Cardiopulmonary effects of betamimetic tocolytic and glucocorticoid therapy in pregnant women

In 35 present women, undergoing tocolytic treatment with betamimetics had intensive monitoring by balloon-tipped catheter. After the administration of 2-4 micrograms/min of fenoterol the cardiac output (CO) increased from 8.2 l/min to over 11 l/min with a corresponding increase in mean pulmonary artery pressure (MPAP) from 11.7 mmHg to over 18 mmHg. The correlation coefficient between MPAP/CO was highly significant. In the 10 patients in whom we were able to monitor pulmonary capillary pressure (PCP), we observed no significant increase to suggest compromised cardiac performance. The calculated total resistance of the pulmonary vessels (TPR) decreased during the first 24 h followed by a return to initial values. Our investigations suggest that the principal cardiovascular effect of betamimetics in pregnant women is a volume-dependent increase in pressure in the pulmonary circulation. The simultaneous administration of betamethasone had no additional effects.

[Is rupture of the symphysis a predictable event?]

A rupture of the symphysis that was complicated by recurrence is described. In order to determine possible causes, individual factors are discussed on the basis of the literature. In spite of possible early symptoms of increased stress of the pelvic girdle during pregnancy, rupture of the symphysis is a rare and unforeseeable obstetric complication, whose cause may possibly lie in the coincidence of several stress factors, such as increased loosening processes or a large fetus.

[Physical performance in pregnancy]

To evaluate their physical efficiency, 14 healthy untrained women were examined during pregnancy weeks 16-20, 25-29 and 34-38 and 5 to 10 weeks post partum, by spiroergometry at various exercise levels on the bicycle ergometer. Besides the spiroergometric values, circulatory parameters were measured and serum analyses were carried out. The physical efficiency of the subjects was by no means reduced in the stages of pregnancy investigated. Indeed, several factors indicated an improvement of performance. Thus common features were found regarding the physiological effects of pregnancy and endurance training: increase of the maximum oxygen uptake, lower lactate production when the aerobic/anaerobic threshold was exceeded at high exercise intensity, as well as a relatively lower pulse under exercise. The increased metabolic fat utilisation for energy production in physical work is likewise similar to the effect of endurance training. Many pregnant women occasionally feel that they have reduced physical efficiency. Pregnant subjects were subjected to a standardised exercise test to appraise these complaints objectively. The study carried out was intended to answer the question as to whether the specific processes of adaptation of the cardiopulmonary system in pregnancy would lead to an impairment of physical efficiency. Furthermore, the question was to be answered as to whether the altered metabolic conditions of pregnant women under exercise will influence energy production from carbohydrate and fat metabolism.

The importance of antepartum cardiotocography

The significance of antepartum cardiotocography was examined on patients at the University of Cologne in the years 1982 and 1983. We analyzed 13,310 cardiotocograms of 1,463 women and correlated their pregnancies and deliveries with the status of their newborns. There were only 66 suspect/prepathologic fetal heart rate recordings in 50 patients. All these patients had severe complications during their pregnancies. Impending prematurity, toxemia, first and second trimester bleeding as well as placental insufficiency and polyhydramnios were the leading complications. The analysis of the cardiotocograms using Hammacher's criteria demonstrated that the CTG characteristics "floating line" and "oscillation type" together accounted for the largest proportion (43.9%) to the total score and thus constituted the most important parameters. Fetuses with abnormal CTGs had a birthweight of less than 1500 grams in 30% of the cases. This group also had poorer Apgar scores and umbilical artery pH values than neonates with normal antepartum cardiotocograms. After excluding non-viable malformations the perinatal mortality was 80 per 1000, i.e. it was nine times higher for newborns with abnormal antepartum heart rate patterns. The study demonstrated that abnormal antepartum CTGs in non-selected patients are rare and are always associated with severe complications of pregnancy. Thus, the method is not suitable as a general screening method but should be used for specific indications in high risk pregnancies and for the evaluation of any tocolytic treatment. The recognition of abnormal CTG characteristics requires technically adequate recording and accurate analysis.(ABSTRACT TRUNCATED AT 250 WORDS)

[Clinical aspects and therapy of trophoblastic tumors]

Over a period of ten years 14 women with trophoblast tumours (rarely seen in Europe) underwent diagnosis, treatment and follow-up, appropriate for the time. The high specificity of human beta-chorionic gonadotropin as marker in the recognition and follow-up of this tumour contributed to the good prognosis, as well as the cytostatic treatment, varied according to risk factors. Twelve of the 14 women are either cured or free of recurrences for a long time.

