Management Of High-risk Pregnancies Research Articles

The pediatrician's role in the management of high risk pregnancy.

The pediatrician's role in the management of high risk pregnancy.

Plasma unconjugated estriol values in high-risk pregnancy

The usefulness of plasma estriol concentrations in the management of high-risk pregnancy is controversial. In this study, serial plasma unconjugated estriol (E3) concentrations determined by radioimmunoassay were evaluated in 321 patients with high-risk pregnancy for correlation with fetal and neonatal performance. A plasma E3 concentration of 4 ng. per milliliter or less in late pregnancy correlated significantly with low one- and five-minute Apgar scores and selected neonatal problems in pregnancies complicated by chronic hypertension and intrauterine growth retardation, with a similar trend for pregnancies complicated by moderate and severe pre-eclampsia. Most perinatal deaths in the study were associated with acute problems which began during labor and delivery, or fetal death occurred before early intervention was practical. Therefore, the perinatal mortality rate is not likely to be influenced by the use of E3 values, and the perinatal mortality rate is not a realistic measure of the usefulness of plasma E3 values in management of high-risk pregnancy. Low plasma E3 values were not always ominous, and for this reason it is suggested that clinical indications and the results of other tests for fetal-placental function be considered along with plasma E3 values in the selection of patients for early delivery to reduce the possibility of inappropriate intervention.

Management of High-Risk Pregnancy and Intensive Care of the Neonate

The authors have collaborated again on a third edition of this very practical and most informative book. As one who has recently been outmaneuvered by the pediatric neonatal board examination, I reviewed and studied the book in greater detail than I otherwise might. It does not, as its title implies, try to develop in detail the physiological principles for most of the recommended management cited, but nevertheless manages to allude to some basic concepts. Furthermore, it would appear these four authors must actually work together, for the book is written in a uniform style. While this book certainly could be used by anyone in a community hospital practicing obstetrics or newborn care, at the same time it is complete and comprehensive enough to be an excellent guide for tertiary care centers. When compared to the general textbooks on neonatal medicine (many of them 1,500 or more pages in length), this

A high-risk pregnancy management protocol

A simple high-risk pregnancy management protocol is presented. Three basic quantitative tests of fetal-placental function are utilized. The advantages and proper application and interpretation of these laboratory tools are discussed. Perinatal outcome is analyzed in the initial 225 high-risk pregnancies managed according to the protocol. Over 94 per cent of the infants achieved 5 minute Apgar scores of 8 or above. The corrected perinatal mortality rate was only 8.8 per 1,000 live births.

An assessment of the total estron stradiol-17β and estriol in high risk pregnancy plasma

A fluorometric method has been established for the simultaneous measurement of total estrone (E 1), estradiol-17β (E 2) and estriol (E 3) using 1 ml of late pregnancy plasma. Serial determinations of the three estrogens were performed on fourteen patients in their third trimester of pregnancy. Mean E 1 levels (5.3 ± 3.1 μg/100 ml plasma) were significantly higher ( P < 0.001) than mean E 2 values (2.9 ± 1.8 μg/100 ml plasma). Excellent correlation ( P <0.01) was observed between E 1 and E 2 values. Though there was a lack of correlation when either E 1 or E 2 was compared with E 3, good correlation was observed ( P < 0.05) when E 1 and E 2 together were compared with E 3. Estriol levels were found to be 1.8 to 12.7 times higher than the combined E 1 and E 2 values. Of the total classical estrogens, E 1 accounted for 15.9 ± 10.2%, E 2 8.4 ± 5.7% and E 3 75.7 ± 11.6%. Of the total estrone 88 ± 5% was conjugated, whereas 46 ± 2% of the total E 2 and 86 ± 12% of the total E 3 were in the conjugated form. Plasma from a severe-preeclamptic patient was found to convert [ 14C]-E 2 to [ 14C]-E 1, the extent of this conversion being 17% and 22% of the initial [ 14C]-E 2 used. It is suggested that the use of E 2 in the management of high risk pregnancies may occasionally provide misleadingly low values, unless E 1 is measured as well.

