Idiopathic thrombocytopenic purpura in pregnancy treated with pulsed high-dose oral dexamethasone

Idiopathic thrombocytopenic purpura in pregnancy is usually treated with prednisone or intravenous immune globulin. Because of the fetal risk, there are few good alternatives for women who do not respond. We report a case of refractory idiopathic thrombocytopenic purpura successfully treated with pulsed high-dose oral dexamethasone, which offered ease of administration, low cost, and low risk.

Clinical risk factors for placenta previa-placenta accreta

OBJECTIVE

Our purpose was to define the clinical risk factors associated with placenta previa-placenta accreta.

STUDY DESIGN

Hospital records were reviewed of all cases of placenta accreta confirmed histologically between January 1985 and December 1994. Additionally, we reviewed the records of all women with placenta previa and all those undergoing cesarean hysterectomy during the same period. Multiple logistic regression analysis was used to identify independent clinical risk factors for placenta accreta.

RESULTS

Among 155,670 deliveries, 62 (1/2510) were complicated by histologically confirmed placenta accreta. Placenta accreta occurred in 55 of 590 (9.3%) women with placenta previa and in 7 of 155,080 (1/22,154) without placenta previa (relative risk 2065, 95% confidence interval 944 to 4516, p < 0.0001). Among women with placenta previa, advanced maternal age (> or = 35 years) and previous cesarean delivery were independent risk factors for placenta accreta. Placenta accreta was present in 36 of 124 (29%) cases in which the placenta was implanted over the uterine scar and in 4 of 62 (6.5%) cases in which it was not (relative risk 4.5, 95% confidence interval 1.68 to 12.07). Among women with placenta previa, the risk of placenta accreta ranged from 2% in women < 35 years old with no previous cesarean deliveries to almost 39% in women with two or more previous cesarean deliveries and an anterior or central placenta previa.

CONCLUSION

Placenta accreta occurs in approximately 1 of 2500 deliveries. Among women with placenta previa, the incidence is nearly 10%. In this high-risk group advanced maternal age and previous cesarean section are independent risk factors.

Intrapartum rupture of the unscarred uterus

OBJECTIVE

To examine risk factors and maternal and neonatal outcomes in ten cases of intrapartum rupture of the unscarred uterus.

METHODS

Uterine ruptures in women without previous cesarean deliveries were identified from an ongoing log for a 12-year period beginning January 1, 1983. Detailed information was obtained by review of hospital records.

RESULTS

From January 1, 1983, through December 31, 1994, we identified 13 uterine ruptures in women without previous cesarean deliveries. Three resulted from motor vehicle accidents and were excluded from analysis. Ten occurred during labor and are the subjects of our report. The incidence of intrapartum rupture of an unscarred uterus was 1 in 16,849 deliveries. Associated factors included oxytocin use (four cases), prostaglandin use (three cases), use of vacuum or forceps (three cases), grand multiparity (two cases), and malpresentation (two cases). Intervention was prompted by fetal heart rate decelerations in seven cases and by severe hemorrhage in three. Uterine rupture was associated with acute abdominal pain in six cases, maternal tachycardia in five, and severe hypotension in two. Neonatal outcomes were normal in nine cases. There were no maternal or perinatal deaths.

CONCLUSION

Intrapartum rupture of the unscarred uterus is a rare obstetric emergency. Maternal and perinatal outcomes are optimized by awareness of risk factors, recognition of clinical signs and symptoms, and prompt surgical intervention.

The efficacy of prophylactic erythromycin in preventing vertical transmission of Ureaplasma urealyticum

To determine if prophylactic erythromycin alters the vertical transmission rate of Ureaplasma urealyticum. Randomized prospective study of 51 singleton pregnancies between 22 and 35 weeks' gestation with preterm premature rupture of membranes or preterm labor. Patients received oral erythromycin for 7 days in addition to routine prophylactic intravenous ampicillin or ampicillin alone. Lower genital colonization with U. urealyticum was 33 of 51 (65%). Vertical transmission of U. urealyticum was 25% (3 of 12) in the erythromycin group and 4 of 17 (24%) for the controls. The average interval from randomization to delivery was 303.5 hr in the erythromycin group and 70.9 hr for controls (p = 0.04). Although not statistically significant, histologic chorioamnionitis in patients colonized with Ureaplasma was lower in the erythromycin group (3 of 12, 25%) compared to the controls (10 of 17, 59%). Prophylactic erythromycin does not decrease vertical transmission of Ureaplasma. It may decrease the incidence of histologic chorioamnionitis and increase the latency period.

The McRoberts' maneuver for the alleviation of shoulder dystocia: how successful is it?

OBJECTIVE

Our purpose was to determine the rate of success of the McRoberts' maneuver as the initial treatment for shoulder dystocia and to compare the rate of maternal and neonatal morbidity with those cases of shoulder dystocia requiring additional obstetric maneuvers. A secondary goal was to assess those factors associated with successful McRoberts' maneuvers.