[Follow-up study of former prenatally dystrophic newborn infants now 6 to 12 years old]

58 small-for-date (SFD) aged 6 to 12 years, born between 1970 and 1975 were followed-up. Retardation of motor skills and speech during early infancy was found in 20-30%. At 6 to 12 years of age one third still had deficits in body weight und height. Neurological abnormalities in 17 children were usually mild, most often affecting fine motor function. Significant impairment of visuomotor perception on psychological testing was seen in 21 children, and EEG abnormalities in 20 cases. The results in neurological, psychological and EEG investigations for 23 children (group I) were normal. 24 patients (group II) showed one or two abnormal findings. In 9 children (group III) results of all three examinations were abnormal. The follow-up results were influenced by socioeconomic factors. Small-for-date babies showed on the whole encouraging results on follow-up during later childhood, with 40% of the children being normal, and mostly mild abnormalities in the remaining patients. Prognosis may be further improved by preterm delivery, i.e. early termination of intrauterine growth retardation.

[Risks in pregnancy after kidney transplantation]

Two women had four supervised pregnancies after renal transplantation. A striking feature was that the children had fetal growth retardation which led to premature termination of pregnancy by section. Likely causes of the growth retardation are, in the first instance, long-term treatment with corticosteroids and increased incidence of toxaemia. There is no evidence for a significant rise in the risk of teratogenicity for the embryo by the immunosuppressive treatment. However, an increased mutagenicity risk must remain a possibility in view of the one case of Turner's syndrome. Close interdisciplinary control of mother and child makes it possible to reduce risks to a reasonable level in case of pregnancy after renal transplantation.

[Prenatal diagnosis of fetal meconium peritonitis, therapy and clinical course. With a contribution to the differential diagnosis of fetal ascites]

We report on the prenatal diagnosis of a case of foetal meconium peritonitis pursuant to colon perforation in the 34th week of gestation. A sonographic examination of the foetus showed ascites, dense zones around the peritoneum and intestine, hepatosplenomegaly and hydroceles, as well as a slight hydramnios. The foetal abdomen was punctured under ultrasonographic control, and ascitic fluid was withdrawn. It was sterile but included granulocytes, leucocytes, epidermal epithelial cells and lanugo hairs, thereby confirming the diagnosis. The bilirubin concentration was very high, and the protein content was also increased. An amniofoetography gave a clear picture of the small intestine and showed a calcified zone in the upper left abdomen. A Caesarean section was performed prior to term, and the prenatal diagnosis was confirmed. After surgical correction the infant has developed satisfactorily up to the present age of 15 months, even though mucoviscidosis was diagnosed at the age of 5 months. In addition to ascites due to meconium peritonitis, several other types of foetal ascites are discussed.

[Outcome of pregnancy following amniocentesis in the prenatal diagnosis of genetic birth defects]

From 1973 to 1982, genetic amniocenteses were performed in 2548 women with singleton pregnancies. Of the cases done up to the end of 1979 the outcome of the pregnancy is on record in 1163 of 1232 cases. Of the cases done from 1980 to 1982 the outcome up to three weeks after the amniocentesis is known in all cases. The final outcome of the pregnancy is known in 25% of these cases. The over-all abortion rate due to the amniocentesis was 0.5%. In the first group, the abortion rate was 0.8% for ultrasound guided amniocenteses and 2.9% for blind punctures. The fetal loss rate from abortion and stillbirth was 3.5%. The abortion rate was correlated to the maternal age, threatened abortions prior to the amniocentesis, the placental site and the technique of puncture. Because of pathological findings, the pregnancy was terminated in 3.2% of the cases. The majority of the amniocenteses was performed between the 16. and 18. week of gestation. Repeat punctures were required in 1.9% of the women. The incidence of discoloration of the amniotic fluid was 2.0%. The rate of frankly blood stained fluid was 2.2%. The frequency of minimally blood stained fluid was 3.2%. Blood stained samples of amniotic fluid were significantly more often obtained with larger canulas , blind punctures and in cases with anterior placentas. A feto-maternal transmission of red blood cells was detected in 10 of 699 tested cases (1.4%). Serious maternal complications or fetal injuries did not occur.(ABSTRACT TRUNCATED AT 250 WORDS)

[Threatened extension of myocardial infarction in situ and coronary spasm]

The authors report a case of threatened spread occurring 4 days after posterior-inferior myocardial infarction and involving the same territory. The spontaneous occurrence during coronary angiography of an occlusive spasm of the right coronary artery with recurrence of angina and ST elevation in the area of initial necrosis suggests that this mechanism might be the contributory factor to the threat of in situ spread. Thus intermittent coronary occlusion from repeated spasm can bring about incomplete necrosis of the area of dependent myocardium and by extension threaten the viability of groups of still healthy cells. A syndrome of this kind initially requires coronary-dilating medical treatment, with nitrate derivatives and calcium inhibitors and then early coronary angiography with the use of pharmacodynamic tests to assess the suitability of surgery.