Total Urinary Estrogens in Complicated Pregnancies

One hundred fifty-seven pregnancies complicated by different degrees of diabetes, toxemia, and hypertension were studied with serial urinary placental estrogen determinations. A simple and fast method for total placental estrogen determination was used. The level of total estrogen excretion was related to Apgar score in cases of class B diabetes, severe toxemia, and also in moderate toxemia when estrogen excretion was falling. Mean estrogen levels did not differ as a function of severity of diabetes. Levels did differ with severity of toxemia; however, only the difference in mean estrogen excretion between mild and severe toxemia was significant. Estrogen excretion was very low in hypertension but was not related to Apgar score. This study concludes that total urinary estrogens constitute only a single parameter necessary in the management of high-risk pregnancies.

ALPHA-FETOPROTEIN IN THE MANAGEMENT OF HIGH-RISK PREGNANCIES

Isolation of alpha-fetoprotein and development of a radioimmunoassay for alpha-fetoprotein has enabled quantitative determination in normal human serum and during pregnancy to monitor fetal development. The studies leading to these developments are summarized, and other results on alpha-fetoprotein relative to the study of fetal physiology and pathology and the management of high-risk pregnancies are summarized.

Suprapubic vs. periumbilical amniocentesis

Amniocentesis has assumed a major and increasing role in the proper management of high-risk pregnancies but the procedure is not without complications. This study was undertaken to compare the suprapubic with the periumbilical or “small-parts” approach. A total of 308 amniocenteses were included. The suprapubic method had fewer failures and fewer complications. The rate of premature rupture of the membranes was identical with both approaches; in fact, following either type of amniocentesis, the percentage of premature ruptured membranes was no different from the anticipated spontaneous rate. In all cases of premature rupture of the membranes there were no cases of respiratory distress syndrome, maternal infection, or neonatal infection.

The oxytocin challenge test in the management of high-risk pregnancies

Appearance of a repetitive late deceleration pattern following oxytocin-induced uterine contractions in the prepartum patient may indicate fetal compromise, while absence of this finding may reflect fetal well-being. In this study, 72 patients at risk for intrauterine asphyxia underwent 81 satisfactory oxytocin challenge tests. Eight tests in seven patients were interpreted as positive; 72, as negative; and one, as suspicious. In 64 patients with negative tests, no fetal deaths or neonatal asphyxial depressions were observed. One patient developed intrapartum fetal distress with late decelerations 8 days after a negative test and was delivered by cesarean section. The positive test appears to correlate meaningfully with other clinical parameters reflecting intrauterine compromise.

Spectral analysis as a diagnostic aid in the management of high-risk pregnancy

Spectral analysis of the fetal heart rate and intrauterine pressure was done with data obtained during labor for 24 patients delivered of their infants in an obstetric intensive care unit. The patients were grouped according to clinical assessment of labor and neonatal outcome as normal (11), abnormal/premature (4), and prolonged labor/cesarean section (9). A comparison among groups of spectral density functions and of coherence functions and phase angles failed to reveal consistent features that could be used to distinguish between groups. However, an analysis of the variance (integrated spectrum) and the mean of the base-line component of the fetal heart rate showed that the values for the normal and abnormal/premature groups could be distinguished from the background population. It is suggested that a study of the joint statistics of the variance and the mean may lead to the development of a diagnostic aid to the early detection of incipient fetal distress.

High-Risk Pregnancy

To the Editor.— The recent summary on the management of high-risk pregnancy by Pearson (229:1439, 1974) was clear, concise, and almost comprehensive. There is, however, one additional general consideration that practicing obstetricians should keep in mind. Pregnancy is a time of joy for most couples, but also a time of great stress and anxiety. There are reports suggesting that excessive amounts of emotional stress or anxiety may increase the probability of spontaneous abortion and prematurity. 1 In addition, there is a gradually increasing body of information suggesting that stress and anxiety during pregnancy can affect both the neonatal behavior of the infant and the attachment between the parents and the infant. 2,3 Since couples in high-risk pregnancies are likely to be especially anxious, it is important that obstetricians make special provisions to provide these parents with emotional support. Such support can be provided in a variety of ways, including the

