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Fetal survival with premature delivery in complications of pregnancy
volume
98
number luly
American
Journal
I,
5
1967
of Obstetrics and Gynecology
Transactions of the Thirty-third Annual Meeting of the Pacific Coast Obstetrical and Gynecological Society
Fetal survival with premature delivery in complications WILLIAM Los Angeles,
J.
of pregnancy
DIGNAM,
M.D
California
The fetal outcome was noted for the last 10,000 deliveries occurring at UCLA. Patients with premature ruptures of the membranes, toxemia, renal disease. RH sensitization, premature separation of the placenta, diabetes, and hypertenrion were compared to the remainder of the obstetric patients delivered during the same period of time. Our present management is preventing any actual rise in fetal loss due to fetal death in utero in successive stages of pregnancy. However, fetal death in utero does remain a continuing important factor throughout the stages of pregnancy, and if it could be prevented by a test of fetal welfare, infant survival might approach that expected for patients at the corresponding stages of pregnancy with no con,plications.
T H I s R E v I E w was undertaken with the purpose of determining the effectiveness of our present methods of management in certain groups of patients who might be expected to have higher rates of fetal loss than our general obstetric population. From these observations we might be able to predict the probable usefulness of a test
Table I. Groups of patients fetal loss encountered .vierT!s Ruptured membranes Toxemia Renal disease Rh-negative, sensitized Premature separation of the placenta Diabetes Hypertension All others
From the Department of Obstetrics and Gynecology, UCLA School of Medicine. Computing assistance was obtained from the Heabh Sciences Computing Facility, UCLA, sponsored by National Institutes of Health Grant F-3. Presented at the Thirty-third Annual Meeting of the Pacific Coast Obstetrical and Gynecological Society, Santa Barbara, California, Nov. 2-5, 1966.
Total
587
reviewed
wit11
IFe~~o~~ssjFe~~~sr a77 577 389
27 26 13
3 4.5 3
117
11
9
92 59 55 8,336
11 4 3 109
1’ 7 5.5 1
204
2
10,502
588
Dignam
reflecting infant welfare, such as urinary estriol determinations, in the management of these patients. To that end all deliveries occurring at the UCLA Medical Center during the past 5 years were reviewed. They were divided into the groups listed in Table I, which also includes the gross fetal loss noted in these groups o’f patients.
we may expect increased fetal loss. and, therefore, they are seen at freyttent intzt.vals in a. clinic for abnormal obstetric patients. Here they are seen in consultation with one or more members of the senior staff and a decision is made as to when delivery is most likely to gi1.e the best chances for infant survival based on the severity of the complicating illness and the apparent growth of the infant. When appropriate, patients are admitted to the hospital for closer observation, more careful super\Gsion of therapeutic measures, and decision concerning the time and appropriate means for delivery.
Present method of management Our present method of management of patients in the groups listed in Table I is to recognize that these are patients in whom
Table labor having
II. Fetal loss in patients entering spontaneously compared to those elective termination of pregnancy
Results with spontaneous termination of pregnancy and elective termination of pregnancy ‘There are a number of possible ways to judge the degree of success of this
Diagnosi* 1t~~~~ fijizig
Table nancy
Ruptured
membranes
17
Toxemia Renal disease Rh-negative, sensitized Premature separation of placenta Diabetes Hypertension AIi others
15 10
Table
IV.
Fetal
2 3 3
10 11 3
7
10
-l
10 2 3 94
14 8 7 1
1 2 0 15
loss by duration
4 8 5
of (weeks)
Antepartum loss
~
28-31 32-35 36-38 39-41 42-44
5 6 0 2
of pregnancy
fetal
(70)
loss by duration of pregwith no complications
8.5
Rupture Duration pregnancy
III. Fetal in patients
in
3 7 8 12 3
patients
6 5 1 0.2 0.5
with
23 17 4 24 5
premature
of membranes
Intrapartum neonatal fetal
(%)
47 13 0.4 0.4 0.7
53 18 1.4. 0.6 1.2
rupture
of
----
--
and loss
Total
fetal
loss (%)
Antepartum loss (%)
28-31
11 (2 infants)
39 (7 infants)
50
100 (3 infants)
32-35
6 (3 infants)
a (4 infants)
14
1'8 (5 infants)
36-38
0.6 (1 infant)
1 (2 infants)
1.6
5 (5 infants)
39-41
0.5 (3 infants)
0.7 (4 infants)
1.2
1.3 (5 infants)
42-44
0 (0 infants)
2 (1 infant)
2
0 (0 infants)
fetal
the
Volume Number
98 5
Fetal
plan of management. One, for example, is to compare those patients who have a particular complication and are permitted to continue their pregnancies without interference with the patients who have that same complication but have their pregnancies terminated by election at such times or are considered to be in the best interests of the infants and mothcrs. Such a comparison is made in Table 11. Taken at face value these figures might indicate a superiority for a program of selective and elective delivery in certain complications or for a program of permitting all patients to enter labor spontaneously in other complications, but these conclusions are not valid since patients having elective deliveries are not the same as those having spontaneous labor. Those patients who have ruptured membranes, toxemia, or renal disease and in whom pregnancy is terminated electively are more likely to have more serious examples of these complications than are those who are permitted to enter labor spontaneously. That is, patients with ruptured membranes for longer periods of time with increased possibilities for infection are more likely to be delivered early. In view of the more serious nature of the complication, the increased fetal loss is not unexpected.
