Amniotic fluid catecholamines and metabolites in intrauterine growth retardation

Simultaneous determinations of amniotic fluid levels of the catecholamines dopamine (DA), norepinephrine (NE), and epinephrine (E), and the intraneuronal metabolites of DA, 3,4-dihydroxyphenylacetic acid (DOPAC) and NE, 3,4-dihydroxyphenylglycol (DOPEG), were made, by radioenzymatic assay, in pregnancies resulting in growth-retarded (n = 14) and normal (n = 63) infants. Significant elevations in the mean concentration of NE (p less than 0.000005), E (p less than 0.005), and DOPEG (p less than 0.000001) as well as a significant decrease in the mean concentration of DOPAC (p less than 0.000001) were found in pregnancies resulting in growth-retarded infants as compared to pregnancies resulting in normal infants. Amniotic fluid DOPEG levels were found to be the most discriminative. As amniotic fluid catecholamines are predominantly of fetal origin, these findings suggest that an increase in adrenergic activity and a decrease in dopaminergic activity occur in intrauterine growth retardation as a response to chronic stress.

Double-blind comparison of intravenously injected butorphanol and meperidine in parturients

One hundred women with moderate-to-very-severe prepartum pain participated in a double-blind study of intravenously injected butorphanol and meperidine that compared the analgesic properties, effect on the process of labor, condition of the newborn and the incidence of side effects associated with the two drugs. Cervical dilation, infant birth weight and Apgar scores were not significantly different between the test groups. The mean fetal heart rate for the butorphanol group was significantly faster than that of the meperidine group. Butorphanol provided significantly more analgesia than meperidine at 30 minutes and one hour after administration, based on pain intensity and pain relief scores. Some side effects, including sedation, dizziness, lightheadedness, nausea, vomiting and pain at the injection site, were reported for both drugs.

The conservative aggressive management of placenta previa

One hundred and seventy-three cases of placenta previa managed at the Women's Hospital of Los Angeles County-University of Southern California Medical Center from July, 1975, through June, 1978, were reviewed and compared to a similar series of cases studied in the same institution in 1969. The perinatal mortality of 12.6% was roughly one half of that in the earlier study. The fetal death rate did not change significantly, but the neonatal mortality was markedly less, especially in the 27-to-32-week range. Expectant management was employed in 65.8% of patients, as compared to 42.6% in 1969. The higher rate of expectant management was characterized by the aggressive use of antepartum transfusions in the face of moderate-to-severe bleeding in lieu of delivery, as well as the occasional use of tocolytic agents for inhibition of premature labor in the presence of vaginal bleeding. Elective termination of pregnancy utilizing the lecithin/sphingomyelin (L/S) ratio for determination of pulmonary maturation also resulted in significantly less overall neonatal morbidity and mortality. These multiple factors appear to have contributed to a dramatic reduction in the perinatal mortality associated with placenta previa.

The randomized management of term frank breech presentation: a study of 208 cases

A prospective study of 208 women in labor at term with singleton fetuses in a frank breech presentation was carried out. One hundred fifteen patients were randomized to a vaginal delivery group and 93 to an elective cesarean section group. Of the 93 women scheduled for cesarean section, 88 were delivered according to protocol. Five women progressed rapidly in labor and were delivered vaginally without complications. Of the 115 women scheduled for vaginal delivery, x-ray pelvimetry was obtained on 112. Three women were delivered vaginally without incident before x-ray pelvimetry could be obtained. One of these women was delivered of an infant who died shortly after birth of lethal congenital anomalies. Of the 112 women with x-ray pelvimetry, 52 had one or more inadequate pelvic measurements and were scheduled for indicated cesarean section. Three women, however, were delivered vaginally without incident before operation could be performed. Of the remaining 60 patients in this group, 49 were delivered vaginally without a perinatal death. Eleven women required cesarean section for difficulties during labor. There were no maternal deaths, but 73 (49.3%) of the 148 women who were delivered by cesarean section in this study experienced postpartum morbidity. Only four (6.7%) of the 60 women delivered vaginally had postpartum complications. Based on the data, it seems resonable to allow vaginal delivery in carefully selected cases of term frank breech presentation.

Clinical fetal monitoring. The usage and relationship to trends in cesarean delivery and perinatal mortality

During the six years 1970--1975, 62,266 deliveries occurred at Women's Hospital, Los Angeles Country--University of Southern California Medical Center. Of these patients, 18,106 (29 per cent) were monitored, with an incidence of 18 per cent in 1970 which rose to 35 per cent in 1975. The patients were divided into monitored and unmonitored groups for comparison of cesarean section rates and various aspects of perinatal mortality. The overall cesarean section rate was 9.6 per cent with 2,830 cesareans performed in monitored patients (16 per cent) and 3,124 in those unmonitored, a 7 per cent incidence including repeat cesarean. The cesarean rate remained remarkably stable over the 6-year study period even though the monitoring incidence nearly doubled. From 1970 to 1975, the intrapartum death rate fell progressively in contrast to the incidence of antepartum fetal deaths, which remained unchanged. Overall, 50 per cent survival rate was achieved in the birth weight range of 1,200 grams. A particular group of perinatal patients who apparently benefited from intrapartum monitoring were those liveborns with birth weights of 1,500 grams or less. Over the study period, the neonatal mortality in monitored patients declined, whereas mortality in the neonates which were not monitored during labor remained high.