STUDY DESIGN

A retrospective review of shoulder dystocia cases occurring between 1991 and 1994 was performed. The identified cases were divided into two groups on the basis of the maneuvers used to relieve the shoulder dystocia. The first group comprised cases in which the McRoberts' maneuver was used as the sole treatment and the second group consisted of cases in which additional maneuvers were subsequently used. Exclusion criteria included lack of documentation concerning the maneuvers used or cases in which the McRoberts' maneuver was not the initial technique used. The two groups were compared with respect to various antepartum, intrapartum, and neonatal characteristics.

RESULTS

During the study period we identified 250 cases of shoulder dystocia among 44,072 vaginal deliveries, for an incidence of 0.57%. Of these, 236 cases (94%) fulfilled entry criteria. The McRoberts' position alone successfully alleviated the shoulder dystocia in 98 cases (42%). In the group of cases where the McRoberts' maneuver was the sole maneuver used, there were significantly lower mean birth weights (p = 0.008), shorter durations of the active phase of labor (p = 0.009), and shorter second stages (p < 0.0001). In the group of cases that required additional maneuvers to relieve the shoulder dystocia, there was a trend toward an increased incidence of postpartum hemorrhage and brachial plexus injury (p = 0.07).

CONCLUSIONS

These data suggest that the McRoberts' maneuver is associated with a significant degree of success in relieving shoulder dystocia and may be associated with decreased morbidity compared with other maneuvers. On the basis of these findings, we recommend the McRoberts' maneuver as the initial technique for disimpaction of the anterior shoulder.

Radiologic studies in acute fatty liver of pregnancy. A review of the literature and 19 new cases

OBJECTIVE

Radiologic findings thought to be characteristic of acute fatty liver of pregnancy have been described in a limited number of cases. We describe wide experience with liver imaging of this disease.

STUDY DESIGN

A retrospective review was performed on charts from 1982 to 1994 to identify those patients with acute fatty liver of pregnancy who had radiologic studies.

RESULTS

Twenty-eight patients with acute fatty liver of pregnancy were identified, for an incidence of 1/6,692 births. Nineteen patients underwent at least one imaging study, and seven had more than one. Findings consistent with fatty infiltration of the liver are found in 3/11 patients with ultrasound, 5/10 with computed tomography (CT) and 0/5 with magnetic resonance imaging (MRI). Three patients with normal ultrasound scans subsequently had evidence of fatty filtration on CT scan.

CONCLUSION

Detection of fat in the liver of patients with acute fatty liver of pregnancy with current imaging techniques is limited and did not contribute to the management of patients in this series. Further studies are necessary to define to role of MRI--in particular, spectroscopy.

Intrahepatic cholestasis of pregnancy: perinatal outcome associated with expectant management

OBJECTIVE

Our goal was to compare the pregnancy outcomes of patients with intrahepatic cholestasis of pregnancy managed expectantly with antepartum testing with those of other patients who were followed up with a similar testing scheme.

STUDY DESIGN

Cases of intrahepatic cholestasis of pregnancy monitored with antepartum testing at our institution over a 7-year period were reviewed. Their pregnancy outcomes were compared with those of control patients followed up with the same testing scheme for a history of stillbirth. Both groups had at least weekly nonstress tests and amniotic fluid assessment until spontaneous labor or delivery for standard obstetric indications

RESULTS

Seventy-nine patients were analyzed in each group. The two groups did not differ with respect to the mean gestational age at delivery (38.5 vs 38.8 weeks), birth weight (3216 vs 3277 gm) or incidence of preterm delivery (14% vs 7.6%). Abnormal antepartum testing prompting delivery was more common in the control group (25% vs 7.6%, p < 0.05). The risk of meconium passage was higher in the cholestasis group (44.3% vs 7.6%, p < 0.05). Two antepartum fetal deaths occurred in the cholestasis group at 36 to 37 weeks' gestation within 5 days of normal results of antepartum testing. Thick meconium and appropriate birth weight were noted in both infants. No gross anomalies were found in either infant.

CONCLUSION

Intrahepatic cholestasis of pregnancy is associated with adverse perinatal outcome not predicted by conventional fetal surveillance.

Preeclampsia and liver infarction in early pregnancy associated with the antiphospholipid syndrome

BACKGROUND

Usually, preeclampsia is a disease of the second half of pregnancy (i.e., beyond 20 weeks' gestation). Early-onset preeclampsia has been reported in association with the antiphospholipid syndrome, however, the cases reported have been at 25-30 weeks' gestation.

CASES

Three pregnant women presented with clinical and laboratory features of severe preeclampsia and the syndrome of hemolysis, elevated liver enzymes, and low platelets (HELLP) before 20 weeks' gestation. On evaluation, they were found to have antiphospholipid antibodies (anticardiolipin and/or lupus anticoagulant). Two of the patients had abdominal computed tomography scans that showed a low-density area along the hepatic periphery, compatible with hepatic infarction. Spontaneous resolution of all clinical and laboratory manifestations of preeclampsia and HELLP syndrome was observed after fetal death and pregnancy termination.

CONCLUSION

Preeclampsia and HELLP syndrome can present before 20 weeks' gestation in association with the antiphospholipid syndrome and may be associated with hepatic infarction.

Dose ranging study of the oxytocin antagonist atosiban in the treatment of preterm labor. Atosiban Study Group

OBJECTIVE

To evaluate the minimal effective dose regimen of the oxytocin antagonist atosiban in the treatment of acute preterm labor and the effect of a bolus on uterine activity within the first 2 hours compared with no bolus and the same infusion rate.

