Anemia as a sign of abdominal pregnancy

Advanced abdominal pregnancy is an ominous occurrence. The diagnosis is usually made when the physician considers this possibility as the answer to a puzzling obstetric problem. Marked, unexplained anemia, associated with unusual second- and third-trimester signs and symptoms, should warn the physician of the possibility of a near-term abdominal pregnancy.

Calcium metabolism in the hypertensive mother, fetus, and newborn infant

Calcium metabolism in otherwise uncomplicated term pregnancies associated with essential hypertension is characterized by significantly reduced levels of parathyroid hormone and ionized calcium, as well as significantly increased levels of phosphorus in both the mother and fetus. It is not possible at this time to delineate with certainty the precise pathophysiology of these changes.

Efficacy of home glucose monitoring in diabetic pregnancy

A randomized, prospective study was performed to evaluate the efficacy of daily home glucose monitoring on the outcome of pregnancies in women with insulin-dependent diabetes mellitus. Home glucose monitoring was compared with a weekly venipuncture protocol. No differences were observed between groups in clinical features (age, parity, White's classification) or representative delivery outcomes (method of delivery, weeks' gestation, or weight at birth). No statistically significant differences were observed between the groups in several aspects of perinatal morbidity. However, home glucose monitoring was associated with fewer readmissions for diabetic control (p = 0.05), fewer days in the hospital (p less than 0.01), and decreased total patient expense (p less than 0.05).

Midtrimester amniocentesis. An analysis of 923 cases with neonatal follow-up

Maternal, fetal, and neonatal results and complications were analyzed after 923 genetic amniocenteses. Maternal age of 35 years and beyond was associated with a 2.0% risk of fetal trisomy 21 and a 3.0% risk of all major chromosome abnormalities. Comparable rates for women aged 40 and beyond were 4.8% and 7.2%. Neural tube defects were detected in 0.15% of procedures done for maternal age and 3.4% of those done for a previous involved child. The risk of spontaneous abortion as a result of amniocentesis was 0.2% to 1.4%. Mahogany or green fluid was associated with a 29% rate of fetal loss. Unexplained midtrimester elevations of maternal serum alpha-fetoprotein were associated with a 38% risk of a subsequent low-birth weight infant. The only neonatal complication associated with amniocentesis was an apparent marked increase in the incidence of lower-extremity orthopedic abnormalities.

Endotoxin enhancement as a possible etiology of early-onset group B beta-hemolytic streptococcal sepsis in the newborn

Group B streptococcal cells, either viable or heat-killed, contain a substance that induced fever in rabbits with maximal responses occurring four hours after intravenous injection. In contrast, supernatant fluids failed to induce significant fever. Group B streptococcal cells also enhanced host susceptibility to lethal shock by endotoxin as much as 40,000-fold. A graph of log streptococcal cell dose used for pretreatment versus log LD50 endotoxin gave a straight line with a slope of approximately -1. Rabbits that received both streptococcal cells and endotoxin showed initial fever followed by hypothermia, labored breathing, watery diarrhea, evidence of vascular collapse, and finally death. Animals that received streptococcal cells or endotoxin alone showed only fevers and mild diarrhea. A possible theory for the cause of death in the neonate infected with group B streptococci is presented.

Pregnancy in patients with systemic lupus erythematosus

This retrospective study of 31 patients with systemic lupus erythematosus during 38 pregnancies shows a spontaneous or missed abortion rate of 7.9%, elective abortion rate of 10.5%, and a perinatal mortality rate of 12.9%. There was one maternal death 5 weeks post partum. If the onset of systemic lupus erythematosus during pregnancy included nephritis or significant thrombocytopenia, the mothers were acutely ill. All of the perinatal mortality occurred in these patients. Management of systemic lupus erythematosus during pregnancy need not differ from that in the nonpregnant state. However, immunosuppressive therapy should not be diminished or discontinued during pregnancy. Clinical parameters, renal function studies, and hematologic information were far more useful than immunologic laboratory data in assessing the course of systemic lupus erythematosus during pregnancy and indicating alterations in treatment. Antepartum fetal surveillance is advised. The timing of and route of delivery must be individualized, and systemic lupus erythematosus in and of itself is not an indication for delivery by cesarean section.