The management of high-risk pregnancy

The management of high-risk pregnancy

The Management of High-Risk Pregnancy

ANY practicing obstetrician should have a schema for the identification and management of his high-risk pregnancy population. The science of obstetrics has progressed so rapidly in the last two decades that it has become increasingly difficult for the average practitioner to keep up with advances, much less to incorporate them into his practice. In many instances, it may serve the patient best if she is referred to a perinatologist or a regional center that is better prepared to manage all of the ramifications of a truly complicated pregnancy. Not infrequently, however, geography or a patient's circumstances may demand the services of the nonspecialist. The high-risk pregnancy candidate may be identified either on her initial visit or during her prenatal course. In the first instance, the need for caution may be recognized on the basis of past history. A poor past obstetric performance that may have required a cesarean section for

Alpha-Fetoprotein in the Management of High-Risk Pregnancies

Isolation of alpha-fetoprotein and development of a radioimmunoassay for alpha-fetoprotein has enabled quantitative determination in normal human serum and during pregnancy to monitor fetal development. The studies leading to these developments are summarized, and other results on alpha-fetoprotein relative to the study of fetal physiology and pathology and the management of high-risk pregnancies are summarized.

Application of plasma estriol estimations in the management of high-risk pregnancies

Serial plasma estriol levels were determined in 51 uncomplicated and 58 complicated pregnancies. Additionally, in 13 uncomplicated, 16 toxemic, and 4 diabetic pregnancies, urinary estriol levels were also collated with plasma estriol values. Highly significant correlation was observed between plasma and urinary estriol levels in both uncomplicated and complicated pregnancies. In 5 of 37 toxemic patients, unusually high plasma estriol levels were found, though no definite correlation could be established between estriol levels and the severity of toxemia. From the thirty-fourth week of gestation, plasma estriol levels in diabetic and pre-eclamptic patients were essentially the same as those found in uncomplicated pregnancies; however, the levels in hypertensive pregnant patients were significantly lower. Broad guidelines have been postulated to correlate plasma estriol levels with fetal status from the thirty-sixth week of gestation to term. Levels of less than 5 μg per 100 ml. of plasma in this period are not compatible with a living fetus; values of less than 10 μg per 100 ml. with a dropping estriol pattern are indicative of fetal distress.

The Value of the Amniotic Fluid Lecithin: Sphingomyelin Ratio in the Management of High Risk Pregnancy

Summary: The amniotic fluid lecithin: sphingomyelin ratio was used to assess fetal maturity in the management of 62 high risk pregnancies. Correlation between the ratio and the onset of respiratory distress syndrome was good in 58 of the 62 cases (93%). In 7 patients delivered with an immature‐type ratio, one baby died in utero, 4 babies developed respiratory distress syndrome and of these 2 died from hyaline membrane disease.The value of the test in the management of high risk pregnancies is discussed.

Management of High-Risk Pregnancy and Intensive Care of the Neonate, ed. 2, by S. Gorham Babson, M.D. and Ralph C. Benson, M.D., St. Louis: The C. V. Mosby Company, 1971, 313 pp., $16.50

The authors have prepared a timely and up-to-date treatise on two major but interdigitating areas in medicine as their title suggests and have done a thorough but concise and work-man-like job of presenting the material in out-line form. Frequently outline books are either too sketchy or they are so concise that they are of little value.