METHODS

A randomized, double-blind (except the ritodrine group), parallel group, multicenter study compared four different intravenous atosiban regimens (6.5 mg bolus plus 300 micrograms/minute, placebo bolus plus 300 micrograms/minute, 2mg bolus plus 100 micrograms/minute, and 0.6 mg plus 30 micrograms/minute) and intravenous ritodrine with respect to the cessation of uterine contractions for 1 hour or more during infusion, four or fewer contractions per hour in the last hour of therapy, and discontinuation because of adverse experiences. Three hundred two patients were enrolled.

RESULTS

The lowest dose of atosiban (0.6 mg plus 30 micrograms/minute) was significantly less effective than ritodrine with respect to cessation of contractions and four or fewer contractions per hour in the last hour of therapy. Other atosiban regimens were comparable to ritodrine, except for the drug discontinuation rate for adverse experiences. Bolus therapy with high-dose atosiban resulted in a significantly greater proportion of patients who stopped contracting within the first 2 hours of treatment (17 of 63) compared with those not receiving a bolus (six of 58, P = .017). Because of adverse experiences, the study drug was discontinued in one of 244 atosiban patients and 15 of 58 ritodrine patients.

CONCLUSION

Atosiban's effect on uterine activity in preterm labor was enhanced by bolus infusion and was similar to the effect of ritodrine, but with fewer side effects.

Treatment of preterm labor with the oxytocin antagonist atosiban

The purpose of this study was to describe the course of preterm labor in patients receiving a standard intravenous infusion of the oxytocin antagonist atosiban. An open-labeled, non-randomized study was conducted at 4 sites. Successful tocolysis was defined as delay of delivery larger than 48 hours from starting atosiban and no need for an alternate tocolytic. Atosiban was administered by continuous intravenous infusion at a rate of 300 micrograms per minute until uterine contractions were absent for 6 hours, or up to a maximum infusion time of 12 hours. Sixty-two patients of between 20 and 36 weeks' gestation were enrolled over 6 months. One had rupture of membranes and was excluded. Successful tocolysis was noted in 43 of 61 (70.5%). Four delivered spontaneously within 48 hours and 14 (23.0%) required an alternate tocolytic agent. The chance of successful tocolysis was related to the degree of cervical dilation at the start of therapy. Cessation of uterine contractions was noted in 38 patients (62.3%). A decrease in uterine contraction frequency of 50% or more was noted in 50 of 61 patients (82.0%). Four patients reported side effects (nausea, vomiting, headache, dysguesia, chest pain), but in no case did side effects require discontinuation of the medication. Intravenous administration of atosiban is associated with a delay in delivery comparable to that seen with other tocolytics. If this effect is confirmed in planned placebo-controlled trials, its favorable side effect profile may give it a place in the armamentarium.

Disseminated intravascular coagulation and antithrombin III depression in acute fatty liver of pregnancy

OBJECTIVE

Acute fatty liver of pregnancy has been associated with a syndrome of marked depression of antithrombin III and disseminated intravascular coagulation. We sought to identify the clinical importance of this accelerated coagulation.

STUDY DESIGN

The medical records of patients with acute fatty liver of pregnancy identified during the period of 1982 to 1994 were retrospectively reviewed.

RESULTS

Twenty-eight patients with acute fatty liver of pregnancy were identified for an incidence of 1:6692 births. Laboratory evidence of persistent disseminated intravascular coagulation was found in all patients tested. Six patients had clinical bleeding, all associated with genital tract injury. Twenty-three of twenty-three patients tested had markedly decreased antithrombin III levels (average 11%, normal range 80% to 100%). Seven patients received antithrombin III transfusions, which was associated with a significant transient rise in the plasma level. Compared with patients not transfused, however, there was a similar clinical outcome.

CONCLUSION

Profoundly depressed antithrombin III levels and laboratory evidence of disseminated intravascular coagulation were present in all cases of acute fatty liver of pregnancy but rarely influenced clinical outcome unless there was concomitant genital tract injury. Antithrombin III transfusions increased plasma levels, but no definite clinical benefit was established in this series because of the small number of cases.

Heterozygous protein C deficiency presenting as severe protein C deficiency and peripartum thrombosis: successful treatment with protein C concentrate

BACKGROUND

Complications of pregnancy, including thrombosis and increased fetal loss, have been described in women with heterozygous protein C deficiency.

CASE

We report an unusual case of umbilical cord thrombosis, acute renal failure, and cutaneous venous thrombosis associated with severe protein C deficiency in the heterozygous infant of a normal mother. Repeated infusions of protein C concentrate made successful heparinization of the infant possible, with the subsequent resolution of cutaneous thrombosis and improvement of renal status.

CONCLUSION

Heterozygous protein C deficiency in the fetus may result in perinatal thrombosis, which can be treated with viral-inactivated protein C concentrate. Heterozygous protein C deficiency should be considered in cases of fetal compromise or death associated with umbilical vein thrombosis.

Salivary estriol as risk assessment for preterm labor: a prospective trial

OBJECTIVE

Increased understanding of human parturition allows for novel approaches to (1) identification of women at increased risk for preterm birth and (2) development and controlled testing of etiology-based strategies to prevent preterm birth.

