Controlled prospective study of postpartum mood disorders: psychological, environmental, and hormonal variables

Demographic, psychiatric, social, cognitive, and life stress variables were used to determine the etiology of depression in childbearing (CB; n = 182) and nonchildbearing (NCB; n = 179) women. Hormonal variables in postpartum depression were also evaluated. In the CB group predictors of depression diagnosis were previous depression, depression during pregnancy, and a Vulnerability (V) x Life Stress (LS) interaction; predictors of depressive symptomatology were previous depression, depressive symptoms during pregnancy, life events, and V x LS. Only estradiol was associated with postpartum depression diagnosis. In the NCB group V X LS was the only predictor of depression diagnosis; depressive symptoms during pregnancy and life events were predictors of depressive symptomatology. Previous findings about depression vulnerability were replicated. The significant V x LS interactions support the vulnerability-stress model of postpartum depression.

Neuroophthalmologic effects of intravenous magnesium sulfate

To test the hypothesis that visual disturbances are more common during intravenous magnesium sulfate administration than at 1 to 4 days after discontinuation of the drug, 13 women underwent bedside neuroophthalmologic examinations during intravenous magnesium sulfate tocolysis at 2.0 to 3.0 gm hr and again at 1 to 4 days after cessation of therapy. Visual symptoms were common during intravenous magnesium sulfate administration. Blurred vision was present in 12 of 13 patients and diplopia was present in 10 of 13 patients. Abnormal findings during neuroophthalmologic examination occurred in all patients during intravenous magnesium sulfate administration. Findings included ptosis, accommodative and convergence insufficiency, and abnormal pupillary responsiveness to light and near. All patients were symptom-free and had normal examinations after magnesium sulfate was discontinued. These findings suggest that visual disturbances with therapeutic magnesium sulfate are common.

Relationship of admissions for false labor to perinatal outcome

While false labor is a common clinical problem, little information exists for correlating hospital visits (for false labor) with the subsequent labor course or perinatal outcome. We evaluated the obstetric and perinatal outcomes in 112 consecutive patients with one or more hospital visits for false labor and compared them with those in matched controls. The only statistically significant difference was the incidence of oxytocin induction following premature rupture of the membranes in the false-labor group (16 vs. 6, chi 2 = 5.05, P less than .05). This study suggests that a previous false-labor admission does not increase the risk of a labor abnormality or suboptimum perinatal outcome.

Amaurosis fugax associated with antiphospholipid antibodies

In more than 50% of amaurosis fugax patients under 45 years of age no cause for the episodes of visual loss is identifiable. We have encountered 6 young adults (4 women and 2 men) with episodes of amaurosis fugax associated with elevated levels of antiphospholipid antibodies. Splinter hemorrhages of the nail beds were present in most patients. Treatment with antiplatelet medications and anticoagulants appeared to reduce the frequency of episodes and might prevent central retinal artery occlusions or stroke.

Maternal orbital hematoma associated with labor

We examined two women with orbital hematomas that occurred during labor. Both women developed sudden diplopia, proptosis, and orbital pain. The location of the hematoma was confirmed by orbital echography and computed tomography. The patients were observed without surgical intervention. Neither patient developed clinical or echographic signs of compressive optic neuropathy. Clinical resolution occurred during the following two weeks. Serial standardized orbital echographic examinations documented resolution of the hematomas.

Origin of deoxycorticosterone and deoxycorticosterone sulfate in human pregnancy: absence of steroid 21-sulfatase activity in sulfatase-deficient placenta

The activity of steroid 21-sulfatase, the enzyme that catalyzes the hydrolysis of deoxycorticosterone sulfate (DOC-SO4) is demonstrable in human placenta. Thus, it is possible that this placental enzyme, by way of the hydrolysis of either DOC-SO4 or 21-hydroxypregnenolone mono- or di-sulfate of fetal origin, may be important in the biosynthesis of DOC, which is present in the plasma of pregnant women in high concentration. To investigate this issue further, we evaluated steroid 21-sulfatase activity in microsomal preparations of a sulfatase-deficient placenta. Immediately after delivery, at term, of a living male fetus with sulfatase deficiency, a microsome-enriched fraction of placental tissue was prepared; sulfatase activity was evaluated by use of three substrates, viz. dehydroisoandrosterone sulfate (DS), estrone sulfate (E1-SO4), and DOC-SO4, in various concentrations. Similar incubations were conducted with aliquots of a microsome-enriched fraction prepared from placental tissue of a normal fetus that was delivered, at term, within minutes of the time of delivery of the infant with sulfatase deficiency. In microsomal fractions from the normal placenta, each of the steroid sulfates was hydrolyzed. In the absence of microsomes, and in the presence of microsomal fractions from the sulfatase-deficient placenta, the hydrolysis of DOC-SO4 and DS was not detected. Moreover, in microsomes prepared from the sulfatase-deficient placenta, E1-SO4 was hydrolyzed at a rate that was only 10% of that in incubations with microsomal preparations of the normal placenta. We conclude that with sulfatase deficiency, the placenta is deficient not only in sulfatase activity for steroid-3-sulfates but for steroid 21-sulfates, e.g. DOC-SO4, as well.