membranes,
toxemia,
or renal
disease Renal
Total
589
Fetal death in utero With the problems of Rh sensitization, premature separation of the placenta, diabetes, and hypertension, the higher fetal loss with spontaneous termination of pregnancy is due to fetal deaths in utero which occur before elective delivery is considered proper. Since it is possible that earlier delivery might avert some of these catastroto know, for phes, it becomes important successive stages of gcastation, the likely fate of an infant if left in utero compared with the fate if delivered, in the presence of a given complication of pregnancy. In order to provide some basis for comparison, the results noted in the patients without any of the listed complications are provided in Table III. It is quite apparent, and is, of course, a very well-recognized fact, that for most obstetrical patients the likelihood of fetal survival is greatest if pregnancies are permitted to continue to term without interference. If, however, l.he rate of fetal death in utero increases in the later weeks of pregnancy, as suggested for some of the complications of pregnancy, it may be that infant survival would be better with earlier delivery. Some of tEe figures bearing on this point are included in Table IV. With these complications no increase in the rate of fetal death in utero was noted
T&Xemia Intrapartum and neonatal fetal loss (%,)
survival
fetal
loss (TO)
Antepartum fetal loss (70)
disease
Intrapartum and neonatal fetal loss f%;‘o)
Total
fetal
losr
0 (0 infants)
100
0 (0 infants)
60 (3 infants)
60
22 (4 infants)
50
25 (2 infants)
12.5 (1 infant)
37.5
1 i 1 infant)
6
4 (2 infants)
2 (1 infant)
6
0.7 (3 infants)
2.0
0.3 (1 infant)
0.3 (1 infant)
0.7
0 (0 infants)
0
3 (1 infant)
(0
0 infants)
3
(VC)
590
Dignam
Table
V.
Fetal
by duration
loss
of pregnancy
Rh-Negative, Duration pregnancy (weeks)
of Antepartum fetal loss
sensitized
patients
Total loss
fetal (So)
28-3 1
100 (2 infants)
X2-35
4-k (,-1 infants)
0 (0 infants)
-I ,1-
36-38
7 (3 infants)
0 (0 infants)
7
1.5 (1 infant)
1.5 (1 infant) 0 (0 infants)
39-41
(0
Table pared
VI. Over-all to those with
fetal loss by duration no complications
of
Toxemia
Renal disease
(%,J
(lo)
f%)
50 14 1.6 1.2 2.0
100 50 6 2 0
60 37.5 6 0.7 3
of membranes’
28-31 32-35 36-38 39-41 42-44
with successively more advanced stages of gestation, but rather, each shows a progressive fall. Since all patients were not permitted to continue uninterrupted in their pregnancies I cannot be certain of what the total incidence of late fetal death in utero would be. If there is an increased likelihood of fetal loss before labor occurs it is being prevented by our current management based on clinical criteria. The data for the other complications observed are noted in Table V. Here, too, there is no particular increase in late fetal death in utero as pregnancy progresses. Over-all
fetal
loss
An impression of the over-all of infant survival in pregnancies by these particular complications
likelihood marked can be
(Vo)
l)rrmaturc
of
separation Intrapartum and neonatal fetal loss (%)
placenta i I
Total loss
fetnl (%)
20 I 1 infant)
20 1 1 infant)
.I0
5 ( I infant)
10 ( :! infants)
Ii
7
I
i I infant i
:i
8 (3 infants)
I) (0 infants)
1:
0
0 (0 infants)
0 (0 infants)
I)
Rhnegatir?e, sensitized I
sensitization.