STUDY DESIGN

Five hundred forty-two women were enrolled at five study sites in a prospective evaluation of salivary estriol in samples obtained weekly beginning at 22 weeks' gestation (Salest, Biex, Inc., Boulder, Colo.). Estriol concentrations were determined with a well-characterized enzyme-linked immunoassay. Women adjudged at either high risk or low risk for prematurity were evaluated through to delivery.

RESULTS

A total of 267 women submitted serial samples that were analyzed; 241 women with singleton pregnancies submitted sufficient samples. Twenty-three women with singleton fetuses went into idiopathic preterm labor (without prior rupture of membranes) and were delivered preterm (mean 35 weeks' gestation); 182 were delivered at term (> or = 37 weeks' gestation). Mean (geometric) estriol concentrations were higher from 24 to 34 weeks in women with singleton pregnancies delivering preterm (p < 0.05). A surge in estriol concentrations occurred approximately 3 weeks before the onset of labor in both women delivering at term and those delivering preterm. This increase occurred approximately 4 weeks earlier in women delivered preterm versus term. Receiver-operator curve analyses showed that exceeding a 2.3 ng/ml saliva estriol level was associated with occurrence of preterm labor (71% sensitivity, 77% specificity, 23% false-positive rate).

CONCLUSION

Detection of an early estriol surge or increased level (> or = 2.3 ng/ml) may be clinically helpful in identifying women at elevated risk for preterm labor and birth, allowing for evaluation of biologically based interventions in controlled trials.

The pharmacokinetics of the oxytocin antagonist atosiban in pregnant women with preterm uterine contractions

OBJECTIVE

Our purpose was to evaluate the pharmacokinetics of atosiban, an oxytocin antagonist, during and after intravenous infusion in pregnant patients having at least six contractions per hour. The relationship between atosiban infusion and uterine activity was also assessed.

STUDY DESIGN

Plasma samples from eight pregnant patients treated with intravenous atosiban (300 micrograms/min for 6 to 12 hours) were analyzed for atosiban concentration by a specific radioimmunoassay procedure. Contraction rate data were obtained by external tocodynamometry for 1 hour before the infusion and during the subsequent infusion.

RESULTS

The average steady-state plasma concentrations of patients receiving intravenous atosiban were 442 +/- 73 ng/ml (mean +/- SD), with steady state achieved by 1 hour after the start of the infusion. After the completion of the infusion, plasma concentrations declined rapidly in a biexponential manner with initial and terminal half-life estimates of 13 +/- 3 and 102 +/- 18 minutes, respectively. The effective half-life was 18 +/- 3 minutes. The plasma clearance of atosiban was relatively high (42 L/hr) and the volume of distribution (approximately 18 L) was consistent with distribution into extracellular fluid. Of the seven patients evaluated for uterine activity, the mean contraction rate decreased by 75% during the third hour of treatment and remained low until treatment termination.

CONCLUSION

On the basis of earlier published reports, the pharmacokinetics of atosiban in pregnant patients are similar to those in nonpregnant women. Although the patient population was small, a consistent reduction in uterine activity was observed during atosiban infusion.

Fetal fibronectin improves the accuracy of diagnosis of preterm labor

OBJECTIVE

Our purpose was to assess the utility of cervicovaginal expression of fetal fibronectin in the diagnosis of preterm labor.

STUDY DESIGN

Women seen between 24 and 34 weeks' gestation with symptoms of preterm labor, intact membranes, and cervical dilatation < 3 cm were enrolled at five university medical centers. Cervicovaginal swabs were obtained and assayed for the presence of fetal fibronectin by means of a monoclonal antibody assay. Results were compared with cervical dilatation and uterine contraction frequency as indicators of interval to delivery and delivery before 37 weeks.

RESULTS

A total of 192 eligible women at a mean gestational age of 30.8 +/- 2.9 weeks were enrolled from a population of 418 subjects screened. The rate of preterm birth was 32.3% (62/192). The mean interval from presentation to delivery was 25.3 +/- 24.1 days in the 45 subjects with a positive fibronectin assay and 52.4 +/- 24.8 days in the 147 subjects with a negative assay (p = 0.0001). The sensitivity, specificity, and positive and negative predictive values of fetal fibronectin expression for delivery < 37 weeks were 44% (27/62), 86% (112/130), 60% (27/45), and 76% (112/147). The fetal fibronectin assay was especially useful in predicting risk of delivery within 7 days (sensitivity 93% [13/14], specificity 82% [146/178], positive predictive value 29% [13/45], and negative predictive value 99% [146/147]) and was notably superior to both cervical dilatation > 1 cm and contraction frequency greater than or equal to eight per hour (sensitivities 29% and 42%, specificities 82% and 67%, positive predictive values 11% and 9%, and negative predictive values 94% and 94%, respectively.

CONCLUSION

Cervicovaginal fetal fibronectin predicts delivery within 7 days more accurately than do cervical dilatation and contraction frequency in a population of women evaluated for early preterm labor.

