Routine monitoring not supported

tions, breast stimulation produced contractions with a frequency of 3.6 minutes and intensity of 48 mmHg. In patients with infrequent contractions, the frequency increased, but there was no increase in intensity. Fourteen patients needed bilateral stimulation to improve the frequency from 6.6 minutes/40 mmHg to 4.5 minutes/39 mmHg. Eighteen patients (50%) had at least one episode of tachystole (contractions less than two minutes apart); there was only one minor fetal heart deceleration among the group with tachystole. Five patients (14%) had prolonged contractions of greater than 90 seconds; there were no fetal heart decelerations in this group.

Epidural Delivery

and Instrumental

Kaminski H, Stafl A, Aiman J: The Effect of Epidural Analgesia on the Frequency of Instrumental Obstetric Delivery. OBSTET GYNECOL 69(5): 770-773, 1987. Previous studies on the effect of epidural analgesia on instrumental delivery have either not used a control group or have not defined the characteristics of the group that might also affect the rate of instrumental delivery. This retrospective study examined 155 women who delivered at Milwaukee County Medical Center and who had epidural analgesia for the sole indication of pain relief; no one with dysfunctional or arrested labor was included. They were matched by age, parity, and race with 155 women who used only pudendal or local anesthesia. There were 125 primiparous and 30 multiparous women in each group. Delivery management for 95% of the patients was by the same group of obstetric residents. There was no statistical difference in infant birth weight or Apgar scores between the groups. The infant was in the posterior position in 27% of the epidural group; only 8% of the control group had an infant in the posterior position. The overall frequency of instrumental delivery was 2.5 times greater in the epidural group.

Routine Hepatitis B Screening Summers P, Biswas M, Pastorek J, Pernoll M, Smith L, Bean B: The Pregnant Hepatitis B Carrier: Evi-

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dence Favoring Comprehensive Antepartum Screening. OBSTET GYNECOL 69(5):701-703, 1987. Cruz A, Frentzen B, Behnke M: Hepatitis B: A Case for Prenatal Screening of All Patients. AM J OBSTET GYNECOL 156(5):1X30-1183, 1987. Both of these articles recommend that institutions serving low socioeconomic groups require routine screening for Hepatitis B carriers in pregnancy. The Summers article presents data from Charity Hospital in New Orleans in 1983. All pregnant women (N = 15,399) were screened; 136 carriers were found, for a prevalence of 0.88%. The race-specific prevalence was 0.56% white/0.62% blacW8.8% oriental. The cost in their institution was $2.30 per screening test or $261 per maternal carrier identified. Assuming 30% risk of perinatal transmission, the cost becomes $871 per neonatal carrier prevented. The Cruz article retrospectively reviewed data from University of Florida Hospital in Gainesville, which began screening all patients on admission in 1983. The prevalence rate among obstetrical patients was 0.54%; only one third of the carriers identified had recognized risk factors for Hepatitis B. The cost of screening in their community was $27.60, ten times that of the Charity Hospital study. Nevertheless, these authors recommend routine screening at 34-36 weeks gestation in low socioeconomic groups; They felt that screening on admission of the mother to the hospital did not provide the necessary information in a timely enough manner to protect the hospital staff and to treat the newborn within 12 hours after birth.

Routine Ultrasound Recommended Belfrage P, Fernstrom I, Hallenberg G: Routine or Selective Ultrasound Examinations in Early Pregnancy. OBSTET GYNECOL 69(5):747-750, 1987. This Swedish study prospectively studied 2054 women who were routinely screened with ultrasound at lo-14 weeks (95% of total registrants screened). They were compared with an

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historic control group of 1358 women who had been selectively scanned for clinical criteria the previous year (50% of total registrants screened). The expected date of delivery (EDD) was calculated by last menstrual period (LMP) and biparietal diameter (BPD)/ crown rump; if the dates did not differ by more than one week, the LMP date was used. If the discrepancy was greater than one week, the ultrasound (U/S) date was used; They changed the due date 20% of the time. The authors compared the accuracy of the LMP and U/S dates to predict the onset of spontaneous labor. When the LMP needed no correction, the length of pregnancy was 279 days. In cases in which the EDD was changed according to the ultrasound examination, the length of pregnancy calculated from LMP changed accordingly. There were fewer statisticallysignificant inductions for postdates in the ultrasound group.

Routine Monitoring

Not Supported

Luthy D, Shy K, vanBelle G, et al: A Randomized Trial of Electronic Monitoring in Preterm Labor. OBSTETGYNECOL 69(5):687-695, 1987. Six randomized clinical trials have been conducted to determine if routine electronic fetal monitoring (EFM) improves neonatal outcomes. None of the studies have found a significant difference in perinatal mortality rates although two studies suggest decreased neonatal seizures in the EFM group. All studies were done on low-risk populations. In 1981 the authors began a randomized clinical trial for high-risk, particularly preterm, pregnancies. The study examined the effect of monitoring on perinatal mortality and neurodevelopment at 18 months corrected age. This article addresses the issue of perinatal mortality. Three tertiary institutions in the Pacific Northwest enrolled a total of 376 women into the study. Participants had a singleton, cephalic infant with an estimated fetal weight (EFW) of 700-1750 g at 26-32 weeks. All study participants were followed on a one-to-one basis by a trained study nurse. The EFM group had external monitoring until 7 cm, at which time ROM was performed and an internal monitor applied; internal monitoring was used from