(2 infants)
of pregnancy
Rupture Duration pregnantcy (weeks)
KH
Premature
Antepartum fetal loss
100
0 infants)
42-44
with
~_.. .~~ / ~~_...
Intrapartum and neonatal fetal loss (70)
(%)
in
in patients
Premature separation
f%)
(%I
100 44 7 3 0
40 15 11 8 0
with
II
complications
Hypertension
Diabetes f%)
0 43 3 0 0
All
com-
otherr
(“/o)
(%I
0 100 17 0 0
53 18 1.4 0.6 1.2
of
optimum
time
delivery
From the data it appears that little is to be gained by a consideration of delivem before the thirty-second week of pregnancy. Even in uncomplicated pregnancies, the infants have only a 50 per cent chance of survival before that time. Examination of the amniotic fluid has greatly improved our ability to judge the proper time for delivery in Rh-negative, sensitized women. Rupture of the membranes in itself gives us the indication for the proper time for delivery in patients with that particular complication. These patients are included mainly to give a comparative idea of thr
Volume Number
98 5
separation
Fetal
of the placenta,
diabetes,
loss
fetal (%)
Hypertension
Intrapartum neonatal loss
Intrapartum
and fetal (%)
Total
fetal (To)
loss
0 (0 infants)
0 (0 infants)
0
43 (3 infants)
0 (0 infants)
43
0 infants)
3
0 (0 infants)
0 (0 infants)
0
0 (0 infants)
0 (0 infants)
0
il
3 infant)
(0
Antepartum loss
I
32 to 35 Total
loss
(%)
17 (2 infants)
(No.)
(%)
0 (0 infants) 0 (0 infants)
100
0 (0 infants)
17
0 (0 infants)
0
0 (0 infants)
0
labor compared to that with at 32 to 35 weeks, and 36
Weeks
No.
Total fetal loss (%)
fetal
1oc (1 infant)
Infant
patients
and
neonatal
fetal
Table VII. Intrapartum and neonatal fetal loss with spontaneous elective termination of pregnancy in patients with complications to 38 weeks of gestation
Diagnosis
591
or hypertension
Diabetes Antepartum
survival
36 to 38 loss
Total %
patients (No.1
Weeks Infant
_
loss
No.
%
0 1
0 2.5
Toxemia Spontaneous Elective
15 3
3 1
Total Renal
20 33
56 40
22
1
diseases
Spontaneous Elective
6 2
1 0
TotaI
17 0
33 15
0 1
K5
0 7 2.5
Diabetes Spontaneous Elective
5 2
0 0
Total
0 0
6 25
0 0
0
0 0 ii-
Hypertension Spontaneous Elective
1 0
1 0
Total All
100 -
10 2
0 0
100
0 0 0
other Spontaneous Elective Total
119 8
17 0
14 0 13
831 98
3 1
0.4 1.4 0.4
592
Dignam
likelihood of infant survival. Patients with premature separation of the placenta certainly have an increased likelihood of fetal or infant loss and it is well to keep this prominently in mind in their management and to consider elective delivery strongly. The time for delivery is usually suggested rather clearly by the patients’ episode of bleeding. Patients with toxemia, renal disease, diabetes, or hypertension are particular problems, particularly in the 32 to 38 week period of pregnancy. For patients who reach that stage of gestation without having sustained a fetal death in utero and in whom delivery is effected electively the infant losses are as depicted in Table VII where a comparison is made between those patients who start labor spontaneously and those in whom deli\.-ery is carried out electively. There has been much speculation concerning the hardiness of these infants from complicated pregnancies compared to infants from normal pregnancies of the same
duration. The data presented here do not permit of any meaningful conclusions. Thr few infants who died in these groups of patients do not suggest that these complications compromise the ability of infants to prosper in the extrauterine environment when compared to the abilitv of infants from normal pregnancies of the sam<’ dur&ion. It is possible that infants currentl) bein,g lost by fetal death in tltero ~voulcl not be so hardy, but again thry mi%ght tlo just as well as their normal counterparts once removed from the unfavorable environment. It therefore behooves us to apply a trst for fetal welfare to these high-risk patients, in order that we may strive to pre\,ent the antepartum deaths which contribute so heavily to infant and fetal loss. These data do not provide any evidence to demonstrate that, if delivered alive? these infants have any worse pro,cnosis than babies from normal pregnancies deliverccl at corresponding stages of gestation.
