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Elevated MSAFP
colonized women were totally asymptomatic, a large group had mild symptoms that would not have led them to seek medical consultation, and a small group were severely symptomatic.
Luteal Phase Defect Daya S, Ward S, Burrows E: Progesterone Profiles in Luteal Phase Defect Cycles and Outcome of Progesterone Treatment in Patients with Recurrent
Spontaneous
AM J OBSTET GYNECOL
Abortion. 158(2):225-
232, 1988. Luteal phase defect is defined as inadequate progesterone production by the corpus luteum and consequent inadequate development of the endometrium. Its existence has been the focus of considerable debate and inconsistencies in diagnosis and management. This study was done to compare progesterone profiles in normal menstrual cycles with those with luteal phase defect to establish the discriminatory level of progesterone; 65 patients with recurrent SABs were studied. The patients underwent endometrial biopsy in two cycles of four to five days each before expected menses while using barrier contraception. They also had one to four serum progesterone samples drawn each biopsy cycle. Twenty-six women (40%) were diagnosed as having luteal phase defect by histologic confirmation. The mean serum progesterone was significantly lower in this group as well; a level of 21 rim/L was the cutoff point with 70% sensitivity and 71% specificity. These women were treated with 25 mg progesterone intravaginally b.i.d. starting on the third day after ovulation. Endometrial biopsy and serum progesterone were checked to confirm the adequacy of treatment. Some patients required a doubling of the dose to achieve a satisfactory endometrium. All then attempted conception. Replacement therapy was continued until menses, or, if pregnancy was confirmed, patients received 250 mg progesterone intramuscularly every week until 12 weeks. The 26 women diagnosed with luteal phase defect had a total of 94 first trimester SABs among them. With this therapy, 16 of the 26 women became pregnant; 13 or 81% had a successful outcome and 19% still aborted.
Journal of Nurse-Midwifery
l
The author feels therapy must begin immediately after ovulation and continue through the first trimester. They admit that randomized, double-blind studies still need to be done to confirm their findings.
Exercise in Pregnancy South-Paul J, Rajagopal K, Tenholder M: The Effect of Participation in a Regular Exercise Program upon Aerobic Capacity During Pregnancy. OBSTET GYNECOL 71(2):175-179, 1988. Seventeen patients aged 19-35 completed this study at a military facility. Healthy, nonsmoking pregnant women in the second trimester were randomly assigned to a nonexercising control group or to a supervised exercise group. Subjects were given a graded exercise test on a cycle ergometer. Ventilatoy parameters were measured at 20 and 30 weeks. The experimental group exercised three times per week, for one hour each time, with a warmup, cycling, and cool-down routine adapted to each individual. Although pregnancy did not cause a decrease in physical fitness, ventilatoy function improved in the exercising group.
Elevated MSAFP Richards D, Seeds J, Katz V, Lingley L, Albright S, Cefalo R: Elevated Maternal Serum Alpha-Fetoprotein with Normal Ultrasound: Is Amniocentesis Always Appropriate? A Review of 26,069 Screened Patients. OBSTET GYNECOL 71(2]:203-207, 1988. Six hundred nine women out of 26,069 who were screened at University of North Carolina, Chapel Hill from 1981-1986 had elevations of MSAFP greater than 2.25 multiples of the mean. These women were counselled regarding the risk of neural tube defects and the risks of amniocentesis. They then underwent a detailed high-resolution sonogram by experienced examiners. If clear ultrasound images of the intracranial anatomy and fetal spine could find no reason for the MSAFP elevation, the risk of neural tube defect was reduced by 90% and recalculated. Women
Vol. 33, No. 4, July/August
1988
were then recounselled and made an informed decision whether to pursue amniocentesis; 67% declined amniocentesis after the risk was revised. Ultrasound exams found an incorrect gestational age in 20%, twins in ll%, fetal death in 3%, other fetal anomalies in 6%, and neural tube defects in 3%, leaving 56% of the elevations unexplained. Two neural tube defects were missed on ultrasound, one was found on amniocentesis and one aborted spontaneously at 21 weeks. There were a total of 22 neural tube defects among the 609 women with elevated values. There were no false positive diagnoses.
