Faculty Bibliography

OBJECTIVE:Our purpose was to determine whether a borderline amniotic fluid index observed during antepartum testing confers a significant risk of adverse perinatal outcome. STUDY DESIGN/METHODS:We conducted a retrospective review of all patients entering antepartum testing at Los Angeles County-University of Southern California Women's and Children's Hospital during a 4-month period beginning January 1, 1996. Women with singleton pregnancies who underwent antepartum testing within 1 week of delivery and who were delivered at our institution were identified for our study. An amniotic fluid index >5 and <10 cm was defined as "borderline" and an amniotic fluid index of 10 to 24 cm was considered normal. Markers of adverse perinatal outcome included intrapartum fetal distress, 5-minute Apgar score <7, meconium-stained amniotic fluid, and intrauterine growth restriction. RESULTS:There was a 2-fold increase in the incidence of adverse perinatal outcome among the women with borderline amniotic fluid index in comparison with control subjects with normal amniotic fluid volume. This difference reflected a 4-fold increase in the incidence of fetal growth restriction among women with a borderline amniotic fluid index. CONCLUSIONS:A borderline amniotic fluid index observed in antepartum testing is associated with an increased risk of intrauterine growth restriction and overall adverse perinatal outcome. These observations suggest that borderline amniotic fluid index merits twice-weekly antepartum testing.

The purpose of this study was to determine if a group of patients with unexplained second or third trimester fetal demise have an increased prevalence of antinuclear antibodies (ANA) when compared to controls. During a 5-year period from January 1989 through December 1993, the records of all fetal deaths > or = 500 g or > or = 20 weeks of gestation that occurred at our institution were reviewed. In these women the ANA titers were checked at the discretion of the physician. The proportion of positive ANA tests in the group of women with explained fetal deaths was compared to that in women with unexplained fetal deaths. These results were then compared to a control group of healthy gravidas presenting to labor and delivery in the third trimester. During this time period, 848 fetal deaths were recorded. Our study population consisted of 286 patients who had an unexplained second or third trimester fetal demise with a record of having an ANA drawn. Of the 376 explained fetal deaths, 190 had an ANA assayed. The control group included 299 healthy third trimester gravidas. In the group of patients with unexplained fetal death, 11.5% (33/286) had a positive ANA, whereas 16% (31/190) of ANA tests were positive in cases of explained fetal death (P = 0.17). In the control group, 14% (43/299) had a positive ANA. There were three distinct immunofluorescence patterns: nucleolar, speckled, and homogeneous. The first two were seen more often in the control group, whereas the latter was seen more frequently in those patients with fetal death (P = 0.10). The incidence of a significant circulating ANA titer was similar in patients and controls. Moreover, there was no significant association between circulating antinuclear antibody titers and fetal outcome. More patients with a fetal death had a homogeneous nuclear fluorescence pattern when compared to controls; however, this finding was not statistically significant. Therefore, we do not recommend routine testing for ANA in women with unexplained second or third trimester fetal death.

We present three cases of shoulder dystocia unrelieved by standard maneuvers, including cephalic replacement. Symphysiotomy was performed in an effort to preserve fetal life. All three infants sustained severe neurologic injury and later died. Maternal morbidity including urinary incontinence was significant but responded to treatment. Symphysiotomy may be the only method of relieving some cases of shoulder dystocia, but its role remains unclear because of operator inexperience and maternal morbidity.

Blunt innominate chest trauma is relatively rare, with only 70 cases being reported in the surgical literature since 1960. This report describes a 20-year-old male who sustained a blunt chest injury that resulted in an innominate artery dissection. The patient's clinical course and management are discussed, as well as a review of the surgical literature.