Discussion PHILIP H. ARNOT, San Francisco, California. I have reviewed the delivery records of our first 10,950 patients beginning with July 1, 1922, and extending to July 1, 1953, a 31 year span. In those days, during the first 25 years at least, we had no readily available blood, no antibiotics, poor anesthesia, and very few anesthetists. Accordingly, we used the vaginal route for delivery most frequently and did very few cesarean sections. In our 10,950 patients we had 591 prematurr deliveries (Table I). I have arbitrarily picked DR.
19 days
before
the estimated
date
of confinement
and earlier as defining premature delivery. There were 47 infants born alive who died, as a rule, from immaturity or prematurity. Of this group 33 were stillborn. In many of those, the baby was dead when the mother was admitted. Seventeen per cent were macerated. The total perinatal loss of premature infants amounted to 16.4 per rent. Of the group, 406 had spontaneous deliveries and I? per cent had forceps drlivcries. This is to be compared with our
over-all forceps delivery rate of 14.6 per c.cn(. Breech presentation was seen in 7.7 per cent of our premature deliveries compared w?th 3.13 peg cent for term breech deliveries. The cesarean section incidence was high it! this group. The Voorhees bag was used in 5.3-H per cent compared to 1.26 per cent for general use. A large portion of these cases in which it was used were instances of a dead baby whorl cesarean section was not performed. We used to induce labor with the Voorhees bag in COIII( patients with toxemia, marginal placenta prcvia, ruptured membranes, or prolapsed cord. There was a medical reason for prrmaturc delivery in 56 patients (57.7 per cent). Premature separation of the placenta, as Dr. Dignanl points out, is the prime offending factor. Eclampsia, and pre-eclampsia with or without separation of the placenta, renal disease, and placenta previa cause many early labors. Rh factor senkitization, diabetes, degenerating fibroids. fettil anomalies, anencephaly? and strangulated hernia in an infant at ti month%
Fetal
Table
I. Premature deliveries (19 or more before the estimated date of confinement) 1, 1922, to July 1, 1953)”
No.
of premature deliveries Born alive but died Stillborn Macerated Total Type
deaths
591 out (5.4% 47 33 17 y
of 10,950 deliveries incidence)
(16.4%
incidence)
of delivery General
1. 2. 3. 4. 5. 6.
days (July
Spontaneous Forceps Breech Cesarean Voorhees bag Version and extraction
406 71 (12.01%) 46 (7.7%) 33 (5.49%) 32 (5.48%) 3
(0.50%)
average (%I 14.6 3.13 4.4 1.26 0.20
“Medical reasons for premature delivery were present in 56 or 57.7 per cent of the 97 dead babies. No medical reason uas found for premature delivery in 41 or 42.3 per cent of the 97 dead babies.
causing death were all contributing factors. Also, febrile states, such as acute pyelitis, severe sunburn, and acute encephalitis, can cause premature labor. DR. KEITH P. RUSSELL, Los Angeles, California. I think it is important to know whether Dr. Dignam lists premature rupture of the membranes as a single entity. In other words, do any of these cases that he refers to with premature rupture of the membranes have something else, such as a transverse lie of the infant, or maternal disease, maternal infection, and so forth. This point must be clarified if we are going to relate these statistics to the method of delivery or the
fetal outcome to the rupture of the membranes
condition only.
survival
of
593
premature
REFERENCE
1. Russell, K. P., and Anderson, OBST. & GYNEC. 83: 930, 1962.
G.:
AM.
J.
DR. J. 0. MCCALL, Portland, Oregon. As you all know the United States Government has been very much interested in trying to improve our fetal salvage. I take exception, however, to the inclusion of the separation of the placenta in this study because this has no temporal aspects to its treatment. It does Ilot give us time to contemplate management over weeks of waiting and watching. DR. DIGNAM (Closing). With regard to classification of patients, I tried to take the patients in whom I felt that this particular complication was the thing that was most important in the patient’s course. The patients with premature rupture of the membrane are all of those who had rupture of the membranes for 24 hours without going into labor and did not have other complications that I felt to be more important. The reason for including cases of premature separation of the placenta was that I was trying to take several groups of patients that had been recognized to contribute heavily to fetal mortality out of the “all others” group so that I could try to get some idea of our supposed “normal incidence” of fetal mblrtality. As I indicated, with premature rupture of the membranes, Rh sensitization, and premature separation, the time for decision is brought up by the patient. It is the others in which we have: to consider timing more carefully.