Misoprostol: an effective agent for cervical ripening and labor induction

OBJECTIVE

Our purpose was to compare the safety and efficacy of intravaginal misoprostol versus intracervical prostaglandin E2 gel (dinoprostone) for preinduction cervical ripening and induction of labor.

STUDY DESIGN

Two hundred seventy-six patients with indications for induction of labor and unfavorable cervices were randomly assigned to receive either intravaginal misoprostol or intracervical dinoprostone. Twenty-five micrograms of misoprostol were placed in the posterior vaginal fornix every 3 hours, with a potential maximum of eight doses. Prostaglandin E2 in gel form, 0.5 mg, was placed in the endocervix every 6 hours, with a maximum of three doses. Further medication was withheld with the occurrence of spontaneous rupture of membranes, entry into active phase of labor, or a "prolonged contraction response."

RESULTS

Among those evaluated, 138 received misoprostol and 137 received dinoprostone. The average interval from start of induction to vaginal delivery was shorter in the misoprostol group (1323.0 +/- 844.4 minutes) than in the dinoprostone group (1532.4 +/- 706.5 minutes) (p < 0.05). Need for oxytocin augmentation of labor occurred more commonly in the dinoprostone group (72.6%) than in the misoprostol group (45.7%) (p < 0.0001). There were no significant differences in the routes of delivery. Twenty-eight of the misoprostol-treated patients (20.3%) and thirty-eight of the dinoprostone-treated patients (27.7%) required abdominal delivery. Complications such as uterine tachysystole and thick meconium passage occurred with similar frequency in the two treatment groups.

CONCLUSIONS

Intravaginal administration of misoprostol appears to be as effective as intracervical dinoprostone for cervical ripening and labor induction. Complications associated with prostaglandin administration were not statistically different between the two treatment groups. The cost of misoprostol ($0.36/100 micrograms) is much less than that of dinoprostone ($75/0.5 mg).

A comparison of misoprostol and prostaglandin E2 gel for preinduction cervical ripening and labor induction

OBJECTIVE

Our purpose was to compare the safety and efficacy of intravaginal misoprostol versus intracervical prostaglandin E2 (dinoprostone) gel for preinduction cervical ripening and induction of labor.

STUDY DESIGN

One hundred thirty-five patients with indications for induction of labor and unfavorable cervices were randomly assigned to receive either intravaginal misoprostol or intracervical dinoprostone. Fifty microgram tablets of misoprostol were placed in the posterior vaginal fornix every 3 hours for a maximum of six doses. Prostaglandin E2 in gel form, 0.5 mg, was placed into the endocervix every 6 hours for a maximum of three doses. Medication was not given after either spontaneous rupture of membranes or beginning of active labor.

RESULTS

Among 135 patients enrolled, 68 received misoprostol and 67 received dinoprostone. The average interval from start of induction to vaginal delivery was shorter in the misoprostol group (903.3 +/- 482.1 minutes) than in the dinoprostone group (1410.9 +/- 869.1 minutes) (p < 0.001). Oxytocin augmentation of labor occurred more often in the dinoprostone group (65.7%) than in the misoprostol group (33.8%) (p < 0.001). There were no significant differences between routes of delivery. Ten of the misoprostol-treated patients (14.7%) and 13 of the dinoprostone-treated patients (19.4%) had cesarean deliveries. There was a higher prevalence of tachysystole (six or more uterine contractions in a 10-minute window for two consecutive 10-minute periods) in the misoprostol group (36.7%) than in the dinoprostone group (11.9%) (p < 0.001). However, there were no significant differences in frequency of uterine hyperstimulation or hypertonus. There was a higher prevalence of meconium passage in the misoprostol group (27.9%) than in the dinoprostone group (10.5%) (p < 0.05). There was no significant difference in frequency of abnormal fetal heart rate tracings, 1- or 5-minute Apgar scores < 7, neonatal resuscitations, or admissions to the neonatal intensive care unit between the two groups.

CONCLUSIONS

Vaginally administered misoprostol is an effective agent for cervical ripening and induction of labor; however when given at this dosage, it is associated with a higher prevalence of tachysystole and meconium passage than is dinoprostone. Further studies to compare the safety of misoprostol to that of dinoprostone and to delineate an optimal dosing regimen for misoprostol are needed.

Thyroid disorders of pregnancy

Practical aspects in the management of thyroid diseases in pregnancy are reviewed. Information on the hypothalamic-pituitary thyroid axis function in pregnancy and transplacental passages of thyroid hormones is discussed. Diagnosis and management of thyroid dysfunction in pregnancy are updated together with the management of women on thyroid replacement therapy at the time of conception. A practical evaluation of thyroid nodules in pregnancy is suggested. Finally, the syndrome of postpartum thyroid dysfunction is reviewed, stressing the importance of proper diagnosis and the need for long-term follow-up evaluation of these patients.

Increased concentration of the free beta-subunit of human chorionic gonadotropin in hyperemesis gravidarum

OBJECTIVE

The amount of free beta subunit hCG (free beta) has been reported to be increased in trophoblast disease and Down's syndrome, conditions also associated with high total hCG. Increased total hCG has been reported in hyperemesis gravidarum. We sought to determine if sera from singleton gestations with hyperemesis gravidarum contained a higher proportion of free beta hCG compared to controls of comparable gestational age.

