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Occasionally, this results in minor clinical bleeding, such as purpura, ecchymoses, hematuria, or melena. Acute infarction of a fibroid during pregnancy, accompanied by severe abdominal pain, labor, and possibly preterm birth, may appear as internal liquefaction and decreased echogenicity of the fibroid. Several of the important findings are worth emphasizing in the remainder of this section. Cardiac rhabdomyomas typically regress or remain stable in size postnatally,232,233 in contrast to other tumors, which may grow substantially after delivery. In one series, more than half of pregnant patients had a history of a previous blood transfusion. Giannakoulopoulos X, Teixeira J, Fisk N, et al: Human fetal and maternal noradrenaline responses to invasive procedures, Pediatr Res 45:494, 1999. Plasmin is inhibited by 2-plasmin inhibitor, and like plasmin and plasminogen, it is bound to the fibrin clot, where it is positioned to prevent premature fibrinolysis. Most cases of ectopia cordis carry a poor prognosis, with neonatal death related to infection, heart failure, or hypoxemia. Prenatal pediatric orthopedic consultation may be helpful to discuss postnatal management and prognosis. Because of this concern, breathing of 100% oxygen at atmospheric pressure must be limited to a few hours only. In practice, there is a tradeoff between wanting to detect as small a difference as possible and wanting to maintain a reasonable sample size (from a logistical and cost perspective). Repair of aortic regurgitation is much less successful than repair of mitral regurgitation. This is one reason why some obstetricians prefer to manage labor with the patient in the left decubitus position. These data allow a morphologic classification of the anemia and indicate whether the marrow is hyperproliferative or hypoproliferative. Despite these advantages, several limitations of existing data must be considered when assessing such studies. In Simpson J, Elias S, editors: Essentials of prenatal diagnosis, New York, 1993, Churchill Livingstone, p 185. The technique of prenatal closure of the defect is identical to the postnatal surgical procedure. In physiologic pregnancy, the fetal membranes undergo progressive mechanical stretch, allowing their accommodation to the growing uterus. Persistent lack of sonographic stomach visualization after the 14th week of gestation should prompt a thorough ultrasound assessment. The dramatic results are surprising because of the modest association between these thrombophilias and the risk of pregnancy loss in most studies, and they need to be validated before adoption of this method into routine clinical practice. More recently, clinical trials support the notion that administration of a single rescue course of steroids before 33 weeks improves neonatal outcome. Ultrasonography, electronic fetal monitoring, and, frequently, evaluation of the function of the maternal coagulation system make up the foundation on which both diagnosis and management are developed. In addition, ideally, the probe can be rotated slightly from a transverse cut toward a partially sagittal plane. However, a recent report from a cohort in Israel, the Jerusalem Perinatal Study, showed that associations of maternal gestational diabetes with higher blood pressure in offspring are independent of childhood body weight. Lewi L, Jani J, Blickstein I, et al: the outcome of monochorionic diamniotic twin gestations in the era of invasive fetal therapy: a prospective cohort study, Am J Obstet Gynecol 199:514, 2008. Prat C, Blanchon L, Borel V, et al: Ontogeny of aquaporins in human fetal membranes, Biol Reprod 86(2):48, 2012. Hemorrhage and preeclampsia present high opportunities for preventability; pulmonary embolism, sepsis, and cardiomyopathy are intermediate; and, in these analyses, deaths from amniotic fluid embolism were deemed unpreventable. Routine placental examination may therefore provide prognostic information for thromboembolic and hemorrhagic sequelae, providing a useful adjunct to laboratory indices and cranial ultrasonography.

