In the term gestation prolonged rupture of membranes (ROM) is associated with substantial increases in neonatal infections and perinatal mortality. Previous studies have not generally separated the effect of duration of ROM into term and preterm gestations. In a prospectively randomized study all patients were divided into expectantly managed (EM) and actively managed (AM) groups. In the EM group delivery occurred following spontaneous labor, maternal chorioamnionitis, or fetal distress. The AM group was actively managed (i.e. delivered) either after a mature Lecithin:Sphingomyelin ratio or a 48 hour course of corticosteroids. During a three year period there were 247 patients (112 in the EM, and 135 in the AM group). These two groups were well matched for gestational age, birth weight, maternal age and parity. In both groups combined, and in the EM group only, duration of ROM did not correlate with an increased incidence of chorioamnionitis, neonatal mortality or the incidence of neonatal pneumonia, septicemia and/or meningitis; nor was there a difference in these outcome parameters comparing durations of ROM less than and greater than 24 hours. It is concluded that prolonged ROM in the preterm gestation does not increase maternal or neonatal infectious morbidity nor adversely affect neonatal outcome.

Four patients with hypertensive disorders of pregnancy were treated with intravenous diazoxide. In 2 patients there was profound maternal hypotension. Late deceleration of the fetal heart rate occurred in 3 patients following diazoxide administration. Possible implications of this study are discussed.

A single 2-mg dose of quinestrol was demonstrated safe and effective for controlling postpartum lactation and for alleviating breast discomfort. A double-blind comparison to Tace 72 mg every 12 hours for 2 days, and to placebo, was made in 134 patients. The single oral dose of quinestrol showed efficacy equal to the 2-day regimen of Tace. Both were superior to placebo.

Sixty-two consecutive diabetic women hospitalized from one to eight weeks prior to delivery were included in this study. Some 1,100 simultaneous unconjugated plasma estriol, total plasma estriol, 24 hour urinary estriol, and creatinine assays were performed on an almost daily schedule. Clinical management was based upon a weekly oxytocin challenge test and daily 24 hour urinary estriol and creatinine determinations. Twenty patients had spontaneous onset of labor and 32 were delivered electively at 38 weeks while three were delivered for maternal and seven for fetal indications. Gestational age at delivery averaged 38 weeks and ranged from 35 to 42 weeks. A total of 840 day-to-day variations of unconjugated plasma estriol, total plasma estriol, and the urinary estriol/creatinine ratio were computed as the per cent rise or fall from the highest mean of three consecutive preceding values. Observed were 369, 419, and 428 decreases in unconjugated plasma estriol, total plasma estriol, and urinary estriol/creatinine, respectively, averaging 12.8 ± 9.6 (S.D.), 13.4 ± 10.1, and 14.4 ± 10.6 per cent. One stillbirth occurred, which was preceded by a 42 per cent decrease in unconjugated plasma estriol but unheralded by either a drop in total plasma estriol or the urinary estriol/creatinine ratio. There were fewer falls of more than 40 per cent unassociated with perinatal morbidity and death with unconjugated plasma estriol (No. = 3) than with total plasma estriol (No. = 8) and urinary estriol/creatinine (No. = 8). These data suggest that unconjugated plasma estriol is the most predictive test among presently available estriol assays for managing the pregnant diabetic patient.

The amniotic fluid lecithin/sphingomyelin (L/S) ratio was determined in 182 pregnancies complicated by Classes B and C diabetes and in 28 patients with Classes D, F, and R diabetes. These data were retrospectively correlated with the occurrence of the respiratory distress syndrome (RDS) or hyaline membrane disease (HMD). Only four cases of RDS and two cases of HMD were observed in 200 patients with an L/S ratio of 2.0 or greater prior to delivery. This 3 per cent incidence of complications is no higher than that of the nondiabetic population in our institution. Seven of 10 neonates with an antenatal L/S ratio of 1.5 to 1.9 developed RDS. An L/S ratio of 2.0 or more appears to be a reliable predictor of fetal pulmonary maturity even in pregnancies complicated by diabetes mellitus.

