Biomedical subjects
Publications and source records attributed to R L Berkowitz.
Three hundred eighty-five gestations were managed in a perinatal center during a five-year interval. Twins were diagnosed antenatally in 90.4% and before delivery in 95.6% of cases. From this study, the value of hospitalization for bed rest after 28 weeks of gestation seems questionable, for 81% of the perinatal mortality in our study occurred prior to that time.
Sixty-nine documented cases of placenta previa were managed at The Mount Sinai Medical Center during a five-year period. Vaginal delivery was attempted in six instances of partial placenta previa and was successful in five (83%). For these six cases, intrapartum bleeding was not excessive, blood transfusions were not necessary during or after labor, and all Apgar scores were greater than or equal to 7 at one and five minutes. Anemia in a neonate delivered at 32 weeks of gestation was the only neonatal complication that may have been due to intrapartum fetal hemorrhage. This series suggests that routine cesarean section is not necessary for all cases of partial placenta previa. A protocol is proposed for the intrapartum management of suspected placenta previa at term. Further clinical studies are necessary to evaluate the safety and clinical use of this mode of management.
During a two-year period, nine cases of cephalocele were evaluated at the authors' perinatal ultrasound unit. There was one false positive and one false negative diagnosis. In five cases, multiple anomalies were present; three as part of the amnion rupture sequence. The obstetric management consisted of elective termination of pregnancy in five cases and cesarean section in four. The value of sonography in the diagnosis of cephalocele and associated syndromes and malformations is discussed. A plan of management and counseling based upon current understanding of prognosis is presented.
Thirty cases of fetal hydrocephalus were diagnosed at the perinatal ultrasound unit of Yale-New Haven Medical Center during a 41 month period. Prenatal ultrasound was found to be highly valuable in the detection of fetal hydrocephalus. However, the antenatal detection of associated anomalies was not as uniformly successful. The importance of a complete sonographic evaluation of intracranial and extracranial anatomy is stressed, as 10 patients with documented hydrocephalus (37%) had associated intracranial anomalies and 17 patients (63%) had associated extracranial anomalies. In this series, isolated hydrocephalus without associated anomalies occurred in only four patients (15%).
Fetal cystic hygromas are congenital malformations of the lymphatic system appearing as single or multiloculated fluid-filled cavities, most often about the neck. They are thought to arise from failure of the lymphatic system to communicate with the venous system in the neck. They often progress to hydrops and cause fetal death. In an effort to delineate the cause and natural history of this disorder, we studied 15 consecutive cases of nuchal hygroma detected prenatally by ultrasound. None of the 15 fetuses ultimately survived. Thirteen fetuses were hydropic at the time of diagnosis; nine either died or were bradycardic in utero before abortion; one died a few hours after birth. Eleven fetuses (73 per cent) had karyotypes consistent with Turner's syndrome, and an additional fetus with female genitalia had a 46,XY karyotype. Three fetuses had 46,XX karyotypes, and two of these had multiple malformations. When a hygroma is detected during fetal life, careful sonographic examination of the entire fetus, determination of the fetal karyotype, and an evaluation of the family history are indicated.
Fetal echocardiographic studies were performed in 71 patients referred for evaluation of cardiac rhythm disturbances at 24 to 40 weeks' gestation. After 2-dimensional echocardiographic study of cardiac structure was performed, M-mode echocardiograms were analyzed for measurement of cardiac rate, atrioventricular contraction sequence, atrioventricular valve motion, and duration of postectopic pauses. Arrhythmias were diagnosed in 59 patients. In 34 patients with isolated ectopic beats, the arrhythmia resolved during later pregnancy in 26 or within the first 5 days of life in 8. Six patients had mild sinus bradycardia and 8 had frequent sinus pauses; all 14 had resolution of the arrhythmia during pregnancy. Sustained arrhythmias occurred in 11 patients. Deaths occurred when there was associated fetal congestive heart failure (hydrops fetalis), structural heart disease, or both. M-mode echocardiography diagnosed supraventricular tachycardia in 3 fetuses. The echocardiogram was used thereafter for monitoring transplacental digoxin therapy.