98
number luly
American
Journal
I,
5
1967
of Obstetrics and Gynecology
Transactions of the Thirty-third Annual Meeting of the Pacific Coast Obstetrical and Gynecological Society
Fetal survival with premature delivery in complications WILLIAM Los Angeles,
J.
of pregnancy
DIGNAM,
M.D
California
The fetal outcome was noted for the last 10,000 deliveries occurring at UCLA. Patients with premature ruptures of the membranes, toxemia, renal disease. RH sensitization, premature separation of the placenta, diabetes, and hypertenrion were compared to the remainder of the obstetric patients delivered during the same period of time. Our present management is preventing any actual rise in fetal loss due to fetal death in utero in successive stages of pregnancy. However, fetal death in utero does remain a continuing important factor throughout the stages of pregnancy, and if it could be prevented by a test of fetal welfare, infant survival might approach that expected for patients at the corresponding stages of pregnancy with no con,plications.
T H I s R E v I E w was undertaken with the purpose of determining the effectiveness of our present methods of management in certain groups of patients who might be expected to have higher rates of fetal loss than our general obstetric population. From these observations we might be able to predict the probable usefulness of a test
Table I. Groups of patients fetal loss encountered .vierT!s Ruptured membranes Toxemia Renal disease Rh-negative, sensitized Premature separation of the placenta Diabetes Hypertension All others
From the Department of Obstetrics and Gynecology, UCLA School of Medicine. Computing assistance was obtained from the Heabh Sciences Computing Facility, UCLA, sponsored by National Institutes of Health Grant F-3. Presented at the Thirty-third Annual Meeting of the Pacific Coast Obstetrical and Gynecological Society, Santa Barbara, California, Nov. 2-5, 1966.
Total
587
reviewed
wit11
IFe~~o~~ssjFe~~~sr a77 577 389
27 26 13
3 4.5 3
117
11
9
92 59 55 8,336
11 4 3 109
1’ 7 5.5 1
204
2
10,502
588
Dignam
reflecting infant welfare, such as urinary estriol determinations, in the management of these patients. To that end all deliveries occurring at the UCLA Medical Center during the past 5 years were reviewed. They were divided into the groups listed in Table I, which also includes the gross fetal loss noted in these groups o’f patients.
we may expect increased fetal loss. and, therefore, they are seen at freyttent intzt.vals in a. clinic for abnormal obstetric patients. Here they are seen in consultation with one or more members of the senior staff and a decision is made as to when delivery is most likely to gi1.e the best chances for infant survival based on the severity of the complicating illness and the apparent growth of the infant. When appropriate, patients are admitted to the hospital for closer observation, more careful super\Gsion of therapeutic measures, and decision concerning the time and appropriate means for delivery.
Present method of management Our present method of management of patients in the groups listed in Table I is to recognize that these are patients in whom
Table labor having
II. Fetal loss in patients entering spontaneously compared to those elective termination of pregnancy
Results with spontaneous termination of pregnancy and elective termination of pregnancy ‘There are a number of possible ways to judge the degree of success of this
Diagnosi* 1t~~~~ fijizig
Table nancy
Ruptured
membranes
17
Toxemia Renal disease Rh-negative, sensitized Premature separation of placenta Diabetes Hypertension AIi others
15 10
Table
IV.
Fetal
2 3 3
10 11 3
7
10
-l
10 2 3 94
14 8 7 1
1 2 0 15
loss by duration
4 8 5
of (weeks)
Antepartum loss
~
28-31 32-35 36-38 39-41 42-44
5 6 0 2
of pregnancy
fetal
(70)
loss by duration of pregwith no complications
8.5
Rupture Duration pregnancy
III. Fetal in patients
in
3 7 8 12 3
patients
6 5 1 0.2 0.5
with
23 17 4 24 5
premature
of membranes
Intrapartum neonatal fetal
(%)
47 13 0.4 0.4 0.7
53 18 1.4. 0.6 1.2
rupture
of
----
--
and loss
Total
fetal
loss (%)
Antepartum loss (%)
28-31
11 (2 infants)
39 (7 infants)
50
100 (3 infants)
32-35
6 (3 infants)
a (4 infants)
14
1'8 (5 infants)
36-38
0.6 (1 infant)
1 (2 infants)
1.6
5 (5 infants)
39-41
0.5 (3 infants)
0.7 (4 infants)
1.2
1.3 (5 infants)
42-44
0 (0 infants)
2 (1 infant)
2
0 (0 infants)
fetal
the
Volume Number
98 5
Fetal
plan of management. One, for example, is to compare those patients who have a particular complication and are permitted to continue their pregnancies without interference with the patients who have that same complication but have their pregnancies terminated by election at such times or are considered to be in the best interests of the infants and mothcrs. Such a comparison is made in Table 11. Taken at face value these figures might indicate a superiority for a program of selective and elective delivery in certain complications or for a program of permitting all patients to enter labor spontaneously in other complications, but these conclusions are not valid since patients having elective deliveries are not the same as those having spontaneous labor. Those patients who have ruptured membranes, toxemia, or renal disease and in whom pregnancy is terminated electively are more likely to have more serious examples of these complications than are those who are permitted to enter labor spontaneously. That is, patients with ruptured membranes for longer periods of time with increased possibilities for infection are more likely to be delivered early. In view of the more serious nature of the complication, the increased fetal loss is not unexpected.