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If the contraindications to expectant management described previously are absent, the following protocol may minimize the risk of maternal and fetal complications. In the largest series reported to date-740 procedures in 254 fetuses treated at a national referral center in the Netherlands between 1988 and 2001-the overall perinatal survival was 89%. Chest radiography also may be of great value in assessing the severity of the pulmonary infection. Hemoglobin electrophoresis shows hemoglobin E at approximately 40%, hemoglobin A at 1% to 30%, and a significant increase in hemoglobin F (at approximately 30% to 50%). These types of infections typically involve the fetal liver, as that is the first major fetal organ reached, but other organs are often involved. These Doppler techniques can be combined efficiently in the context of a regular fetal assessment examination. In one study, the decline in Hct per day was markedly improved with this technique (0. The term "low-lying placenta" should be reserved for cases in which the placenta is seen on transabdominal ultrasound to extend into the lower uterine segment but its precise limits have not been defined and for cases identified before the third trimester. Postcesarean bacteriuria occurs in approximately 11% of patients and is related largely to routine urethral catheterization. The relationship of marginal and decreased amniotic fluid volume to perinatal outcome, Am J Obstet Gynecol 150:245, 1984. There was no significant difference in the frequency of low Apgar scores between the chorioamnionitis group and the control group. If fetal pulmonary testing reveals an immature result or if amniotic fluid cannot be obtained for assessment, conservative management with antenatal corticosteroid administration for fetal maturation is an appropriate choice. When indicated, and only in the absence of any contraindication, treatment may begin with a digoxin load, using 0. With the use of deep general inhalational anesthesia for adequate fetal anesthesia and uterine relaxation, maternal laparotomy is performed to expose the uterus. A,Normalfour-phasewaveform(1,atrialcontraction,calledana-wave;2,ventricularsystole;3,ascent of annulus; 4, diastole) with the a-wave showing only modest normal reduction in forward flow. The pulmonary microvasculature develops in the mesenchyme around the developing airways by the processes of angiogenesis (the sprouting of new vessels from preexisting vessels) and of vasculogenesis (fusion of primitive vascular plexuses, which then connect with vessels). The duration of pregnancy at birth reflects two major correlates of maternal and fetal health: (1) whether the birth was occasioned by a normal or an aberrant pathway, and (2) whether the infant has reached maturity at birth. Advantages include the immediate identification of retained placental fragments and intrauterine extensions of cervical lacerations and the shortened time of placental removal. When fetal malformations, genetic diseases, or in utero acquired conditions are suspected, patients are referred to tertiary care units with specialized skills, technical equipment, experience, and multidisciplinary counselors to define an accurate prognosis and potential options. In patients with mechanical prosthetic valves, it is reasonable to avoid warfarin between weeks 6 and 12 of gestation because of the high risk for fetal defects. Although a diagnosis of preeclampsia is not made without absolute blood pressures of 140 mm Hg systolic or 90 mm Hg diastolic, women who reach this level from a lower early pregnancy value typically suffer from more vasospasm than those for whom 140/90 mm Hg represents a lesser increase. In addition, acute pyelonephritis in pregnancy can cause significant maternal morbidity and, in rare instances, maternal and fetal mortality. Bradley and colleagues103 summarized findings in 33 women who delivered infants with Smith-Lemli-Opitz syndrome. Magnesium acts by competition with calcium either at the motor end plate (reducing excitation by affecting acetylcholine release and sensitivity at the motor end plate)292 or at the cell membrane (reducing calcium influx into the cell at depolarization). The possibility of uterine dehiscence may have an as yet undefined and unquantified effect on the index and on future pregnancies. The diffusional transfer of carbon dioxide from fetus to mother requires the Pco2 of fetal blood to be higher than the Pco2 of maternal blood.

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Anemia, caused by hemolysis initiated by endotoxemia, occurs in 23% to 66% of these patients. When this short vessel is identified, Doppler insonation and depiction of the characteristic waveform. The average gestational age of delivery with twins is 35 weeks, compared with 30 weeks for quadruplets. Complete removal of the cervix is one of the most difficult and time-consuming aspects of the cesarean hysterectomy procedure, especially if there has been substantial effacement and dilation of the cervix. Restoration of the normal fetal acid-base balance depends on the reversibility of maternal etiologic factors. Abnormalities of rhythm, valvar function, or myocardial motion may reflect important forms of fetal heart disease and may be overlooked with evaluation of only still-frame images. Postnatally, this vein may appear radiographically like a sword, or scimitar; hence, the name of the syndrome. The lower-dose, 14-day regimens for erythromycin can be used for women who are allergic to amoxicillin and azithromycin. A significant number of fetuses classified as having abnormal