Chorionic Villus Sampling Green J, Dorfmann A, Jones S, Bender S, Patton L, Schulman J: Chorionic Villus Sampling: Experience with an Initial 94.0 Cases. OBSTET GYNECOL 71(2):208-212, 1988. Chorionic villus sampling (CVS) offers several advantages over amniocentesis. It is a first trimester procedure providing reduced psychological and physical risk of first trimester termination if necessary, cytogenic analysis within days by direct trophoblast kayotyping, and immediate analysis of tissue samples for select genetic disorders. However, the exact risk of the procedure has yet to be established, although it will decrease with increasing experience. This study reports the results of 1113 women referred to the Genetics and IVF Institute in Fairfax, Virginia in 1985-1986. All CVS procedures were performed by a single physician under ultrasound guidance. Ten percent of women were found to have an abnormal gestational sac at the initial sonogram; all resulted in spontaneous abortion. Six percent declined the procedure after counselling. A few other women with twins, triplets, bleeding, and advanced gestational age were also excluded from CVS, leaving 940 women who underwent the CVS procedure. Only one catheter insertion was required in over 80% of the subjects. In six cases (0.6%), tissue could not be obtained due to cervical fibroids or stenosis. Nine sets of twins underwent the procedure; one set was subsequently miscarried. Two sets of twins could not be 197
Luteal Phase Defect Daya S, Ward S, Burrows E: Progesterone Profiles in Luteal Phase Defect Cycles and Outcome of Progesterone Treatment in Patients with Recurrent
Spontaneous
AM J OBSTET GYNECOL
Abortion. 158(2):225-
232, 1988. Luteal phase defect is defined as inadequate progesterone production by the corpus luteum and consequent inadequate development of the endometrium. Its existence has been the focus of considerable debate and inconsistencies in diagnosis and management. This study was done to compare progesterone profiles in normal menstrual cycles with those with luteal phase defect to establish the discriminatory level of progesterone; 65 patients with recurrent SABs were studied. The patients underwent endometrial biopsy in two cycles of four to five days each before expected menses while using barrier contraception. They also had one to four serum progesterone samples drawn each biopsy cycle. Twenty-six women (40%) were diagnosed as having luteal phase defect by histologic confirmation. The mean serum progesterone was significantly lower in this group as well; a level of 21 rim/L was the cutoff point with 70% sensitivity and 71% specificity. These women were treated with 25 mg progesterone intravaginally b.i.d. starting on the third day after ovulation. Endometrial biopsy and serum progesterone were checked to confirm the adequacy of treatment. Some patients required a doubling of the dose to achieve a satisfactory endometrium. All then attempted conception. Replacement therapy was continued until menses, or, if pregnancy was confirmed, patients received 250 mg progesterone intramuscularly every week until 12 weeks. The 26 women diagnosed with luteal phase defect had a total of 94 first trimester SABs among them. With this therapy, 16 of the 26 women became pregnant; 13 or 81% had a successful outcome and 19% still aborted.
Journal of Nurse-Midwifery
l
The author feels therapy must begin immediately after ovulation and continue through the first trimester. They admit that randomized, double-blind studies still need to be done to confirm their findings.
Exercise in Pregnancy South-Paul J, Rajagopal K, Tenholder M: The Effect of Participation in a Regular Exercise Program upon Aerobic Capacity During Pregnancy. OBSTET GYNECOL 71(2):175-179, 1988. Seventeen patients aged 19-35 completed this study at a military facility. Healthy, nonsmoking pregnant women in the second trimester were randomly assigned to a nonexercising control group or to a supervised exercise group. Subjects were given a graded exercise test on a cycle ergometer. Ventilatoy parameters were measured at 20 and 30 weeks. The experimental group exercised three times per week, for one hour each time, with a warmup, cycling, and cool-down routine adapted to each individual. Although pregnancy did not cause a decrease in physical fitness, ventilatoy function improved in the exercising group.
Elevated MSAFP Richards D, Seeds J, Katz V, Lingley L, Albright S, Cefalo R: Elevated Maternal Serum Alpha-Fetoprotein with Normal Ultrasound: Is Amniocentesis Always Appropriate? A Review of 26,069 Screened Patients. OBSTET GYNECOL 71(2]:203-207, 1988. Six hundred nine women out of 26,069 who were screened at University of North Carolina, Chapel Hill from 1981-1986 had elevations of MSAFP greater than 2.25 multiples of the mean. These women were counselled regarding the risk of neural tube defects and the risks of amniocentesis. They then underwent a detailed high-resolution sonogram by experienced examiners. If clear ultrasound images of the intracranial anatomy and fetal spine could find no reason for the MSAFP elevation, the risk of neural tube defect was reduced by 90% and recalculated. Women
Vol. 33, No. 4, July/August
1988
were then recounselled and made an informed decision whether to pursue amniocentesis; 67% declined amniocentesis after the risk was revised. Ultrasound exams found an incorrect gestational age in 20%, twins in ll%, fetal death in 3%, other fetal anomalies in 6%, and neural tube defects in 3%, leaving 56% of the elevations unexplained. Two neural tube defects were missed on ultrasound, one was found on amniocentesis and one aborted spontaneously at 21 weeks. There were a total of 22 neural tube defects among the 609 women with elevated values. There were no false positive diagnoses.
Chorionic Villus Sampling Green J, Dorfmann A, Jones S, Bender S, Patton L, Schulman J: Chorionic Villus Sampling: Experience with an Initial 94.0 Cases. OBSTET GYNECOL 71(2):208-212, 1988. Chorionic villus sampling (CVS) offers several advantages over amniocentesis. It is a first trimester procedure providing reduced psychological and physical risk of first trimester termination if necessary, cytogenic analysis within days by direct trophoblast kayotyping, and immediate analysis of tissue samples for select genetic disorders. However, the exact risk of the procedure has yet to be established, although it will decrease with increasing experience. This study reports the results of 1113 women referred to the Genetics and IVF Institute in Fairfax, Virginia in 1985-1986. All CVS procedures were performed by a single physician under ultrasound guidance. Ten percent of women were found to have an abnormal gestational sac at the initial sonogram; all resulted in spontaneous abortion. Six percent declined the procedure after counselling. A few other women with twins, triplets, bleeding, and advanced gestational age were also excluded from CVS, leaving 940 women who underwent the CVS procedure. Only one catheter insertion was required in over 80% of the subjects. In six cases (0.6%), tissue could not be obtained due to cervical fibroids or stenosis. Nine sets of twins underwent the procedure; one set was subsequently miscarried. Two sets of twins could not be 197