Hospital guidelines for fetal viability assessment and postdecision responsibilities.
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The maternal-fetal/neonatal considerations regarding management near the limits of viability are becoming increasingly complex. This article presents a data base upon which to formulate clinical decisions. Epidemiologic and financial considerations are discussed, and a perinatal management approach to the more common clinical situations is provided.
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The prospective controlled study investigated the concentrations of free beta-human chorionic gonadotrophin (HCG) subunit in 554 women with a singleton intrauterine or tubal pregnancy. They presented with vaginal bleeding and/or abdominal pain in the first 18 weeks of pregnancy. The control group comprised 156 women with musculoskeletal pain and no vaginal bleeding. Their pregnancies continued to term. The study group comprised 398 women (141 threatened-continuing pregnancies, 37 threatened-miscarriages, 185 non-continuing pregnancies and 35 tubal pregnancies). Free beta-HCG concentrations were significantly lower in the non-continuing, threatened-miscarriage and tubal pregnancy groups [mean 4.62, 6.50 and 4.27 ng/ml respectively; 95% confidence interval (CI) 3.75-5.69, 4.46-9.48 and 2.92-6.2 respectively] than in the control and threatened-continuing groups (mean 41.61 and 48.22 ng/ml respectively; 95% CI 34.53-50.13 and 42.03-55.32 respectively) (P < 0.001 in all cases). A cut-off value at 20 ng/ml was found to differentiate between the 'viable' (control and threatened-continuing) and the 'abnormal' (non-continuing, threatened-miscarriage and tubal) pregnancies, with 88.3% sensitivity and 82.6% positive predictive value. An excellent diagnostic and prognostic usability of free beta HCG was confirmed by a receiver operating characteristic curve plot. In conclusion, a single serum free beta-HCG measurement taken in early pregnancy is valuable in the immediate diagnosis of early pregnancy failure and the long-term prognosis of viability.
Twenty-one pregnant mares with single or twin conceptuses between 41 and 65 days of gestational age were allotted to 5 treatment groups. A ventral median celiotomy was performed in all mares. In group-1 mares (3 mares, single conceptus), the uterus and fetus were palpated for 5 minutes. In group-2 mares (3 mares, single conceptus, flunixin meglumine), 250 ml of sterile placental fluid was injected into the nongravid uterine horn. In group-3 mares (4 mares, unicornuate twin conceptuses), group-4 mares (3 mares, unicornuate twin conceptuses, flunixin meglumine), and group-5 mares (8 mares, bicornuate twin conceptuses, flunixin meglumine), 1 conceptus was removed from the uterus via hysterotomy. All mares received progesterone prophylactically until day 100 of gestation or until the fetus died. The 3 mares in group 1 delivered clinically normal, live foals. The mean prostaglandin F2 alpha metabolite (PGFM) plasma concentration peaked at 180 +/- 5.2 pg/ml during uterine manipulation and fetal palpation, then declined to baseline by 1 hour. Free placental fluid (group 2) undermined the chorioallantois ventrally and resulted in fetal death within 3 hours after surgery. The mean PGFM plasma concentration peaked at 39 +/- 4 pg/ml following injection of placental fluid. None of the remaining fetuses in the 7 mares with unicornuate twin conceptuses (groups 3 and 4) survived. Five mares with unicornuate twin conceptuses (group 5) delivered single viable foals. In another mare in group 5, the fetus was alive 4 days after surgery, when the mare was euthanatized for a fractured femur.(ABSTRACT TRUNCATED AT 250 WORDS)