SAM and fine mesh gauze dressings were compared on 60 consecutive skin graft donor sites. SAM dressings are significantly better than fine mesh gauze dressings for healing of split-thickness skin graft donor sites; healing occurs much more rapidly with much less pain. In patients known to be colonized with Pseudomonas, care should be taken when using SAM dressings, although it is not an absolute contraindication. There were no clinically significant differences between Tegaderm and Op-Site.
Synthetic Adhesive Moisture vapor permeable (S.A.M.) dressings, Op-Site and Tegaderm, are compared to Fine Mesh Gauze (F.M.G.), as a dressing for split-thickness skin graft donor sites. Scalp as a donor site is compared to nonscalp donor sites. The combination of S.A.M. dressings and scalp as a donor site allows for rapid reuse of a donor site. Pain is substantially decreased and rate of healing is increased when this combination is used. The scalp, because of its availability, accessibility, excellent color match for facial grafting, and rapid healing, is recommended as a donor site.
An epidemiologic case-control study exploring possible risk factors for preterm delivery was undertaken at Yale-New Haven Hospital during 1977. The study groups consisted of 175 mothers of singleton preterm infants and 313 mothers of singleton term infants. Analysis of questionnaire responses provided no evidence that employment, housework, child care and leisure-time physical activity during pregnancy increased the risk of preterm delivery. Women who participated in sports or physical fitness exercises during pregnancy were found to have a significantly decreased risk of preterm delivery as compared to those who were not similarly active; this finding suggests that certain forms of moderate physical activity may actually protect against preterm delivery.
Twenty-five external cephalic versions were attempted on 14 transverse and 11 breech malpositioned second twins. In ten of 14 (71%) transverse presentations and eight of 11 (73%) breech presentations, version was successful and resulted in subsequent vertex vaginal delivery. Successful version was not associated with parity, gestational age, or birth weight but was associated with mode of anesthesia and disparity in twin size. Among the 25 attempted versions, seven (28%) had one-minute and two (8%) had five-minute Apgar scores below 7. Analysis by birth weight and mode of delivery is presented. Time interval between delivery of twins had no association with outcome. One neonatal death occurred in a 28-week, 1100-g infant. The authors believe that external version is useful in the management of the second twin who has an abnormal presentation, and that routine cesarean section is not always necessary. Further investigation, especially at lower birth weights, is necessary to confirm the safety and efficacy of this method of management.
A massively obese patient (199 kg) presented at term with a fetus in the transverse lie. External cephalic version with sonographic guidance was successful, and subsequent vertex vaginal delivery occurred. External cephalic version in the massively obese gravid patient is a therapeutic possibility, and the dangers of cesarean section may be avoided using this procedure.
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A case-control study of 175 mothers of singleton, preterm infants and 313 mothers of singleton, term infants was undertaken at Yale-New Haven Hospital during 1977 to explore possible risk factors of preterm delivery. Heavy alcohol consumption (an average of two or more drinks per day) during the pregnancy was associated with an approximately 3-fold risk of preterm delivery. Women who smoked 10 or more cigarettes per day were also at an increased risk of a preterm delivery, but the effect of cigarette smoking was less pronounced once confounding variables had been taken into account. No association was observed between coffee drinking and shortened gestations. Tea consumption, especially four or more cups of tea per day, was more frequent among women with a preterm as compared to a term infant, but no significant relation was evident between heavy tea consumption and preterm delivery after controlling for the effects of other risk factors.
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Fetal inner orbital diameter and outer orbital diameter were measured in the occipital transverse and occipital posterior positions in 180 normal pregnancies. The outer orbital diameter was found to be closely related to the biparietal diameter. After a nomogram had been constructed, 463 patients whose fetuses were at risk for various anomalies were studied in two cases, hypotelorism was suspected because the orbital measurements fell below the 95% confidence limits, and this diagnosis was confirmed at the time of delivery. The conclusion is that, in situations in which fetal head position precludes accurate biparietal diameter determinations, the outer orbital diameter can often be obtained and used to estimate that variable and, therefore, gestational age. Furthermore, the nomogram constructed has proved to be a useful tool in diagnosing hypotension in utero. Theoretically, this should also be true of fetal hypertelorism.
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