membranes,
toxemia,
or renal
disease Renal
Total
589
Fetal death in utero With the problems of Rh sensitization, premature separation of the placenta, diabetes, and hypertension, the higher fetal loss with spontaneous termination of pregnancy is due to fetal deaths in utero which occur before elective delivery is considered proper. Since it is possible that earlier delivery might avert some of these catastroto know, for phes, it becomes important successive stages of gcastation, the likely fate of an infant if left in utero compared with the fate if delivered, in the presence of a given complication of pregnancy. In order to provide some basis for comparison, the results noted in the patients without any of the listed complications are provided in Table III. It is quite apparent, and is, of course, a very well-recognized fact, that for most obstetrical patients the likelihood of fetal survival is greatest if pregnancies are permitted to continue to term without interference. If, however, l.he rate of fetal death in utero increases in the later weeks of pregnancy, as suggested for some of the complications of pregnancy, it may be that infant survival would be better with earlier delivery. Some of tEe figures bearing on this point are included in Table IV. With these complications no increase in the rate of fetal death in utero was noted
T&Xemia Intrapartum and neonatal fetal loss (%,)
survival
fetal
loss (TO)
Antepartum fetal loss (70)
disease
Intrapartum and neonatal fetal loss f%;‘o)
Total
fetal
losr
0 (0 infants)
100
0 (0 infants)
60 (3 infants)
60
22 (4 infants)
50
25 (2 infants)
12.5 (1 infant)
37.5
1 i 1 infant)
6
4 (2 infants)
2 (1 infant)
6
0.7 (3 infants)
2.0
0.3 (1 infant)
0.3 (1 infant)
0.7
0 (0 infants)
0
3 (1 infant)
(0
0 infants)
3
(VC)
590
Dignam
Table
V.
Fetal
by duration
loss
of pregnancy
Rh-Negative, Duration pregnancy (weeks)
of Antepartum fetal loss
sensitized
patients
Total loss
fetal (So)
28-3 1
100 (2 infants)
X2-35
4-k (,-1 infants)
0 (0 infants)
-I ,1-
36-38
7 (3 infants)
0 (0 infants)
7
1.5 (1 infant)
1.5 (1 infant) 0 (0 infants)
39-41
(0
Table pared
VI. Over-all to those with
fetal loss by duration no complications
of
Toxemia
Renal disease
(%,J
(lo)
f%)
50 14 1.6 1.2 2.0
100 50 6 2 0
60 37.5 6 0.7 3
of membranes’
28-31 32-35 36-38 39-41 42-44
with successively more advanced stages of gestation, but rather, each shows a progressive fall. Since all patients were not permitted to continue uninterrupted in their pregnancies I cannot be certain of what the total incidence of late fetal death in utero would be. If there is an increased likelihood of fetal loss before labor occurs it is being prevented by our current management based on clinical criteria. The data for the other complications observed are noted in Table V. Here, too, there is no particular increase in late fetal death in utero as pregnancy progresses. Over-all
fetal
loss
An impression of the over-all of infant survival in pregnancies by these particular complications
likelihood marked can be
(Vo)
l)rrmaturc
of
separation Intrapartum and neonatal fetal loss (%)
placenta i I
Total loss
fetnl (%)
20 I 1 infant)
20 1 1 infant)
.I0
5 ( I infant)
10 ( :! infants)
Ii
7
I
i I infant i
:i
8 (3 infants)
I) (0 infants)
1:
0
0 (0 infants)
0 (0 infants)
I)
Rhnegatir?e, sensitized I
sensitization.
