diueasc can be exacerbated on infrequent occasions 1~) cryotherapy. With all relatively new surgical procedures that are performed, complications are more likely to be noted as the number of patients increase. The reported case would not have occurred if the patient had not jerked back as a result of a loud noise emitted when the rubber tubing became obstructed and ruptured because of increased carbon dioxide pressure. It was a freak circumstance, to be sure, but one that could occur again under similar conditions. All women undergoing cryosurgery should be warned about abnormal sounds. It is my opinion that extremely apprehensive patients should be sedated prior to the cryosurgery procedure. This case epitomizes the statement, “When one deals with human beings, no surgical procedure can be considered minor or felt to be of an innocuous nature.”
Ostergard, D. R., Townsend, D. E., and Hirose, F. M.: AM. J. OBSTET. GYNECOL. 102: 426, 1968. Kaufman, R. H., Strama, T., Norton, P. K., Conner, J. S., et al.: J. Obstet. Gynecol. 42: 881, 1973. Miller, J. F., and Elstein, M.: J. Obstet. Gynaecol. Br. Commonw. 80: 658, 1973.
Unforeseen sudden intrapartum death in a monitored labor ROBERT MURRAY
H. HAYASHI, E. FOX, M.D.
Department of Obstetrics School, The University Center at San Antonio,
and Gynecology, Medical Texas Health Science San Antonio, Texas
c L I N ICAI. EX PERIE N c E has supported the association between ominous fetal heart rate (FHR) patterns such as late decelerations, severe variable decelerations, a rising base line, or a prolonged deceleration and the occurrence of subsequent neonatal depression or even intrapartum fetal death. The absence of an ominous FHR pattern is generally predictive of a good fetal outcome.‘, 2 This report documents an unexpected sudden intrapartum fetal death in the absence of an ominous FHR pattern. Schifrin and Dame2 stated that “. . not a single case of unexpected fetal death has been documented in a monitored fetus,” although Paula subsequently noted the unexpected intrapartum death of a fetus with cardiac arrhythmia ten minutes before fetal death. Reprint requests: Dr. Robert H. Hayashi, Department of Obstetrics and Gynecology, The University of Texas Health Science Center at San Antonio, San Antonio, Texas 78284.
Hours After Fig. 1. Sequence
An 18-year-old para 0 patient in the forty-second gestational week was admitted in early labor. The prenatal course was without problems. Admission data base revealed a weight of 234 pounds, blood pressure, 150/80: l+ pretibial edema; and no proteinuria or hyperreflexia. The term fetus was in cephalic presentation at station -1 with the cervix 4 cm. dilated and fully effaced. The pelvis was normal by clinical and radiologic examination. Three and a half hours after admission, membranes were artificially ruptured to correct the hypocontractile dysfunctional labor (Fig. 1) Thick meconium in the amniotic fluid was noted. A monitor* was applied for recording intrauterine pressure and FHR.t No ominous FHR patterns and labor was allowed to were observed (Fig. 2A). continue. Five and a half hours after admission, oxytocin infusion was begun to correct the hypocontractile dysfunctional labor. After an hour of increasing oxytocin dosage, a period of polysystole and elevated base-line tone at 4 mu. per minute necessitated lowering the oxytocin dosage. The FHR pattern remained unchanged throughout this episode (Fig. 2B). A normal labor contraction pattern was established with minor dosage adjustments. Progressive cervical dilatation occurred without any change in FHR pattern or descent of the presenting part which was in the right occipitoposterior position (Fig. 2C). Ten and a half hours after admission, at 8 to 9 cm. dilatation, the FHR suddenly dropped from 1.50 to 86 beats per minute (Fig. 2D). Vaginal examination revealed a scalp electrode properly placed and the absence of a palpable prolapsed cord. A second electrode was placed which revealed an identical rate which was synchronous with the maternal pulse. This phenomenon of recording *Hewlett-Packard California, 94304. tFeta1 scalp spiral tems, Inc., 2 Barnes Connecticut 06492.
Corometrics Park Rd.,
Fig. 2C. Monitor
Fig. 2D. Monitor
maternal cardiac activity through the scalp electrode attached to a dead fetus has been documented.41 s A search for the fetal heart tones with ultrasound* was unsuccessful. The patient was delivered of a fresh 3,374 gram female stillborn infant through the vagina 16 hours after admission. There were no visible abnormalities of the fetus, cord, or placenta. Postmortem examination revealed only anoxic damage to the brain. Since there was no ominous FHR pattern, vaginal delivery was accomplished despite the presence of thick meconium in the amniotic fluid. This reassurance led us to ignore the lack of FHR response during the period of hypertonus and polysystole. Furthermore, we did not feel that a fetal scalp pH evaluation was necessary. A retrospective analysis of the monitored tracings revealed that there was a short-term, beat-to-beat variation, but there was a conspicuous absence of long-term, periodic variation, even during an episode of hypertonus and polysystole. The question is raised as to the significance of this lack of long-term variation in this monitored fetus. Hammacher and colleagues” described a periodic or continuing narrowed undulatory oscillation pattern between 5 and 10 beats per minute as a frequent indication of placental insufficiency. They suggested that the infrequent combination of that pattern with late deceleration is the result of inhibited or reduced adaptability of that fetal heart to stress. One of the six fetuses in their report which died in utero had such a pattern with a normal FHR. That fetus had severe erythroblastosis. Perhaps the initial insult leading to thick meconium in the amniotic fluid in our patient severely reduced the fetal cardiac adaptability; yet there was no progressive decrease in the oscillation pattern or FHR before death. This patient is presented as an example of sudden, unexpected intrauterine fetal death in a monitored labor occurring without antecedent classical changes in FHR *Doptone,
or its patterns, celerations.
1. Hon, E. H.: AM. J. OBSTET. GYNECOL. 118: 428, 1974. 2. Schifrln, B. S., and Dame, L.: J. A. M. A. 219: 1322, 1972. 3. Paul, R. H.: AM. OBSTET. GYNECOL. 113: 573, 1972. 4. Hammacher, K.: Int. J. Gynaecol. Obstet. 10: 173,
1972. 5. Timor-Tritsch, 6.
Brandes, J. M.: Hammacher, K., Werners, P. H.:
Gergely, Z., Abramovici, H., and Obstet. Gynecol. 43: 713, 1974. Huter, K. A., Bokelmann, J., and Gynaecologia 166: 349, 1968.
Obstetrics and Hospital, Allentown,
N E 0 N A T A L P E R F 0 R A T I 0 N of the colon is a rare and serious problem, and its etiology is still uncertain. The obstetric literature contains no reports of such a case, despite the fact that the obstetrician can give invaluable assistance in suspecting this complication for early diagnosis and intervention. We are reporting a case of premature labor which resulted in a neonate with this disease. The mother had chorioamnionitis; her pregnancy occurred and continued with an intrauterine contraceptive device (IUD) in situ. We suggest that the etiology of perforation of the colon in a fetus or neonate is the result of an infected intrauterine environment. The route of inReprint requests: Dr. F. Obstetrics and Gynecology, Rural Ave., Williamsport,
M. Georgy, Williamsport Pennsylvania
Department Hospital, 17701.