Cranial magnetic resonance imaging in eclampsia

Although the precise neuropathologic basis for eclamptic convulsions remains unclear, intracranial hemorrhage is frequently associated with fatal cases. Magnetic resonance imaging (MRI) is a recently developed neuroimaging technique that appears superior to other processes for defining intracranial anatomy and pathophysiology. This technique has not yet been reported in eclampsia. The authors performed serial MRIs on an eclamptic woman, with findings compatible with previously described neuropathologic changes.

Maternal obesity and pregnancy

We examined the risk of maternal obesity in 588 pregnant women weighing at least 113.6 kilograms (250 pounds) during pregnancy. Compared with a control group matched for age and parity, we found a significantly increased risk in the obese patient for gestational diabetes, hypertension, therapeutic induction, prolonged second stage of labor, oxytocin stimulation of labor, shoulder dystocia, infants weighing more than 4,000 grams and delivery after 42 weeks gestation. Certain operative complications were also more common in obese women undergoing cesarean section including estimated blood loss of more than 1,000 milliliters, operating time of more than two hours and wound infection postoperatively. These differences remained significant after controlling for appropriate confounding variables. We conclude that maternal obesity should be considered a high risk factor.

Abnormal pregnancy sonogram: selective indication for fetal karyotype

The inability to make a definitive diagnosis in the fetus with a sonographically identified abnormality often results in parental and physician uncertainty. An antenatal chromosome evaluation could resolve this uncertainty. Forty-one fetuses with an abnormal ultrasound examination were tested for karyotypic abnormality using a variety of specimens. Nearly one-third (13 of 41) of these fetuses had various chromosome abnormalities. There were only seven survivors in this series, underscoring the often poor prognosis when a significant ultrasound defect is detected antenatally. Knowledge of the fetal chromosome constitution in the setting of an abnormal ultrasound has important epidemiologic, cost-benefit, counseling, and pregnancy management implications.

Pregnancy in a patient with a history of myocardial infarction and coronary artery bypass grafting

A 37-year-old woman conceived after experiencing a myocardial infarction and undergoing three-vessel aortocoronary artery bypass grafting. Pregnancy was complicated by angina, which was successfully treated with propranolol and bed rest. At term the patient underwent vaginal delivery, without evidence of intrapartum myocardial ischemia or failure.

Comparison of cefotetan and cefoxitin as prophylaxis in cesarean section

A study comparing the efficacy of cefotetan versus cefoxitin for prophylaxis in patients undergoing cesarean section was carried out at the University of Iowa. After institutional review, 36 subjects who met the study criteria and agreed to participate were entered into the study; of these, 29 were evaluable for efficacy. Twenty subjects received a single 2 gm dose of cefotetan, and nine subjects received three 2 gm doses each of cefoxitin. Both antibiotics were administered intravenously at the time the umbilical cord was clamped. The subsequent doses of cefoxitin were given intravenously at four and eight hours after the initial dose. Clinical and bacteriologic responses were evaluated; there were no statistically significant differences between the two groups, and both antibiotics provided effective prophylaxis against infection. It appears that cefotetan is a satisfactory antibiotic choice for cesarean section prophylaxis. Further, in this small study it appears that a single dose of cefotetan is as effective as three doses of cefoxitin. This implies that cefotetan would not only decrease administration time and supplies but would decrease the cost to the patient while maintaining very acceptable infection rates.

Reduction in amniocentesis risks using a real-time needle guide procedure

Rates of complications associated with a second trimester genetic amniocentesis were studied in 918 patients, and complete infant follow-up was obtained. In 903 singleton pregnancies and 15 twin gestations, the procedure was performed under continuous sector scanning guidance through an attached needle guide. Eight fetal deaths in the 903 cases occurred at less than 28 weeks after amniocentesis (0.89%), none within two weeks after the procedure. Only one fluid was visibly blood contaminated. Comparisons are made with other series from the literature.

Ultrastructural alterations of term human amnionic epithelium following incubation with group B beta-hemolytic streptococci

The association between the group B beta-hemolytic streptococcus (GBBHS) and premature labor, premature rupture of the membranes, and chorioamnionitis with intact membranes is well known. However, the mechanisms involved in this association remain unclear. In this study we incubated term chorioamniotic membranes from patients undergoing elective repeat cesarean section in double-armed incubation vessels that isolated the maternal from the fetal surfaces. The GBBHS was placed adjacent to the maternal surface and incubated for 2, 4, 8, 12, and 24 hr. Control membrane specimens from the same patient were incubated under identical conditions for identical time periods but without the presence of GBBHS. Examination of the specimens by transmission electron microscopy revealed progressive nuclear and basement membrane alteration in the study group that was maximal at 12 hr. There was also a progressive decrease in desmosome counts in the study membranes. These in vitro changes support the in vivo association of GBBHS with the aforementioned obstetric complications.