cardiac function would have been classified at a lower severity if the Quintero system alone had been used. These late decelerations were probably vagal reflex types caused by chemoreceptor activity. Immunization is 70% to 90% effective in either preventing influenza or diminishing the severity of illness. There is 38 Multiple Gestation: Clinical Characteristics and Management 593 A single center, 30 sets of twins were considered to have lethal conditions, because it was not feasible to separate them. Magnesium sulfate should not be used in women with myasthenia gravis, because the magnesium ion competes with calcium. Jeaggi E, Fouron J, Fournier A, et al: Ventriculoatrial time interval measured on M-mode echocardiography: a determining element in diagnosis, treatment, and prognosis of fetal supraventricular tachycardia, Heart 79:582, 1998. This type of acidosis results from protracted periods of oxygen deficiency to a degree that results in anaerobic metabolism. Summary Many potentially thrombophilic polymorphisms are being uncovered at an ever-increasing pace. Magnesium levels may be obtained to answer safety concerns, but the infusion should be reduced or stopped without waiting for drug level results if respiration or urine output declines. Although a mild anemia caused by iron deficiency during pregnancy is of little consequence to either the mother or the fetus, a similarly mild anemia caused by carcinoma of the colon has grave implications. Determination of gestational age by ultrasound measurement of fetal structures has greater accuracy than other methods when used in the first 12 to 20 weeks of pregnancy. Ovarian vein thrombosis can be recognized in patients with postoperative abdominal pain and a palpable tender mass extending from the lower quadrant into the flank, usually on the right side. In cases of suspected septal hypertrophy, the septal thickness should be measured, typically during both diastole and systole. This type of evidence has led to the conclusion that oxygen consumption per unit body weight is much less variable in prenatal than in postnatal life. Structural Anomalies About 25% of stillborns have detectable structural anomalies as fetal causes of death.

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Zalar and Quilligan294 found that the use of fetal scalp blood sampling substantially reduced the number of cesarean deliveries performed for presumed fetal distress. These efforts are often initially resisted-particularly by veteran nurses and physicians who are confident in their experience and abilities. If only maternal well-being is considered, delivery of all preeclamptic women, regardless of disease severity or gestational age, is appropriate. Tongsong T, Tongprasert F, Srisupundit K, et al: Venous Doppler studies in low-output and high-output hydrops fetalis. Because evidence documenting clear superiority of any one diagnostic test is lacking, the values and preferences of a patient and her physician should determine the final choice and sequence of tests performed. Perinatal mortality rates for brow and face presentations are higher than for vertex presentations, but the differences can be accounted for by fetal anomalies (anencephaly), prematurity, and asphyxia and trauma associated with manipulation during vaginal delivery. In addition to labor and delivery personnel, emergency department staff and primary care providers must also recognize that women who present in the third trimester with nausea, vomiting, or malaise should have a complete blood count including platelets, and liver function tests should be completed before discharge home. Therefore, if amniocentesis is performed for this finding, testing for the other potential etiologies should be considered. According to a survey of liability cases, approximately 50% of paid liability claims involve alleged misuse of oxytocin. After the lesions have become encrusted, the mother may handle and feed her infant. Blood or semen contamination, alkaline antiseptics, and bacterial vaginosis can cause false-positive nitrazine test results. National Institutes of Health Consensus Development Conference Statement, February 28-March 24, 1994: Effect of corticosteroids for fetal maturation on perinatal outcomes, Am J Obstet Gynecol 173:246, 1995. The diagnosis required visualization of intraluminal filling defects observed on two or more views, or an abrupt cutoff of contrast material. Vascular thrombosis: One or more clinical episodes of arterial, venous, or small-vessel thrombosis; any tissue or organ confirmed by objective, validated criteria. The most dangerous clinical settings are hemorrhage occurring in women who have disseminated intravascular coagulation, placental implantation abnormalities, and broad ligament or posterior uterine tears that result in internal bleeding only. The usefulness of serial laboratory tests, such as fibrinogen or platelet count, is uncertain. A, Color Doppler image of entangled umbilical cords, which is typical of monoamniotic twin pregnancy. However, if mild bleeding is present, vitamin K can be administered subcutaneously. Team members will use a checklist to assist the staff in incorporating all necessary steps before or during a procedure. Even in the presence of significant arterial abnormalities, the preservation of normal ductus venosus flow and normal biophysical variables strongly correlates with normal fetal status, allowing successful extension of the pregnancy at very preterm gestations. Cicero S, Dezeraga V, Andrade E, et al: Learning curve for sonographic examination of the fetal nasal bone at 11-14 weeks, Ultrasound Obstet Gynecol 22:135, 2003.

