Academy of Pediatrics were asked their practice regarding neonatal screening and antimicrobial prophylaxis. Respondents were asked to define how maternal fever, group B Streptococcus carriage, intrapartum antimicrobial therapy, and prolonged membrane rupture would affect their decisions regarding neonatal therapy. RESULTS: A total of 982 responses were obtained (72.4%). Routine antimicrobial prophylaxis is given to asymptomatic preterm neonates by 33.7% of pediatricians. Prophylaxis is inconsistently given at 32 to 36 weeks but is early universal after intrapartum fever, regardless of intrapartum therapy. If empiric intrapartum prophylaxis was given before a preterm birth, both the incidence (47.1% vs 29.1%) and frequency of prolonged neonatal therapy (30.1% vs 17.4% ≥7 days) would be increased. Knowledge of maternal group B Streptococcus carriage would lead to a 2.6-fold increase in treatment (75.1% vs 29.1%) and 1.8-fold increase in the incidence of prolonged therapy of preterm infants (30.9% vs 17.4%), with 45.3% giving antibiotics for ≥1 week if intrapartum treatment had been instituted. Surprisingly, 18% of pediatricians would treat term neonates without any risk factors other than maternal group B streptococcal carriage, and 32.7% would continue treatment for ≥7 days. The majority of pediatricians (82.6%) felt that intrapartum prophylaxis would reduce early-onset group B streptococcal sepsis, but only 46.0% felt overall neonatal sepsis would be decreased by such therapy. CONCLUSIONS: Antepartum screening and intrapartum prophylaxis against group B Streptococcus by obstetricians may lead to an increased incidence and duration of treatment of preterm and term neonates by the pediatrician. The efficacy, cost, and risks of such treatment in broadly applied screening and treatment programs should be considered before a standard of care is established.

Prenatal screening for group B Streptococcus: I. Impact of antepartum screening on antenatal prophylaxis and intrapartum care

OBJECTIVE: Our purpose was to evaluate current obstetric practice regarding screening and prophylaxis for group B Streptococcus and to evaluate the impact of screening on antepartum and intrapartum care. STUDY DESIGN: A total of 1232 members of the Society of Perinatal Obstetricians were asked to indicate their practices regarding screening for group B Streptococcus. Respondents were then asked their practices regarding antepartum and intrapartum prophylaxis on the basis of screening cultures, prior antimicrobial treatment, and other risk factors for neonatal sepsis. RESULTS: Of the 925 respondents (75.1%), 30.8% performed routine screening in all pregnancies: first prenatal visit (42.3%), 26 to 28 weeks (41.3%), and 34 to 38 weeks (22.1%). In addition, 65.9% would screen patients only under high-risk situations. Although 70.5% sample multiple sites, respondents were inconsistent regarding the sites from which cultures are obtained: distal vagina (64.2%), cervix (53.9%), proximal vagina (40.0%), anal canal (38.5%), and urethra (4.3%). A total of 34.7% of respondents would treat the patient at the time of a positive culture. Knowledge of maternal group B Streptococcus carriage would significantly alter intrapartum prophylaxis in low-risk (60.3% vs 0.5%) and various high-risk populations (74.0% to 98.4% vs 11.3% to 55.0%). However, no consensus as to optimal practice was identified. CONCLUSIONS: This survey demonstrates significant inconsistencies in screening and prophylaxis for group B Streptococcus by specialists in maternal-fetal medicine. In addition, it reveals that the recommendations of The American College of Obstetricians and Gynecologists and the American Academy of Pediatrics are not routinely followed by these specialists. Knowledge of group B Streptococcus carriage significantly increases antepartum and intrapartum treatment regardless of the presence of other risk factors for neonatal sepsis. The impact of this practice on neonatal therapy warrants further evaluation.

Group B Streptococcus and Pregnancy

EDITORIAL COMMENT: We have accepted this paper for publication as an Editorial because it is an overview of the experience from a centre with a longstanding interest in routine screening for Group B streptococcus in pregnancy. The fact remains that universal screening for Group B streptococcus during pregnancy is not routinely performed in many major hospitals in Australia although it is widely advocated. It may be noted that in Victoria in 1992 there were only 2 perinatal deaths considered to have resulted from Group B streptococcal infectionA; the extent to which this low mortality rate is related to antenatal screening and intrapartum treatment is not known.

Identification of Sepsis in Neonates Following Maternal Antibiotic Therapy

To examine the value of current diagnostic tests identifying neonatal sepsis related to intrapartum treatment with antibiotics, we reviewed the charts of 219 mother-infant pairs, of which 139 mothers received intrapartum antibiotics (group 1) and 80 mothers did not (group 2). When compared with group 2 infants, group 1 infants had fewer positive blood cultures (4.3% vs 20%, P < 0.003), blood cultures positive for group B streptococci (GBS) (P < 0.001), and positive urine GBS latex agglutination (LA) tests (P < 0.001). Although the sensitivity of the white blood cell count (WBC) was 81%, the specificity was < 60% in both groups. The specificity of the urine GBS LA test was 92%. These results suggest (1) the WBC will neither confirm nor rule out neonatal septicemia; (2) blood cultures are indicated in suspected neonatal sepsis even if there was maternal intrapartum treatment with antibiotics; and (3) a urine GBS LA test is a useful adjunct in the diagnosis of neonatal GBS septicemia.