The influence of scalp sampling on the cesarean section rate for fetal distress

One year's obstetric experience at Los Angeles County-University of Southern California Medical Center was reviewed and compared with previous years. The incidence of cesarean section for fetal distress is low and has remained constant over the past 7 years. Periodic changes and decreased baseline variability of the fetal heart rate accounted for 39% of the diagnoses of fetal distress in this group. Scalp sampling clarified the diagnosis of fetal distress and prevented unnecessary cesarean section. Compromised perinatal outcome in the greater than 2,500 gram weight group was confined to those who were monitored, had indications for monitoring, or had identifiable prospective risk factors, with rare exceptions.

Pre-ejection period of cardiac cycles in fetal lamb

The pre-ejection period (PEP) of the fetal cardiac cycle was studied on 22 chronically instrumented pregnant ewes. The PEP was measured from the onset of the Q wave on fetal electrocardiogram to the onset of the upstroke on the fetal arterial blood pressure curve. Lengthening of the PEP was observed in association with an increase in gestational age, fetal body weight, fetal brow-rump length, and fetal heart weight. Consequently, the PEP values were calculated to those at fetal heart weight of 10 grams. The PEPc (calculated) was prolonged by acidosis but no significant relationship was found between the PEPc and arterial blood pO2. An increase in coronary blood flow was associated with a shortening of the PEPc in the fetuses under normal physiologic conditions. Fetal hypoxemia and respiratory acidosis created by administration of 10 per cent O2 and 20 per cent CO2 with 20 per cent O2 to the mother increased fetal coronary flow and was in general associated with a prolonged pre-ejection period.

Extraabdominal uterine exteriorization at cesarean section

A series of 386 consecutive cesarean sections is presented in which postpartum uteri were randomly exteriorized or left in situ for suturing the hysterotomy incision in an attempt to evaluate differences in morbidity. Both groups were shown to be similar with respect to overall morbidity, although a high-morbidity subgroup exhibiting increased blood loss was defined and included significantly more patients in the noneventrated group. Emesis occurred in 4 (3.4%) patients in the eventrated group and was directly related to fundal traction under regional anesthesia. Although a larger prospective series is needed to evaluate more serious morbidity, the data presented suggest that uterine eventration at cesarean section is not to be condemned.

The randomized management of term frank breech presentation: vaginal delivery vs. cesarean section

A prospective study of the management of term frank breech presentation is currently ongoing at LAC-USC Medical Center. To date, 57 patients have been randomized to an elective cesarean section group and 70 to a vaginal delivery group. Of the 70 patients selected for vaginal delivery, 35 had one or more inadequate pelvic measurements by x-ray pelvimetry and were scheduled for indicated cesarean section. Of the remaining 35 patients in this group, 30 delivered vaginally without perinatal death. Two of the infants, however sustained brachial plexus injuries. Of the 57 patients scheduled, 55 underwent elective cesarean section. There were no maternal deaths, but 20 (36.4%) patients experienced morbidity and 5(9.1 per cent) patients experienced intraoperative complications. Based on the data accumulated to date, it seems reasonable to allow vaginal delivery in carefully selected cases of term frank breech presentation.

Management and outcome of pregnancy in diabetes mellitus, classes B to R

During the period 1971 to 1975, 260 women with diabetes mellitus, Classes B through R, were delivered of their infants at Los Angeles County Women's Hospital. The plan of patient management included frequent clinic visits and hospitalization to assure good control. A program of intensive antepartum fetal surveillance was begun at 34 weeks' gestation, with the use of daily 24 hour urinary estriol determinations and a weekly contraction stress test (CST). A lecithin/sphingomyelin ratio was evaluated for all patients before elective delivery. The perinatal mortality rate in these diabetic pregnant women was 46 per 1,000 as compared to 24 per 1,000 in the general population. Only three stillbirths occurred in the diabetic group, none within one week of a negative CST. Congenital malformations were responsible for almost half of the neonatal deaths. There were no deaths due to iatrogenic prematurity or trauma. Mean gestational age at delivery was 37.9 weeks and vaginal delivery was the mode for approximately half of the women. Two thirds of the infants did experience some morbidity.

Fetal carbohydrate metabolism: its clinical importance

A basic understanding of fetal nutrition and metabolism is essential in the clinical management of the obstetric patient. The fetus depends upon a constant infusion of glucose for energy production and growth. Maternal glucose is the prime source of this nutrient. Alterations in maternal carbohydrate homeostasis will lead to changes in fetal metabolism. In diabetes mellitus, hyperglycemia may produce hyperinsulinemia and macrosomia. The growth-retarded fetus may have a decreased supply of maternal glucose and reduced amounts of hepatic glycogen and adipose tissue. The fetus must depend upon these stores for survival during periods of intrauterine hypoxia. In the newborn period, hypothermia and hypoxia may rapidly deplete energy reserves. With this information, the clinician may more knowledgeably manage dietary demands in the antepartum patient, fetal distress during labor, and the immediate newborn period.

Circulatory response to atropine in sheep fetus

Atropine was given to the semichronic sheep fetus intravenously. Fetal heart rate, fetal perfusion pressure, and carotid blood flow increased. Cerebral blood flow was measured with the radioactive microsphere technique. Atropine was capable of increasing the cerebral blood flow. Elevation of carbon dioxide also caused an increase in cerebral blood flow, adding to the effect of atropine.