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This disorder is characterized by hemolytic crises, usually in response to various stimuli including sulfa drugs, aspirin, and fava beans. The condition occurs because of early first-trimester circulatory failure of one fetus in a monochorionic twin pregnancy, together with the development of arterioarterial and venovenous anastomoses between the umbilical arteries of both fetuses. More than 25% choose to undergo another elective cesarean delivery if given the chance. In a normally developing brain, choroid plexus almost fills the ventricle initially. Although randomized trials have shown that prostaglandins in general, and misoprostol specifically, result in cervical ripening as manifested in a significant increase in the Bishop pelvic score, they have not demonstrated a significant decrease in the incidence of failed induction of labor or a decrease in the risk of cesarean delivery after induction of labor in nulliparous patients. Complex biochemical and neurohormonal interactions among maternal, fetal, and placental compartments are required during normal term parturition in humans. For example, fetal pulmonary artery diameter may correlate with outcome in cases of congenital diaphragmatic hernia. In this situation, a diagnosis of placental abruption can be established on the basis of fresh macroscopic or histologic examination of the placenta. A short humerus is more strongly related to Down syndrome, with reported likelihood ratios ranging from 2. In some cases, the factors leading to membrane rupture are subacute or chronic in nature. Although deferred removal might enhance pregnancy prolongation for corticosteroid administration, the risks and benefits of this approach have not been determined. However, in others, such as cardiac defects, diaphragmatic hernias, and fetal skeletal and neurologic abnormalities, a true relationship appears likely. Vitamin B6 deficiency should be considered in women unresponsive to oral iron therapy, as vitamin B6 normally decreases in pregnancy and supplementation with B6 and iron was associated with an increase in hemoglobin. As a result of these concerns, attempts have been made to move prenatal diagnosis into the first trimester. This type of study design was successful in identifying carbamazepine therapy as a human teratogenic exposure. Five sets of twins underwent surgical separation, and, in total, six children survived, giving an overall survival rate of only 8. Warburton D, Kline J, Stein Z, et al: Does the karyotype of a spontaneous abortion predict the karyotype of a subsequent abortion Uehara S, Yaegashi N, Maeda T, et al: Risk of recurrence of fetal chromosomal aberrations: analysis of trisomy 21, trisomy 18, trisomy 13, and 45,X in 1,076 Japanese mothers, J Obstet Gynaecol Res 25:373, 1999. Despite the fact that this cohort was assembled more than 50 years ago, the low rate of obstetric intervention makes it an ideal cohort in which to study the natural history of the first stage of labor with minimal obstetric intervention that would alter the normal progression. Seventy percent of these women demonstrate grief reactions, and 84% describe the procedure as very stressful. Fourth, the mitral and tricuspid valves should be thin and delicate, with 23 Fetal Cardiac Malformations and Arrhythmias: Detection, Diagnosis, Management, and Prognosis 285 the tricuspid valve slightly larger than the mitral valve, and the valves should open symmetrically during diastole. Because it is likely that these two groups of physicians cared for different types of patients and probably had differences in clinical management, the possibility of selection bias exists. In asymptomatic patients who are without antenatal bleeding but have been identified by prenatal ultrasonography as having risk factors (placenta previa, placenta accreta, or vasa previa), timing of delivery is the most important clinical decision that has to be made. Remember that the sensitivity and specificity stay constant regardless of the disease prevalence. If the diagnosis of chorioamnionitis is suspected but additional confirmation is needed, amniocentesis may yield helpful results. Cardiomyopathies should be recognized and diagnosed, but if this fails, they should be properly evaluated at the time of autopsy. If a woman with Marfan syndrome chooses to become pregnant, therapy is directed at markedly limiting physical activity, preventing hypertensive complications, and decreasing the pulsatile forces on the aortic wall with the use of a -blocker.