Patients who have a normal fasting serum glucose (FSG) and an abnormal glucose tolerance test, and who require little dietary regulation, have been designated as Class A diabetics by White. During the period 1970 through 1972, 261 Class A women were dilivered at Los Angeles County (LAC) Women's Hospital. These patients were managed by a uniform protocol which included dietary supervision and continued surveillance for the onset of overt diabetes. Elective intervention prior to 40 week's gestation was to be avoided. Twenty-five per cent of the Class A patients—those who had had a previous stillbirth or who developed pre-clampsia—were considered at greater risk for perinatal death and were managed as if they had overt diabetes. The perinatal death rate for the entire Class A group was 19/1,000 as compared to 32/1,000 in the general population. Five perinatal deaths occurred, three associated with congenital malformations. There were no unexplained stillbirths or deaths due to trauma or iatrogenic prematurity. Our data thus indicate that as long as the FSG remains normal, an unexplained intrauterine death is a rare event. Twenty-five per cent of the infants did experience some morbidity.

Sixty-six of 390 patients studied at LAC/USC Women's Hospital between 1970 and 1973 had positive oxytocin challenge tests (OCT). Twenty-four percent of patients who were allowed direct monitored labor after a positive OCT showed no late deceleration and must be assumed to have had false-positive tests. Patients with positive OCT's had significantly increased incidences of perinatal mord late deceleration in labor when compared to patients with no positive OCT. The combination of a positive OCT and abnormal 24-hour urinary estriol excretion should be considered ominous.

The perinatal mortality rate for twin gestation is in the range of 15 %, and this is due predominantly to prematurity, although twins may also be born growth retarded. Ritodrine HCl, a beta sympathomimetic drug, has been shown to be effective, both in stopping premature labor and in preventing intrauterine growth retardation. With this in mind, a double-blind study using ritodrine HCl or placebo was begun in order to study its effect on premature labor, intrauterine growth retardation, and the perinatal mortality rate in twins. Thus far, 30 patients have delivered and have been followed to 6 weeks postpartum. Although the results on individual patients have remained blinded to the investigators, an initial evaluation of the ritodrine and placebo groups have revealed no difference with respect to gestational age, birth weight, or perinatal mortality. These preliminary results are not significant. However, it appears that ritodrine HCl is a safe oral agent for the antepartum gravida and her fetus. The study will be continued until approximately 100 patients have been enrolled.

Normal values of unconjugated, total, and immunoreactive (measured without extraction) plasma estriol (E3) have been determined from radioimmunoassay data obtained in 217 uncomplicated third-trimester pregnancies. Small but significant diurnal variations in unconjugated and total plasma E3 have been observed in a study comprising 12 women who were hospitalized during late pregnancy for diabetes, toxemia, or placenta previa. The late morning decreases in unconjugated and the afternoon/evening decreases in total plasma E3 concentrations, averaging some 10 to 15 per cent, were overshadowed by considerable episodic fluctuations and may thus be clinically irrelevant. Day-to day changes of unconjugated and total plasma E3 concentrations in late pregnancy were similar and smaller than changes in urinary E3 measurements. The urinary E3/creatinine ratio, however, reducing inadequacies of 24 hour urine collections, varied less than unconjugated or total plasma E3. The data suggest that a decrease in unconjugated or total plasma E3 must exceed 40 to 45 per cent of the mean of the three preceeding determinations if it is to be considered a signal of fetal distress.

A retrospective study was designed to determine whether the baseline fetal heart rate (FHR), recorded before oxytocin infusion, would have any correlation with the outcome of the oxytocin challenge test (OCT).

Impairment of umbilical cord blood flow has been associated with periodic fetal heart rate changes termed “variable decelerations.” These patterns may be observed after amniotomy. A chronic fetal rhesus monkey preparation has been used to investigate this clinical observation. Loss of amniotic fluid produced variable deceleration patterns, while restoration of amniotic fluid volume eliminated such changes. These experimental data demonstrate that amniotic fluid may be critical in protection of the cord and maintenance of normal umbilical cord blood flow.