Management of High Risk Pregnancy and Intensive Care of the Neonate

same problems through the eyes of a pediatrician in the second half? For example, the evaluation of fetal growth and fetal age is first encountered in the obstetric section. The pediatric presentation of the same problem, with the same chart, reappears 75 pages later. Although this may be the most complete discussion in the book the statement in the obstetric chapter with cross-reference to the pediatric chapter does not satisfactorily fulfill any definition of perinatology. Those concerned about the modern newborn nursery also recognize the need to break down the barriers which arbitrarily separate the members of the health team caring for the infant through the perinatal period. If this is in fact a realistic goal then the goal is not achieved by the discussion which divides the in¬ tensive of the newborn infant under the headings of physician care and nursing responsibility. The second edition has increased by 60% in both size and price over the previous edition. A resume of the ad¬ ditions to this edition provides a re¬ vealing tally of the changes that have occurred in fetal and neonatal man¬ agement between 1966 and 1971. The discussions of intrauterine and post¬ natal assessment of fetal growth, evaluation of fetal distress, prenatal detection of genetic defects, and management of erythroblastosis have either been added or expanded vastly. New additions include discussions of assisted respiration, intravenous hyperalimentation, arterial puncture, umbilical artery catheterization and phototherapy. The current and impor¬ tant topics of regional neonatal in¬ tensive and transportation of the critically ill newborn are passed over lightly and deserve greater promi¬ nence. The introduction of a discus¬ sion of pulmonary oxygen toxicity and the expanded discussion of retrolental fibroplasia provide a word of caution which is self-evident. The in¬ creased concern regarding sequelae of prematurity, the responsibilities of the social worker, and the prevention of prematurity with a discussion of problems of planned pregnancies and abortion broaden the perspective of the total problem of newborn care. The presentation itself maintains the format of the previous edition, with information presented in didac¬ tic tabular form. This is not a book which answers the question why but addresses itself to the question how. Although objection to this ap¬ proach has previously been raised, its widespread acceptance indicates that the need for such a book exists. Hav¬ ing accepted this format the need for accuracy then becomes essential, and is the single basis on which the merits of this book must be judged. Errors of omission and of fact are unaccep¬ table. Unfortunately the optimal man¬ agement for all clinical problems can¬ not always be defined. To be concise requires an objective synthesis of cur¬ rent knowledge when it is available, combined with mature personal judg¬ ment of unsettled questions. Dis¬ agreement with recommendations in these uncertain areas is permissible and cannot be viewed as a con¬ demnation. As examples, many read¬ ers may disagree with the recommen¬ dations that infants with meconium aspiration require treatment with an¬ tibiotics, or that antibiotic ointment should be applied to the umbilical stump following umbilical catheter¬ ization, or that vitamin E should be added daily to the formula, or that al¬ bumin should be administered before and after exchange transfusion, or that hydrocortisone is indicated in the treatment of sclerema. The con¬ clusion that current intensive in¬ cubators offer the protective environ¬ ment necessary for optimal is certainly questionable. More serious objections can be raised regarding omissions and inaccuracies of more firmly established recommendations. The discussions of life-threatening but curable illnesses such as polycythemia, twin-to-twin transfusion, narcotic withdrawal, and hypogly¬ cemia are either scattered so dif¬ fusely throughout the book or are so scanty as to be of little help to the uninitiated for whom this book is in¬ tended. The role of cord blood screen¬ ing for elevated macroglobulin levels is barely mentioned. Examples of factual errors include statements in¬ dicating that no placental lesions diagnostic of cytomegalic inclusion disease have been described; the ad¬ ministration of chloramphenicol to a patient with glucose 6-phosphate dehydrogenase (G6-PD) deficiency may induce megaloblastic anemia; chlor¬ amphenicol may induce fetal hepatotoxicity; excluding drug related re¬ sponses, the effect of maternal hyperthyroidism on fetal thyroid function is ignored; when term is reached the conjugating mechanism of the fetus for bilirubin is mature. Finally the typographical errors are a nuisance and at times could be confusing or

Management of High-Risk Pregnancy and Intensive Care of the Neonate

What is perinatology? Is the definition satisfied by this book which describes problems of the perinatal period as viewed by an obstetrician in the first half and then describes the same problems through the eyes of a pediatrician in the second half? For example, the evaluation of fetal growth and fetal age is first encountered in the obstetric section. The pediatric presentation of the same problem, with the same chart, reappears 75 pages later. Although this may be the most complete discussion in the book the statement in the obstetric chapter with cross-reference to the pediatric chapter does not satisfactorily fulfill any definition of perinatology. Those concerned about the modern newborn nursery also recognize the need to break down the barriers which arbitrarily separate the members of the health team caring for the infant through the perinatal period. If this is in fact a realistic goal then the goal is

Serum placental lactogen (HPL) as index of placental function.

ABSTRACT A rapid and reproducible radioimmunoassay for serum placental lactogen (HPL) allowed quantitation of the endocrine function of the placenta and of its follow up during gestation. During the course of pregnancy subjects were followed up in order to determine the normal range of HPL levels during pregnancy. Low and decreasing levels of serum HPL were noted in pregnancies with placental insufficiency. The large quantities of HPL present, its autonomous production by the placenta and its short half-life all combine to make its measurement of practical value in the management of high-risk pregnancies.