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Sequential screening is believed to be more useful for groups in which the carrier frequency is lower and when obtaining a simultaneous sample from the partner is impractical. An unplanned event deemed potentially harmful that does not result in an adverse outcome. An emergent cesarean delivery occurs at an exceptionally brisk pace-rarely seen in other medical disciplines-usually in response to an acute hemorrhage, fetal bradycardia, umbilical cord prolapse, or uterine rupture. Newborns with other autosomal abnormalities, such as deletions (chromosomes 4, 5, 13, and 18) and ring chromosome structure alterations, also have had impaired fetal growth. Table 14-2 gives a numerical example of these calculations in a near-term ewe breathing atmospheric air. Cervical cytology screening for premalignant lesions of the cervix is an example of a successful screening program that fulfills all of these criteria. Vitamins C and E and the risks of preeclampsia and perinatal complications, N Engl J Med 354:1796, 2006. If a cutoff at the 95th percentile is used and 5% of all pregnancies would be offered testing, resources to accomplish this may be insufficient. Clinicians had access to oximetry data in the "open" arm and did not in the "masked" arm. Consequently, the focus of attention has been on umbilical artery flow and the venous circulation. A logical progression of diagnostic steps requires, first, that iron deficiency anemia be ruled out. Nygaard and associates,243 in a 30-year follow-up study of anal incompetence, found that the aging process was as important as obstetric events. Doppler echocardiography also allows calculation of the right ventricular pressure and the systolic pressure gradient across the valve. The underlying event in many cases of abruption is thought to be vasospasm of abnormal maternal arterioles. In one study of 448 twin gestations, this form of combined screening was estimated to be able to deliver an 88% detection rate for Down syndrome, with a 7. The increased burden to perfuse the parasitic twin puts the pump twin at risk for congestive heart failure and hydrops. Commercial syringes (1 to 2 mL) containing lyophilized heparin are also available for obtaining specimens. It should incorporate multiple variables to address both the complexity of normal fetal behavior and the individual nature of fetal compensation. Because these relapses usually occurred within 1 year, the term "early latent period" was applied to this time period. Umbilical artery Doppler in particular provides insight into the fetal aspects of placentation, reflecting placental vascular resistance. There is a possible association between these thrombophilic states and abruption, but further study is required. Rh immune globulin is administered, when appropriate, to Rh-negative, nonimmunized women. Accordingly, when testing individuals from the French-Canadian population or other populations with founder mutations, care should be taken to identify a laboratory performing analysis for the appropriate mutations. Some type of sonographic finding (major abnormality, soft marker, or both) was observed in 68. Countless other situations could be used as examples of the difficult decision that faces both physician and patient when evaluating the proper method of delivery.

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Other predictors are determined by the procedure itself, and many are interdependent. Odds ratios are also the output for most statistical packages when multivariable logistic regressions are performed. If no structural cardiac lesion is found, the pathophysiology for the development of hydrops in this situation is unclear. Twelve of the 38 live fetuses had an intrauterine transfusion, three of whom died. Traditionally, patients with acute pyelonephritis were hospitalized and treated with parenteral antimicrobial therapy, but more recent studies have demonstrated that, for women with mild to moderate disease, oral therapy on an outpatient basis is appropriate. Neonatal serum magnesium concentrations are almost identical to those of the mother. A high rate of detection of acrania or anencephaly, alobar holoprosencephaly, omphalocele, gastroschisis, megacystis, and gross limb abnormalities should be expected in the first trimester. Because of these findings, either option for monitoring the fetus during labor is acceptable for patients not considered to be at high risk. After an initial ultrasound assessment, repeated evaluation can be performed every 1 to 2 weeks to determine whether there is reaccumulation of amniotic fluid and to evaluate lung growth. Wounds involving the external anal sphincter or rectal mucosa may be repaired after the field is free of infection. Although this may be true, as suggested by studies in the ovine fetus,29 the clinical evidence to date shows considerable overlap of blood gas and pH values among test groupings and is largely based on arbitrary standards without relation to population norms. The generally downward trend in the syphilis rate was temporarily interrupted in the late 1970s and early 1980s when the rates of primary and secondary syphilis began increasing, in large part due to increases among men having sex with men. The infection is transmitted by respiratory droplets and by direct contact with vesicular lesions. Esmolol can be given intravenously if the patient first presents with severe symptoms. These changes in arterial Po2 and oxygen content do not cause any appreciable change in the uterine blood flow. Congenital leukemia may cause anemia and hydrops, and leukemic infiltration of the myocardium has also been demonstrated. B, Pulsed Doppler image of the same patient in which two separate heart rates are clearly visible within the Doppler gate. Magnesium sulfate must be given parenterally to achieve serum levels above the normal range. It is more common among women and non-Hispanic blacks, consistent with many other autoimmune conditions. The prognosis is generally good but depends on the associated cardiac and extracardiac abnormalities,193 as well as on postoperative mitral, tricuspid, and ventricular function. Glycosuria, which is common in pregnancy, favors an increase in the rate of bacterial multiplication. Elective aortic root replacement should be recommended before pregnancy if the aortic root diameter is 50 mm or greater (European authorities recommend replacement for an aortic diameter of >47 mm). Echocardiographic features in the recipient twin include ventricular hypertrophy and dilation, tricuspid regurgitation, and cardiac failure. The application of principles of patient safety to outpatient settings is just beginning. The uterus is reinverted with gentle but firm and persistent pressure applied on the fundus to elevate it into the vagina. If the second twin is in a transverse lie or a footling breech presentation, or if fetal testing is not reassuring, membranes should be left intact until the feet can be secured in the pelvis, after which immediate amniotomy and total breech extraction should be performed. Poor prognostic factors include tumor size, polyhydramnios, cardiac failure, and location close to the umbilical cord insertion. First, because more than half of preterm infants are born to women without apparent risk factors,142,343 prematurity prevention must be part of prenatal care for every woman. If the data about effacement and dilation of the cervix and station and position of the presenting part are recorded only in narrative form, early and significant abnormalities of labor may not be recognized as soon as they would be if a more visual display of labor progress were available.