METHODS

Sera from 39 patients with hyperemesis gravidarum was compared with that from 23 control subjects of comparable gestational age with respect to beta hCG and its subunits (free beta and free alpha).

RESULTS

Hyperemesis patients and controls were comparable with respect to age, weight and gestational age. The concentration of hCG was greater in hyperemesis patients (9237 +/- 3613 ng/ml, mean +/- s.d.) compared to controls (5543 +/- 2290, p < 0.005) as was the concentration of free beta hCG (101 +/- 70 ng/ml vs. 31 + 31, p < 0.001). Free alpha did not differ between hyperemesis patients and controls (399 +/- 231 ng/ml vs. 377 +/- 214). A percent free beta greater than 0.6 was found in 33/39 hyperemesis patients (85%) compared to 5/23 controls (22%), p < 0.001.

CONCLUSION

Increased free beta hCG is found in hyperemesis gravidarum. This finding strengthens the association of hyperemesis with abnormal metabolism of hCG.

Elimination of fetal scalp blood sampling on a large clinical service

OBJECTIVES

To describe the use of fetal scalp blood sampling on a large teaching service over 7 years and to assess any association between changes in use and the rates of cesarean delivery for fetal distress and of various indirect indicators of perinatal asphyxia in term infants.

METHODS

We reviewed computerized and tabular data bases for fetal scalp blood sampling, cesarean delivery for fetal distress, Apgar score, and the clinical diagnoses of asphyxia and meconium aspiration syndrome for the years 1986-1992.

RESULTS

Live births averaged 16,330 annually. The rate of fetal scalp blood sampling for the first 3 years of the study period was 1.76%, consistent with the rate of 1.5-2.0% noted for the preceding decade at our institution. An increase in sampling in 1987 was followed by a steady decline over the next 4 years, to a low of 0.03% in 1992. During the period of declining scalp pH usage, there was no increase in the cesarean rate for fetal distress, low Apgar score (less than 5 at 5 minutes) requiring neonatal intensive care unit admission, or the clinical diagnosis of perinatal asphyxia or meconium aspiration syndrome.

CONCLUSIONS

Fetal scalp blood sampling has been virtually eliminated without an increase in the cesarean rate for fetal distress or an increase in indicators of perinatal asphyxia. The role of fetal scalp blood sampling in clinical practice is questioned.

Thyrotropic activity of basic isoelectric forms of human chorionic gonadotropin extracted from hydatidiform mole tissues

hCG is known to have thyroid-stimulating activity and may cause hyperthyroidism in patients with trophoblastic diseases. hCG occurs in normal and molar pregnancy with breaks or nicks in the alpha- or beta-subunit peptide linkage and with substantial heterogeneity in the composition and degree of branching within the oligosaccharide side-chains. The bioactivity of hCG is markedly influenced by these structural variations. We purified hCG from five hydatidiform moles, using chromatofocusing separation after gel filtration. The hCG molecules were fractionated according to their isoelectric points, with a linear pH gradient from 3.2-6.1 and a final 1.0 mol/L NaCl step elution. The hCG immunoreactivity of each fraction was measured by RIA, and the thyroid-stimulating activity of hCG was determined by means of the cAMP response in Chinese hamster ovary cells expressing functional human TSH receptors (Chinese hamster ovary-JP09 cells). The chromatofocusing profile showed that hCG from the moles was eluted in six or seven major peaks at pH 6.1, 5.5, 5.3, 4.8, 3.8, and 3.2 and with 1.0 mol/L NaCl, whereas hCG extracted from serum of hydatidiform moles and standard hCG preparation CR-127 extracted from pregnancy urine showed only small peaks at pH greater than 5.3. Each fraction increased cAMP production significantly in Chinese hamster ovary-JP09 cells. The relative bioactivity/immunoreactivity, represented as the ratio of cAMP/hCG (picomoles per IU), was significantly higher in basic components (pI 6.1, 6.2 +/- 1.2; pI 5.5, 4.4 +/- 2.7; pI 5.3, 5.8 +/- 0.3) than in hCG CR-127 (bioactivity/immunoreactivity, 0.42; P < 0.05). The difference in pI of each hCG isoform was attributable to the extent of sialylation; basic hCG isoforms contained less sialic acid by immunological detection using lectins. These results indicate that isoforms of hCG with more thyrotropic activity were produced by trophoblastic tissues in patients with hydatidiform mole. We speculate that these isoforms of hCG may be responsible for the hyperthyroidism in some patients with hydatidiform moles.

The effect of the oxytocin antagonist atosiban on preterm uterine activity in the human

OBJECTIVE

The purpose of this study was to test the hypothesis that infusion of the oxytocin antagonist atosiban results in decreased preterm uterine activity in the human.

STUDY DESIGN

A randomized, double-blind, placebo-controlled trial was performed. One hundred twenty women from 20 to 36 weeks' gestation with a complaint of labor who had more than four uterine contractions per hour after intravenous hydration but no evidence of cervical changes were randomized to receive a 2-hour intravenous infusion of atosiban at a rate of 300 micrograms/min or placebo. Ond hundred-twelve subjects (56 in each arm) were suitable for analysis of efficacy. Both groups remained at bed rest and received hydration.