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the outset in patients who already had ruptured membranes. The auscultation group was auscultated by fetoscope or doptone every 15 minutes x 30 seconds after a contraction in the first stage of labor (after the baseline was obtained between contractions); auscultation was performed every 5 minutes in the second stage. All patients were managed by the house staff with supervision by attending physicians. Tocolysis, steroids, epidural, and oxytocin were used as indicated by institutional policies. Fetal heart patterns judged to be nonreassuring or ominous were treated with left lateral positioning, oxygen, fluids, and fetal scalp sampling if the dilatation was >4 cm (maternal pH was determined simultaneously). There was no difference between the auscultated and monitored groups in the use of these procedures. The primary cesarean rate of 15-16% did not differ significantly between groups either. All infants were evaluated by Apgar score, cord blood gas analysis, and cranial ultrasound on day three or four. Developmental studies were performed at 4, 8, and 18 months corrected age. Two hundred forty-six infants weighed cl750 g. There was no significant difference in infant condition judged by Apgar scores, cord blood acidosis, neonatal seizures, respiratory distress syndrome (RDS), or intracranial hemorrhage. There were 35 infants who died, all weighing cl500 gm; 80% were due to RDS and 9% due to anomolies. There was no difference in maternal morbidity due to monitoring technique. The study concluded that electronic fetal monitoring and periodic auscultation according to their protocol produced similar outcomes in the neonatal period in preterm infants.

Hyperemesis Depue R, Bernstein L, Ross R, Judd

H, Henderson B: Hyperemesis Gravidarum

in Relation

to Estradiol

Level, Pregnancy Outcome, and Other Maternal Factors: A Seroepidemiologic Study. AM J OBSTETGYNECOL 156(5):1137-1141, 1987. Data from the Collaborative Perinatal Project on more than 55,000 pregnancies at 12 university centers between

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1958 and 1965 provide the information for this study. The first part of the study matched subjects with the diagnosis of hyperemesis with controls from the same institution by date of registration and gestational age at registration. Four hundred twenty-six white women with hyperemesis were matched with 836 controls. Younger age, nulliparity, high body weight, and nonsmoking were significantly associated with hyperemesis. There was no difference in birth weight or length of gestation. Women with hyperemesis had a significantly reduced risk of fetal loss; however, they had a greater risk of central nervous system malformations. The second part of the study measured hormones in 35 women with hyperemesis versus 35 matched controls. The mean estradiol was 26% higher and the mean sex hormone binding-globulin binding capacity was 37% higher in the hyperemesis group; there was no significant difference in human chorionic gonadotrophin (HCG). Sons of women who have hyperemesis are at increased risk for testicular carcinoma.

Asymptomatic

Bacteriuria

Jakobi P, Neiger R, Merzbach D, Paldi E: Single-Dose Antimicrobial Therapy in the Treatment of Asymptomatic Bacteriuria in Pregnancy. AM J OBSTET GYNECOL 156(5):11481152, 1987. It has been shown that the use of singledose antibiotics for treatment of urinary infection in nonpregnant women can be effective; however, use in pregnancy has not been studied. This study examined 50 women who had two consecutive positive urine cultures. The women were treated with a single dose of 3 g amoxicillin, or 2 g of cephalexin, depending on sensitivities. Medication was given orally and in the presence of the investigators. Follow-up cultures were done at one, two, four, and eight weeks after therapy. The cure rate from single-dose treatment was 84%; cure was defined as negative cultures during the eight weeks of follow-up. The recurrence rate, including both relapse and reinfection, was 12% overall. No one in the study group devel-

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oped symptomatic infection. Only seven of their patients (14%) would have benefited from seven-day treatment initially. The study concludes that single-dose therapy has acceptable effectiveness, reduces overall drug exposure, increases patient compliance, and is cost effective. Hot Flushes

Rebar R, Spitzer I: The Physiology and Measurement of Hot Flushes. AMJOBSTETGYNECOL 156(5):12841288, 1987. This article is from a symposium in the issue on current perspectives on the management of the menopausal patient. Other articles include estrogen replacement therapy, use of progestogens, and osteoporosis. Hot flushes have only been studied in the last ten years; this article summarizes what is known about them. The incidence of hot flushes is as high as 85% among perimenopausal women. As many as 45% still have hot flushes five to ten years after the last menstrual period. The hot flush is a sudden sensation of warmth in the upper thorax, neck, face, and arms. The skin temperature characteristically rises about 7.5F. The pulse rate increases an average of nine beats. Although the episodes are brief, averaging 2.7 minutes, there is never a premonitory sign that a flush is imminent. The flush is followed by profuse perspiration. In sleep, a flush is called “night sweats”; electroencephalograms (EEGs) show that women awake before the flush, thereby suffering from disturbed sleep. The flush seems to be triggered by sudden downward resetting of the body’s central thermostat. Although several studies have shown improvement with estrogen replacement therapy, other studies have been unable to demonstrate a relationship between circulating estrogens and the occurrence of hot flushes. Recent studies, however, show occurrence of hot flushes with pulses of luteinizing hormone (LH). Low Birth Weight

Meis R, Ernest JM, Moore ML: Causes of Low Birth Weight Births in Public and Private Patients. AM J OBSTET GYNECOL 156(5):1165-1168, 1987. 367