Calcium metabolism in diabetic mother, fetus, and newborn infant

Peripheral blood levels of the minerals and hormones involved in calcium homeostasis were measured in insulin-dependent diabetic patients at delivery, and in umbilical arterial and venous blood. The minerals were also measured in neonatal blood at 24 hours of age. Insulin-dependent diabetic patients at delivery have depressed serum levels of parathyroid hormone, although serum total and ionized calcium levels are not different from those of nondiabetic patients. Fetuses of diabetic mothers are hypocalcemic and have reduced parathyroid hormone levels. Infants of diabetic mothers demonstrate early neonatal hypocalcemia. No differences between diabetic and control patients could be demonstrated in terms of calcitonin or phosphorus levels, in either mother, fetus, or neonate.

Diagnosis of maternal cystic fibrosis during pregnancy

The third and fourth cases of maternal cystic fibrosis diagnosed during pregnancy are presented. Quantitative pilocarpine iontophoresis (sweat chlorides) must be performed to establish the diagnosis. Other important findings include recurrent or persistent respiratory symptoms, chest x-ray abnormalities, abnormal pulmonary function studies, and abnormal arterial blood gases. Gastrointestinal tract dysfunction and a positive family history for respiratory disease also suggest the diagnosis. Pregnant patients with cystic fibrosis require careful and frequent cardiopulmonary and gastrointestinal surveillance. A higher incidence of premature labor is noted and all patients are best managed in tertiary referral centers. Patients should also be monitored carefully during the puerperium because maternal pulmonary decompensation may occur during this time.

Maternal mortality in a major referral hospital, 1926 to 1980

This review describes the changes in the causes of maternal deaths in a major referral hospital over a span of 55 years. There has been a significant decline in direct maternal deaths from infection, hemorrhage, and toxemia. Continued vigilance is needed since 58% of direct obstetric deaths in our hospital during the last 30 years were considered to have been preventable. Heart disease and nonobstetric infection as indirect causes of maternal deaths have decreased also. Greater effort is necessary to identify those patients with conditions that predispose to indirect deaths and to provide appropriate contraception, sterilization, early pregnancy termination, or optimal multidisciplinary care in a referral hospital.

A prospective evaluation of X-ray pelvimetry

One hundred four consecutive patients undergoing x-ray pelvimetry were analyzed prospectively in an attempt to evaluate the efficacy of this procedure. Comparison was made between prepelvimetry and post-pelvimetry clinical management plans. Roentgenographic pelvic measurements led to prompt and significant alterations in clinical management plans in only one of 67 patients with vertex presentation and one of 37 with breech presentation. In 98% of patients, no change in immediate clinical management plan was made on the basis of x-ray pelvimetry findings.

Conservative management of premature rupture of the membrane

Management recommendations for pregnancies complicated by premature rupture of the membranes must consider both the neonatal morbidity and mortality of immaturity associated with prompt delivery and the infectious risks to the mother and fetus associated with prolonged observation. Because these considerations are critical in pregnancies with prematurely ruptured membranes and premature but potentially viable infants, 116 pregnancies with this complication between 28 and 36 weeks' gestation were reviewed. All patients received careful in-hospital surveillance. Six patients (5.2%) developed amnionitis prior to labor. Nine infants (7.1%) developed neonatal sepsis, with the predominant pathogen being the group B beta-hemolytic streptococcus. A decrease in the incidence of respiratory distress syndrome (RDS) and patent ductus arteriosus (PDA) with progressive duration of membrane rupture was observed. The perinatal survival in this study was 96.9%. These findings suggest that in similar patient populations an expectant management plan may be employed with minimal infectious risks to mother and fetus.

X-ray pelvimetry in clinical obstetrics

X-ray pelvimetry has been used in obstetrics for over 80 years, but its clinical usefulness remains uncertain. Review of 101 consecutive x-ray pelvimetries obtained by Brown's modification of the Colcher-Sussman technique demonstrated the anteroposterior measurements to be of no value in predicting the eventual method of delivery. However, a transverse of the inlet of less than 13.0 cm and a transverse of the midpelvis of less than 10.0 cm were each associated with an increased frequency of operative delivery. In 94 cases no new information was obtained by x-ray pelvimetry; in the other 7 patients the information obtained was equally accessible by either ultrasonography or abdominal scout film. The authors conclude that x-ray pelvimetry by the technique used in their institution has very limited usefulness in clinical obstetrics.

hPL: physiologic and pathophysiologic observations

Serum human placental lactogen (hPL) levels were studied in 806 women in late pregnancy. The hPL levels were positively correlated with birth weight but were unrelated to maternal age, parity, socioeconomic status, or the sex of the newborn. The hPL levels peaked at 37 weeks' gestation and then declined moderately. An individual's hPL levels in late pregnancy are quite constant week to week. Patients with severe chronic hypertension have low hPL values; those carrying twins have high values.