RESULTS

The mean percent decrease in contraction frequency was greater in atosiban subjects compared with controls (55.3% +/- 36.3% vs 26.7% +/- 40.4%, mean +/- SD, p < 0.001). A minimal (< 20%) decrease or an increase in contraction frequency was noted in 25 placebo subjects (45%) and seven atosiban subjects (13%). There was no clinically or statistically significant change in maternal blood pressure or heart rate during the infusion. The only adverse experiences possibly related to the drug were nausea and vomiting in one atosiban patient.

CONCLUSION

A 2-hour infusion of the oxytocin antagonist atosiban resulted in a significantly greater decline in contraction frequency compared with controls. Oxytocin appears to play a role in the maintenance of preterm uterine activity in the human.

Increased in vitro thyrotropic activity of partially sialated human chorionic gonadotropin extracted from hydatidiform moles of patients with hyperthyroidism

The intrinsic thyrotropic activity of hCG purified from normal pregnancy urine has been demonstrated in several laboratories. hCG has a specific thyrotropic potency of about 0.04-0.5 microU bovine (b) TSH/IU hCG, depending on the bioassay system. The corresponding potency for hCG derived from pathological sources, such as hydatidiform moles and choriocarcinoma tissue, or from the serum of these patients has not been studied as extensively. Since the biological activity of glycoproteins can be strongly influenced by variations in the oligosaccharide side-chain composition, we have investigated the effect of anion exchange chromatography on the thyrotropic potency of hCG derived from the hydatidiform mole and serum of three hyperthyroid patients with molar pregnancy. The activity for the fraction of total molar hCG immunoreactivity that was not retained by an anion exchange column (0.18-0.90 microM bTSH/IU hCG) was about twice that of the corresponding serum and molar hCG fraction eluting during the NaCl gradient elution (0.08-0.40 microU bTSH/IU hCG). The unretained hCG fraction corresponds to a previously described hCG precursor that is partially desialated in the C-terminal region of the beta-subunit.

Asphyxial complications in the term newborn with severe umbilical acidemia

OBJECTIVE

Our purpose was to determine the relationship of umbilical acid-base status and Apgar score to neonatal asphyxial sequelae in infants with severe acidemia (pH < 7.00).

STUDY DESIGN

The obstetric and neonatal course of 129 term, nonanomalous singleton infants with umbilical pH < 7.00 was reviewed.

RESULTS

There were three stillbirths (failed resuscitation). Seventy-two of 126 (57%) were admitted to the neonatal intensive care unit. Thirty-eight percent had pulmonary dysfunction, 26% renal dysfunction, 31% cardiac dysfunction, and 31% hypoxic ischemic encephalopathy (seizures and hypotonia, n = 29; seizures only, n = 3; hypotonia only, n = 10). There were five neonatal deaths. In 109 cases umbilical arterial values were available, and among these infants there was a significant increase in the incidence of seizures with declining pH from 9% (5/57), with a pH of 6.90 to 6.99, to 80% (8/10), with a pH of 6.61 to 6.70. Respiratory acidemia (PCO2 > 65, base deficit < 10) was identified in 28 of 109 (26%), all but six occurring in the pH range above 6.90. Compared with infants with comparable umbilical artery pH, infants with respiratory acidemia did not differ significantly with respect to asphyxial end-organ injury in general (8/35 vs 6/22), but there was a trend toward a lower incidence of hypoxic ischemic encephalopathy (6/35 vs 1/22, p = 0.06). All infants with definite abnormal outcome (five neonatal deaths and 10 severe neurologic deficit) had seizures, hypotonia, and at least one other organ system dysfunction. Twenty-four of 29 infants (83%) who developed seizures had a 5-minute Apgar score < 7, but only 12 of 29 (41%) had a 5-minute Apgar score of < or = 3. Two infants with Apgar scores of 6 and 7 at 5 minutes and no evidence of nonasphyxial comorbidity subsequently manifested profound neurologic deficit.

CONCLUSIONS

Infants with severe umbilical acidemia can be separated with regard to risk of hypoxic ischemic encephalopathy and abnormal neurologic outcome by consideration of the severity and composition of the acidemia and evidence of other end-organ dysfunction. Even in this pH range the Apgar score is not highly predictive of asphyxial complications.

The role of chorionic gonadotropin in transient hyperthyroidism of hyperemesis gravidarum

Biochemical evidence of hyperthyroidism is frequently encountered in hyperemesis gravidarum, but its relationship to the cause of hyperemesis is unknown. We studied the relationship of serum hCG, thyroid function, and severity of vomiting among 57 hyperemesis patients and 57 controls matched for gestational age. TSH was suppressed in 60% of hyperemesis patients and 9% of controls. hCG correlated directly with free T4(r = 0.45, P < 0.001) and inversely with TSH (r = -0.48, P < 0.001). Hyperemesis patients had significantly greater mean serum hCG, free T4, total T3, and estradiol, and lesser serum TSH compared to controls. Hyperemesis patients with suppressed TSH had significantly greater free T4 and hCG compared to those with TSH in the normal range. Control and hyperemesis subjects were divided into four groups based on the severity of vomiting. The degree of biochemical hyperthyroidism and hCG concentration varied directly with the severity of vomiting. Unextracted serum was tested for thyrotropic activity by measuring its effect on iodide uptake in cultured FRTL-5 rat thyroid cells. Thyrotropic activity correlated with serum hCG (r = 0.50, P < 0.001). These data show that biochemical hyperthyroidism is a common finding in patients with hyperemesis gravidarum and suggest that hCG is the thyroid stimulator in this state. The increased estradiol concentration in patients with hyperemesis gravidarum may be attributed to the effects of hCG on steroidogenesis.