(2 infants)
of pregnancy
Rupture Duration pregnantcy (weeks)
KH
Premature
Antepartum fetal loss
100
0 infants)
42-44
with
~_.. .~~ / ~~_...
Intrapartum and neonatal fetal loss (70)
(%)
in
in patients
Premature separation
f%)
(%I
100 44 7 3 0
40 15 11 8 0
with
II
complications
Hypertension
Diabetes f%)
0 43 3 0 0
All
com-
otherr
(“/o)
(%I
0 100 17 0 0
53 18 1.4 0.6 1.2
of
optimum
time
delivery
From the data it appears that little is to be gained by a consideration of delivem before the thirty-second week of pregnancy. Even in uncomplicated pregnancies, the infants have only a 50 per cent chance of survival before that time. Examination of the amniotic fluid has greatly improved our ability to judge the proper time for delivery in Rh-negative, sensitized women. Rupture of the membranes in itself gives us the indication for the proper time for delivery in patients with that particular complication. These patients are included mainly to give a comparative idea of thr
Volume Number
98 5
separation
Fetal
of the placenta,
diabetes,
loss
fetal (%)
Hypertension
Intrapartum neonatal loss
Intrapartum
and fetal (%)
Total
fetal (To)
loss
0 (0 infants)
0 (0 infants)
0
43 (3 infants)
0 (0 infants)
43
0 infants)
3
0 (0 infants)
0 (0 infants)
0
0 (0 infants)
0 (0 infants)
0
il
3 infant)
(0
Antepartum loss
I
32 to 35 Total
loss
(%)
17 (2 infants)
(No.)
(%)
0 (0 infants) 0 (0 infants)
100
0 (0 infants)
17
0 (0 infants)
0
0 (0 infants)
0
labor compared to that with at 32 to 35 weeks, and 36
Weeks
No.
Total fetal loss (%)
fetal
1oc (1 infant)
Infant
patients
and
neonatal
fetal
Table VII. Intrapartum and neonatal fetal loss with spontaneous elective termination of pregnancy in patients with complications to 38 weeks of gestation
Diagnosis
591
or hypertension
Diabetes Antepartum
survival
36 to 38 loss
Total %
patients (No.1
Weeks Infant
_
loss
No.
%
0 1
0 2.5
Toxemia Spontaneous Elective
15 3
3 1
Total Renal
20 33
56 40
22
1
diseases
Spontaneous Elective
6 2
1 0
TotaI
17 0
33 15
0 1
K5
0 7 2.5
Diabetes Spontaneous Elective
5 2
0 0
Total
0 0
6 25
0 0
0
0 0 ii-
Hypertension Spontaneous Elective
1 0
1 0
Total All
100 -
10 2
0 0
100
0 0 0
other Spontaneous Elective Total
119 8
17 0
14 0 13
831 98
3 1
0.4 1.4 0.4
592
Dignam
likelihood of infant survival. Patients with premature separation of the placenta certainly have an increased likelihood of fetal or infant loss and it is well to keep this prominently in mind in their management and to consider elective delivery strongly. The time for delivery is usually suggested rather clearly by the patients’ episode of bleeding. Patients with toxemia, renal disease, diabetes, or hypertension are particular problems, particularly in the 32 to 38 week period of pregnancy. For patients who reach that stage of gestation without having sustained a fetal death in utero and in whom delivery is effected electively the infant losses are as depicted in Table VII where a comparison is made between those patients who start labor spontaneously and those in whom deli\.-ery is carried out electively. There has been much speculation concerning the hardiness of these infants from complicated pregnancies compared to infants from normal pregnancies of the same
duration. The data presented here do not permit of any meaningful conclusions. Thr few infants who died in these groups of patients do not suggest that these complications compromise the ability of infants to prosper in the extrauterine environment when compared to the abilitv of infants from normal pregnancies of the sam<’ dur&ion. It is possible that infants currentl) bein,g lost by fetal death in tltero ~voulcl not be so hardy, but again thry mi%ght tlo just as well as their normal counterparts once removed from the unfavorable environment. It therefore behooves us to apply a trst for fetal welfare to these high-risk patients, in order that we may strive to pre\,ent the antepartum deaths which contribute so heavily to infant and fetal loss. These data do not provide any evidence to demonstrate that, if delivered alive? these infants have any worse pro,cnosis than babies from normal pregnancies deliverccl at corresponding stages of gestation.