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McBrien A, Sands A, Craig B, et al: Major congenital heart disease: antenatal detection, patient characteristics and outcomes. Ampicillin and first-generation cephalosporins were equally effective in reducing puerperal endometritis. Kestila M, Lenkkeri U, Mannikko M, et al: Positionally cloned gene for a novel glomerular protein: nephrin is mutated in congenital nephrotic syndrome, Mol Cell 1:575, 1998. It is reabsorbed in the proximal tubule by a process limited by transport maximum (Tmax), and its excretion increases as the filtered load increases above the Tmax. Color flow imaging may demonstrate such anomalously draining right-sided pulmonary venous return. Mothers who were treated for syphilis during pregnancy with nonpenicillin regimens 4. A lowered risk of coronary events with higher weight at 3 months was noted, but no analysis was presented of weight gain in the earliest weeks of life (see earlier discussion), although graphic representation suggested a rapid growth trajectory during the first few weeks in those who had coronary events. A normal velocimetry result in a small fetus is usually indicative of a constitutionally small but otherwise normal baby,153 although a normal finding may also be observed in the chromosomally or structurally abnormal fetus. Renal failure with a marked rise in serum creatinine concentration by 1 mg/dL over baseline or urine output less than 0. If the needle is in the umbilical vein, microbubbles can be seen moving toward the fetus. To identify cases complicated by adverse outcomes and system weaknesses, the nurse may review various sources of information, such as anonymous event reporting systems (see next paragraphs) and labor and neonatal logs, which often contain Apgar scores and comments or concerns. Markedlydilatedureter(*)butnormalappearing bladder (Bl), as seen with ureterovesical junction obstruction. In one recently reported case, fetal anemia was also present, and transfusion was used as part of the ultimately successful therapy. Softening and shortening are the features of the digital examination that most strongly correlate with preterm delivery. Recent improvements in the resolution of ultrasound and increasing experience with first-trimester cardiac scanning suggest that major cardiac defects could be identified by the end of the first trimester. Prevention Both secondary and tertiary prevention strategies are critical to prevent acute pyelonephritis during pregnancy. Anencephaly is a lethal anomaly, with approximately 75% of fetuses being stillborn. The incidence is estimated to occur in 1% of monozygotic twin pregnancies, with a birth estimate of approximately 1 in 35,000 births. Sensitivity and specificity are independent of disease frequency, and they describe the anticipated performance of a screening test in the population. At the other end of the spectrum, an extrinsic insult occurring later in pregnancy, usually characterized by inadequate fetal nutrition due to placental insufficiency, is more likely to result in asymmetric growth restriction. Postoperatively, the patient is treated in the intensive care unit and given aggressive tocolysis with magnesium sulfate and, if required, additional agents. In the case of mechanical valve prostheses, warfarin appears to be superior to heparin in preventing valvular thrombosis. Correlations with antepartum umbilical venous pH, Am J Obstet Gynecol 169:755, 1993. However, use of a vaginal swab has been shown to have equivalent or better sensitivity and specificity and is better accepted by patients, especially when patient-obtained specimens are used.