Transient hyperthyroidism and hyperemesis gravidarum: clinical aspects

OBJECTIVES

Our objectives were to describe the presentation and course of hyperemesis gravidarum with respect to thyroid function and to test the hypothesis that patients with biochemical hyperthyroidism differ in clinical presentation from euthyroid hyperemesis patients.

STUDY DESIGN

Sixty-seven patients seen at Los Angeles County Women's Hospital over a 10-month period with hyperemesis gravidarum were studied prospectively with respect to thyroid function.

RESULTS

Forty-four patients (66%) had biochemical hyperthyroidism (increased free thyroxine index [n = 39] or suppressed thyroid-stimulating hormone [n = 40]) that was self-limited, resolving by 18 weeks' gestation. Hyperthyroid patients were more likely than euthyroid patients to have abnormal electrolyte levels (23/39 [59%] vs 6/28 [21%] and increased liver enzyme levels (23/59 [59%] vs 5/28 [18%], p less than 0.01). The severity of hyperemesis was found to vary directly with the degree of hyperthyroidism.

CONCLUSIONS

Hyperthyroidism is a common, self-limited finding in hyperemesis. The cause of the hyperthyroidism may be linked to the cause of hyperemesis itself.

Pregnancy outcome and fetomaternal hemorrhage after noncatastrophic trauma

Two hundred five consecutive cases of noncatastrophic trauma occurring during the second half of pregnancy were evaluated prospectively. Pregnancy complications as a result of trauma occurred in 18 of 205 patients (8.8%): premature labor (n = 10), placental separation (n = 5), fetal injury (n = 1), and fetal death (n = 2). Multiple regression analysis of the data base showed obstetric findings (contractions, uterine tenderness, and bleeding) on presentation to be highly associated with complications (17/88; 19.3%). In their absence complications were rare (1/117; 0.9%). Detectable fetomaternal hemorrhage was significantly more common in trauma patients (18/205) than in control subjects (2/110) (p less than 0.01), but its role in managing trauma patients was limited to detection of rare massive hemorrhage (1/205) and detection of rare hemorrhage exceeding that covered by the standard Rho (D) immune globulin dose (2/205). Fetomaternal hemorrhage need not be quantitated in patients who lack obstetric findings on presentation. Despite rare reports of delayed abruptio placentae, it is doubtful that prolonged observation (greater than 2 to 3 hours) in the hospital is necessary in patients who lack obstetric findings on initial presentation.

Congenital hypofibrinogenemia in pregnancy

A new case of congenital hypofibrinogenemia in pregnancy is reported and the literature is reviewed from an obstetric perspective. An association with spontaneous abortion, abruption, and postpartum hemorrhage is documented and management options are presented.

Chromosome subband 17p11.2 deletion: a minute deletion syndrome

Interstitial deletion of the short arm of chromosome 17 was detected in three unrelated patients with mental retardation and multiple congenital malformations. These patients were identified at a single centre over a six month period suggesting that del(17) (p11.2p11.2) is not a rare constitutional chromosome rearrangement. Comparison of the phenotypic features in a total of 19 patients with del(17)(p11.2p11.2) shows a consistent clinical phenotype with moderate to severe mental retardation, microbrachycelphaly, prominent forehead, broad face, flat midface, prognathism, short, broad hands, and behavioural anomalies such as self-mutilation. The sex ratio is unremarkable, parental ages are normal, and survival is usually unimpaired. Chromosome resolution of at least 500 bands appears necessary to detect this deletion.

Toluene abuse and renal tubular acidosis in pregnancy

Five gravidas presented with severe renal tubular acidosis from paint sniffing. Normal acid-base balance returned within 72 hours with cessation of toluene abuse and standard supportive measures. Fetal heart tracings and dynamic ultrasound parameters were normal in four of five cases. Three of five infants were growth-retarded at birth; two showed anomalies and neonatal hyperchloremic acidosis. These and previous cases of renal tubular acidosis in pregnancy suggest that toluene is teratogenic.

A haemogregarine from the American alligator (Alligator mississippiensis)

Haemogregarina crocodilinorum Börner 1901 is redescribed from the blood of the American Alligator (Alligator mississippiensis). Gametocytes occurred in erythrocytes and erythrocytic schizonts contained about eight merozoites (range, 6--12). Gametogony and sporogony occurred in the gut of the leech, Placobdella multilineata and intracellular, unisporocystic oocysts were found within epithelial cells of the leech's intestinal wall. Presumed sporozoites were present in the intestinal contents. Attempts to transmit the parasite via leeches failed. The haemogregarine was widely distributed in southern United States and was found in 77 (59%) of 130 alligators examined. A comparison of this parasite is made with other haemogregarines reported from crocodilian reptiles.