Triplet gestation: maternal and neonatal implications

Triplet pregnancy of over 20 weeks gestation occurred 20 times during 75,506 deliveries at a referral hospital. Commonly occurring maternal complications included premature delivery (75%), antepartum anemia (35%), postpartum hemorrhage (35%), preeclampsia (20%), and premature spontaneous rupture of the membranes (20%). Malpresentation was common. Neonatal complications were also common and included respiratory distress syndrome (45%), presumptive sepsis (36.6%), hyperbilirubinemia (33%), and neonatal death (21.6%). These high complication rates emphasize the importance of early identification and referral center care for these vulnerable pregnancies.

Premature rupture of the membranes and barometric pressure changes

Barometric pressure changes are thought to possibly affect premature rupture of the membranes. One hundred nine patients with this obstetric complication lived within an area small enough to be subject to the same barometric pressure changes; onset of labor was used as a comparison point in 109 control patients. The two groups did not differ when demographic data were compared. There were no differences in other obstetric complications or neonatal outcome. There was a significant increase, however, in premature membrane rupture within three hours after a fall in barometric pressure. No such increase in the onset of labor was seen in the control group.

Pseudotumor cerebri and pregnancy

Pseudotumor cerebri (PTC) is most commonly seen in obese women of reproductive age. We studied 109 women with PTC between ages 16 and 44 years. In 11, PTC started during pregnancy. Thirteen women with previous diagnosis of PTC, including two of the aforementioned 11, had an additional 17 documented pregnancies. Patients were matched by age and parity with controls. Obstetric complications occurred more frequently in the controls. Visual loss occurred with the same frequency in pregnant and nonpregnant patients. Treatment of PTC patients in pregnancy should be the same as for nonpregnant PTC patients, except that calorie restriction and diuretic use are contraindicated. Obstetric management is no different from that of normal pregnancy.

Bacterial attachment to the chorioamniotic membranes

Intra-amniotic infections are believed to result from bacteria of cervical and vaginal origin which gain access to the amniotic sac. The logical sequence in this process would be bacterial attachment to the maternal surface, followed by migration through the chorioamniotic membranes to the fetal surface. Fresh sterile chorioamniotic membranes were interposed between two arms of specially constructed incubation vessels. Bacteria (Escherichia coli, group B streptococci, or Neisseria gonorrhoeae) were inoculated into the arm (containing a basal salt medium) contiguous with the maternal surface. The arm contiguous with the fetal surface of the membrane contained pseudoamniotic fluid. At intervals up to 24 hours after inoculation, the membranes were removed, washed, fixed in glutaraldehyde, and examined by means of scanning and transmission electron microscopes. The ability of group B streptococci and E. coli to attach to and invade the chorioamniotic membranes was demonstrated by this technique. It appeared that group B streptococci had a greater capacity to attach and invade than did E. coli, whereas N. gonorrhoeae predictably failed to attach.

Multiple gestation: time interval between delivery of the first and second twins

A clinical investigation was undertaken to challenge the commonly accepted view that the interval between the birth of the first and second twins should be preferably within 15 minutes and certainly no more than 30 minutes. During 1981 and 1982, 115 patients with live-born twins at 34 or more weeks' gestation underwent an attempted vaginal delivery at four regional perinatal centers. The interval between vaginal delivery of the first and second twins (mean, 21 minutes, range, one to 134 minutes) was 15 minutes or less in 70 (61%) cases and more than 15 minutes in 45 (39%) cases. Excluding conditions associated primarily with prematurity, all second twins delivered beyond 15 minutes did well despite the delay and had no signs of excess trauma or low five-minute Apgar scores. Maternal complications were also uncommon, although combined vaginal-abdominal delivery was more frequent if there was a delay of more than 15 minutes (eight of 45 versus two of 70, P less than .02). The authors conclude that if there is continuous fetal and uterine monitoring, a time restriction for the delivery interval between the first and second infants is not necessary.

Decidual, amniotic fluid, maternal and fetal prolactin in normal and abnormal pregnancies

In the present studies, the content and the in vitro production of prolactin by decidua as well as the concentrations of prolactin in amniotic fluid, maternal and fetal serum in normal term pregnancies, induced abortions at various gestational ages, and in pregnancies complicated by diabetes mellitus, preeclampsia, chronic hypertension, and polyhydramnios were measured. Maternal and fetal prolactin levels varied considerably throughout gestation, but at term did not differ significantly between normal and abnormal pregnancies. Prolactin levels in amniotic fluid as well as decidual prolactin content and production were significantly lower only in pregnancies complicated by either hypertension or polyhydramnios. In both normal and abnormal pregnancies, decidual prolactin production correlated strongly with amniotic fluid concentrations. The present data suggest that 1) maternal and fetal prolactin levels do not differ significantly between normal and abnormal pregnancies, 2) the decidua is the principal source of amniotic fluid prolactin, and 3) the significantly lower levels of prolactin in amniotic fluid of pregnancies complicated by hypertension or polyhydramnios are probably due to adverse effects of these conditions on the synthesis and release of prolactin by decidua.