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To investigate the effects of magnesium sulfate therapy in premature preterm rupture of membranes (PPROM), this retrospective cohort study of deliveries after PPROM over a 3-year period was performed. Gestational age-matched patients, who received magnesium sulfate therapy after PPROM, were compared with those who did not receive tocolysis. Deliveries within 48 hours (47 versus 22%) and a week (92 versus 44%) of PPROM occurred more frequently in those who received tocolysis. Cervical dilation and frequency of contractions were not different between the two groups. There was no difference at 24 hours in the delivery rates (36 versus 22%). Population demographics and neonatal/obstetrical outcomes were similar between the two groups except for a shorter latency in patients who received tocolysis (60 [1-245] versus 127 [1-1848] hours, median [range]). Magnesium sulfate therapy does not appear to improve maternal or neonatal outcome in PPROM and may in fact shorten the latency period.

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OBJECTIVE: To estimate the efficacy of lidocaine ointment in relieving pain after a vaginal delivery with an episiotomy or perineal laceration. METHODS: In a randomized, double-blind, placebo-controlled trial, 200 women received lidocaine ointment (n = 108) or a placebo (n = 92). Pain relief was assessed by the amount of ointment used (weight of jar before use - weight of jar after use), total number of pain pills used, and a pain questionnaire. The sample size was calculated using a beta of.2 and an alpha of.05 with an expected reduction of other pain medications from an average use of six pills to four pills for the population. RESULTS: There was no significant difference in the amount of lidocaine versus placebo used for postpartum day 1 (5.1 g versus 4.0 g, respectively [P =.13]) or day 2 (3.7 g versus 2.6 g, respectively [P =.18]). Patients receiving lidocaine instead of the placebo showed no significant difference in the total amount of postpartum pain medications (6.3 versus 6.8 tablets, respectively [P =.53]), subjective pain parameters (P =.36), or satisfaction from ointment (P =.99). Patients with an episiotomy used more pain medications than those with a laceration (7.9 versus 5.6 tablets, respectively [P =.003]). Those with minor versus major lacerations required fewer pain pills (6.1 versus 10.8 tablets, respectively [P <.001]) and used less ointment (4.3 g versus 7.9 g, respectively [P =.02]) on the first postpartum day. CONCLUSION: Topical application of 5% lidocaine ointment was not effective in relieving episiotomy or perineal laceration pain.

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BACKGROUND: Pregnancies complicated by congenital heart block usually have a poor prognosis when there is severe fetal bradycardia. CASE: We present a pregnancy with fetal heart rate of 40 beats per minute. She previously delivered a child with third-degree heart block by cesarean at 28 weeks. This pregnancy was complicated by a high ribonucleoprotein antibody anti-Ro/SSA titer and fetal bradycardia. The patient was treated with steroids and beta-mimetics. The fetus continued to grow normally with reassuring biophysical profiles. After fetal lung maturity documentation at 34 weeks, she delivered by repeat cesarean a healthy 2349-g infant who required a permanent pacemaker. CONCLUSION: Reassuring antepartum testing and normal growth in pregnant women with anti-Ro/SSA antibodies and congenital heart block may allow expectant management until fetal maturity.

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OBJECTIVE: To study the association between meconium and maternal infection. METHODS: This was a retrospective cohort study of 678 pregnant women. All term deliveries during a 31-month period with meconium passage were included. Each meconium delivery was matched with a consecutive delivery without meconium at the same gestational age. RESULTS: The overall infection rate was 16%, with 13% of the infections directly related to the pregnancy, labor, and delivery. The endometritis rate was 5%, with 7.1% and 3% in the meconium and no-meconium group, respectively. The chorioamnionitis rate was 8.3%, with 9.5% in the meconium and 7.1% in the no-meconium group. Factors found to be associated with overall obstetric infections had the following odds ratios (ORs) and 95% confidence intervals (CIs): meconium (OR 1.8, 95% CI 1.1, 2.8), internal monitoring (OR 3.4, 95% CI 1.9, 5.9), amnioinfusion (OR 2.0, 95% CI 1.3, 3.3), number of vaginal exams (OR 4.5, 95% CI 2.8, 7.1), length of labor (OR 2.8, 95% CI 1.8, 4.4), and cesarean (OR 3.1, 95% CI 1.9, 5.1). Logistic regression analyses revealed the following ORs and 95% CIs: 1) for endometritis-cesarean (OR 4.2, 95% CI 1.9, 8.9), internal monitoring (OR 2.5, 95% CI 1.1, 5.9), and meconium (OR 2.5, 95% CI 1.1, 5.5), and 2) for chorioamnionitis-length of labor greater than 10 hours (OR 2.7, 95% CI 1.4, 5.6), number of vaginal exams greater than seven (OR 3.4, 95% CI 1.7, 6.6), and use of internal monitors (OR 2.5, 95% CI 1.2, 5.3). CONCLUSION: Meconium passage increases the risk of postpartum endometritis but not chorioamnionitis. Length of labor, internal monitoring, and number of vaginal exams are risk factors for chorioamnionitis.

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BACKGROUND: Prolonged-interval delivery between twins can improve neonatal outcome and, under careful monitoring, poses minimal maternal risk. CASE: A 27-year-old, nulliparous woman conceived after in vitro fertilization and was found to have diamniotic-dichorionic twins. At 17 weeks she presented with premature preterm rupture of the membranes of twin A. She was offered delivery or expectant management. She chose expectant management and was discharged. At 18 weeks she delivered twin A and decided to expectantly manage the second twin. Amniocentesis was performed to evaluate for intraamniotic infections. There was no evidence of them, and a McDonald cerclage was placed. At 32 weeks, spontaneous rupture of the membranes occurred for twin B. The patient delivered vaginally a male infant (2,070 g) who did not need mechanical ventilation and was discharged from neonatal intensive care on the 7th day of life, with no complications. CONCLUSION: Expectant management of a second twin after delivery of the first in selected patients can improve neonatal outcome.

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BACKGROUND: Abdominal pregnancy is a rare obstetric emergency, occurring in 1 in 10,000 pregnancies. CASE: An 18-year-old woman, gravida 3, para 1, presented for evaluation of an abnormal level of maternal serum alpha-fetoprotein. Transabdominal ultrasound examination revealed absence of amniotic fluid with limited imaging ability. Transabdominal amnioinfusion was done to better visualize the fetus. A small uterus was seen in the pelvis, and an abdominal pregnancy was identified with the placenta attached anteriorly over the right pelvic sidewalls. After delivery of the fetus, the placenta was left in situ. The patient recovered postoperatively and was doing well a year after the procedure. A 12 x 10-cm mass remains over the right pelvic sidewall without detectable Doppler blood flow. CONCLUSION: State-of-the-art imaging and prenatal diagnostic techniques allowed correct diagnosis, adequate preparation and optimal management of this dangerous condition.

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