Group B streptococci: Results of a protocol of antepartum screening and intrapartum treatment

OBJECTIVE: Our purpose was to evaluate and report the results of a protocol for the identification and treatment of all group B streptococcal carriers. STUDY DESIGN: In 1991 we instituted a protocol of antepartum cultures for group B streptococci on all pregnant women who attended clinics at the University of North Carolina Hospitals. Cultures were obtained from the lower third of the vagina and rectum at 24 to 28 weeks' gestation. Women with positive cultures were treated with intravenous antibiotics in labor. Women with signs of chorioamnionitis (through intrapartum assessment) were also treated in labor, regardless of carrier status. RESULTS: During the first 2 years of this protocol 1681 women were delivered. Forty percent of the women were from the private practice, 32% were black, and 62% were married. The group B streptococcal carriage rate was 14%. During the period of evaluation there were no infants infected with group B streptococci and no adverse reactions or complications among women who were treated with antibiotics. CONCLUSION: We found antepartum screening and intrapartum chemoprophylaxis of all group B streptococcal carriers to be an acceptable and effective protocol for reducing perinatal group B streptococcal infections. (AM J OBSTET GYNECOL 1994;170:521-6.)

Comparison of a rapid enzyme-linked immunosorbent assay test and the Gram stain for detection of group B streptococcus in high-risk antepartum patients

Early-onset neonatal sepsis with group B streptococci is a major problem in the management of high-risk obstetrics. Intrapartum treatment of the colonized mother reduces neonatal acquisition; however, many high-risk patients are delivered before culture results are available. This study prospectively evaluated a new enzyme-linked immunosorbent assay and the Gram stain for their accuracy in rapid detection of group B streptococci in 131 high-risk patients. Twenty positive cultures for group B streptococci were identified in the study population and were used as the control for test comparisons. The enzyme-linked immunosorbent assay test was 60% sensitive, whereas the Gram stain was 45% sensitive. The enzyme-linked immunosorbent assay showed an increase in sensitivity as the colony count increased; however, two cases of severe neonatal sepsis occurred in patients with low colony counts and both had enzyme-linked immunosorbent assay negative results. In conclusion, the need for a rapid sensitive test for group B streptococci detection still exists.

Cost-effectiveness of intrapartum screening and treatment for maternal group B streptococci colonization

Early-onset neonatal group B streptococci infection occurs in two cases per 1000 live births in the United States and is associated with a mortality rate greater than 20%. Nearly 30% of infected infants have concomitant meningitis and half suffer permanent neurologic damage. Group B streptococci also account for at least 20% of postpartum metritis. The annual cost of group B streptococci infection in the United States is conservatively estimated at nearly 2000 neonatal deaths and greater than $500 million, excluding the costs of long-term neurologic handicaps. Intrapartum chemoprophylaxis with ampicillin is effective in curtailing transmission of group B streptococci from mother to infant. Methods have been developed to identify maternal colonization before delivery. We applied principles of decision analysis to evaluate cost-effectiveness of intrapartum screening for maternal group B streptococci colonization with various reported methods in cohorts of low- and high-risk women. In the United States intrapartum screening for group B streptococci is cost-effective and offers the potential to avert a significant number of neonatal deaths and postpartum infections.

Intrapartum treatment of preeclamptic hypertension by ketanserin

Ketanserin was administered intravenously as either 20 or 10 mg boluses to 16 patients with severe preeclampsia in labor. The fetal heart rate was monitored with a scalp electrode and the uterine contractions were evaluated with a fluid-filled catheter connected to a physiologic pressure transducer. A 10-minute recording before every administration of ketanserin was compared to the same period immediately afterward. Ketanserin lowered the systolic and diastolic blood pressure significantly (p < 0.005, paired Student's t test). Maternal heart rate was unchanged but the mean fetal heart rate increased by 4.6 bpm. Long-term beat-to-beat variability and acceleration patterns were not affected. On four occasions an improvement in variable decelerations of the fetal heart, due to a reduction in uterine activity, was seen. Changes in the amplitute of contractions were not statistically significant. The frequency of contractions, however, was significantly reduced from 3.6 to 2.4 per 10 minutes (p < 0.005). No serious adverse effects occurred.

An obstetric approach to the prevention of early-onset group B β-hemolytic streptococcal sepsis

Group B β-hemolytic streptococcus is one of the most common causes of neonatal sepsis: Despite its relationship to neonatal morbidity and mortality, no consensus exists for an approach to its prevention. Several characteristics of the organism such as high maternal carriage rates, the intermittent nature of this carriage, and the failure of antibiotics to permanently eliminate carriage have limited the success of proposed intervention protocols. In this clinical opinion we review characteristics of the organism and previously suggested intervention protocols. Then, based on this review and an analysis of recently published data, a protocol focusing on preterm births is presented. This proposal favors intrapartum treatment of all mothers who are delivered of preterm infants and who are either carriers of group B β-hemolytic streptococci or whose carriage status is unknown. A comparison of the costs and benefits of this and other approaches is made.

Intrapartum treatment of preeclamptic hypertension by ketanserin—a serotonin receptor antagonist

stolic blood pressures at this stage behave differently from those in term pregnancy. The systolic and diastolic blood pressures in the present study, curiously enough, had no correlation with each other (r = 0.17). They seem to be independent variables, which is not the case in term and midtrimester pregnancies.’ In our previous report we considered the correlation between systolic and diastolic pressures to be autocorrelations, but the present study suggests that this presumption is not justified. The reason for and the basic mechanism behind this phenomenon remain obscure.