Discussion PHILIP H. ARNOT, San Francisco, California. I have reviewed the delivery records of our first 10,950 patients beginning with July 1, 1922, and extending to July 1, 1953, a 31 year span. In those days, during the first 25 years at least, we had no readily available blood, no antibiotics, poor anesthesia, and very few anesthetists. Accordingly, we used the vaginal route for delivery most frequently and did very few cesarean sections. In our 10,950 patients we had 591 prematurr deliveries (Table I). I have arbitrarily picked DR.
19 days
before
the estimated
date
of confinement
and earlier as defining premature delivery. There were 47 infants born alive who died, as a rule, from immaturity or prematurity. Of this group 33 were stillborn. In many of those, the baby was dead when the mother was admitted. Seventeen per cent were macerated. The total perinatal loss of premature infants amounted to 16.4 per rent. Of the group, 406 had spontaneous deliveries and I? per cent had forceps drlivcries. This is to be compared with our
over-all forceps delivery rate of 14.6 per c.cn(. Breech presentation was seen in 7.7 per cent of our premature deliveries compared w?th 3.13 peg cent for term breech deliveries. The cesarean section incidence was high it! this group. The Voorhees bag was used in 5.3-H per cent compared to 1.26 per cent for general use. A large portion of these cases in which it was used were instances of a dead baby whorl cesarean section was not performed. We used to induce labor with the Voorhees bag in COIII( patients with toxemia, marginal placenta prcvia, ruptured membranes, or prolapsed cord. There was a medical reason for prrmaturc delivery in 56 patients (57.7 per cent). Premature separation of the placenta, as Dr. Dignanl points out, is the prime offending factor. Eclampsia, and pre-eclampsia with or without separation of the placenta, renal disease, and placenta previa cause many early labors. Rh factor senkitization, diabetes, degenerating fibroids. fettil anomalies, anencephaly? and strangulated hernia in an infant at ti month%
Fetal
Table
I. Premature deliveries (19 or more before the estimated date of confinement) 1, 1922, to July 1, 1953)”
No.
of premature deliveries Born alive but died Stillborn Macerated Total Type
deaths
591 out (5.4% 47 33 17 y
of 10,950 deliveries incidence)
(16.4%
incidence)
of delivery General
1. 2. 3. 4. 5. 6.
days (July
Spontaneous Forceps Breech Cesarean Voorhees bag Version and extraction
406 71 (12.01%) 46 (7.7%) 33 (5.49%) 32 (5.48%) 3
(0.50%)
average (%I 14.6 3.13 4.4 1.26 0.20
“Medical reasons for premature delivery were present in 56 or 57.7 per cent of the 97 dead babies. No medical reason uas found for premature delivery in 41 or 42.3 per cent of the 97 dead babies.
causing death were all contributing factors. Also, febrile states, such as acute pyelitis, severe sunburn, and acute encephalitis, can cause premature labor. DR. KEITH P. RUSSELL, Los Angeles, California. I think it is important to know whether Dr. Dignam lists premature rupture of the membranes as a single entity. In other words, do any of these cases that he refers to with premature rupture of the membranes have something else, such as a transverse lie of the infant, or maternal disease, maternal infection, and so forth. This point must be clarified if we are going to relate these statistics to the method of delivery or the
fetal outcome to the rupture of the membranes
condition only.
survival
of
593
premature
REFERENCE
1. Russell, K. P., and Anderson, OBST. & GYNEC. 83: 930, 1962.
G.:
AM.
J.
DR. J. 0. MCCALL, Portland, Oregon. As you all know the United States Government has been very much interested in trying to improve our fetal salvage. I take exception, however, to the inclusion of the separation of the placenta in this study because this has no temporal aspects to its treatment. It does Ilot give us time to contemplate management over weeks of waiting and watching. DR. DIGNAM (Closing). With regard to classification of patients, I tried to take the patients in whom I felt that this particular complication was the thing that was most important in the patient’s course. The patients with premature rupture of the membrane are all of those who had rupture of the membranes for 24 hours without going into labor and did not have other complications that I felt to be more important. The reason for including cases of premature separation of the placenta was that I was trying to take several groups of patients that had been recognized to contribute heavily to fetal mortality out of the “all others” group so that I could try to get some idea of our supposed “normal incidence” of fetal mblrtality. As I indicated, with premature rupture of the membranes, Rh sensitization, and premature separation, the time for decision is brought up by the patient. It is the others in which we have: to consider timing more carefully.