[HBs-antigen determination during pregnancy with reference to prevention of a postnatal infection in the newborn infant]

In 1980 and 1981 the blood samples of 2040 pregnant women from the Department of Obstetrics of the University Hospital of Cologne have been examined for HBs-antigen. In 37 samples (1.8%) HBs-antigen was detected. As there are considerable racial as well as geographic differences in the frequency of HBs-antigenemia, we differentiated between German and foreign women. In 10 out of 1519 (0.7%) German and in 27 out of 521 (5.2%) foreign women, respectively, HBs-antigen could be demonstrated. Only 1 woman was known to be HBs-antigen positive. Until now, 38 children have been born in the University Hospital to 33 HBs-antigen-positive mothers. After birth, 35 children received hepatitis B immune globulin (HBIG). So far, none of these immunised children exhibited signs of a hepatitis B infection--22 children have been followed up 5-19 months, and 13 children 1-4 months. Three newborns did not receive HBIG: One child was already infected at time of birth, the 2 other children were erroneously not given HBIG. One of these 2 children fell ill at the age of 5 months with clinical and serological manifestations of hepatitis B, the other child appears healthy up to date (11 weeks).

Perinatal pharmacokinetics of acetylsalicylic acid

Pregnant women were treated with infusions of acetylsalicylic acid (ASA). The plasma concentrations of total salicylate or those of ASA and salicylic acid (SA) were determined. The ASA steady state was reached after 2 h of infusion whereas 3 days seemed necessary to reach the steady state of SA. In a further study during the late phase of cervical dilatation (12 min - 2 h before birth) healthy pregnant women were given 1 g ASA as a single i.v. bolus injection. The resulting plasma levels of ASA and SA in the mothers during delivery, the plasma concentrations in umbilical cord blood and in blood obtained from the newborn several hours after birth were measured. With increasing time the SA concentrations in the umbilical cord blood plasma approached those of the mothers. On the other hand, the umbilical cord blood concentrations of ASA did not approach the maternal concentrations, probably because of the ASA esterase activity at the placental barrier. The plasma concentrations in the newborn indicated that the newborn is able to degrade ASA and to excrete SA. However, the velocities are lower than the respective velocities in adults.

[Incidence and causes of fetal and neonatal macrosomy]

Amongst the 7486 babies born at the Department of Gynecology and Obstetrics in Cologne from 1974 to 1978, 536 neonates displayed a birthweight of more than 4000 g. The obstetrically relevant data from 523 deliveries were evaluated retrospectively. We compared and contrasted the results with a reference group of 511 neonates with a normal weight (2500-3999 g) according to the matched pair principle. The incidence of macrosomic neonates amounted to 7.2% of total deliveries in the observation period. On comparing the average age of the mothers, we found a rise from 27.4 years (mothers of the reference group) to 29.4 years in mothers of babies weighing 4000-4499 g and 30.3 years in mothers with babies weighing 4500 g and more. The proportion of the pregnant mothers over 40 years old was 4.6% as compared to 2% in the reference group in macrosomic babies. The parities show a decrease of the primiparae and an increase of the multiparae amongst mothers of macrosomic babies. The rate of primiparae was 49.3% in the group of babies of normal weight as compared to 33.3% in moderately overweight (4000-4499 g) and 23.4% in the highly overweight babies (4500 g and over). The large proportion of adipose mothers in neonatal macrosomy was also striking. The average weight of the women at the end of pregnancy was 71.4 kg in the reference group and rose to 78.6 or 86.8 kg, respectively, in the mothers of macrosomic neonates. In 453 puerperal mothers who had delivered a macrosomic baby, an oral glucose tolerance test (oGTT) was performed in the first 72 hours after delivery. This was pathological in 25.8% of mothers of moderately overweight children, and was pathological in 29.7% of mothers of distinctly overweight babies. This thus confirmed the correlation between diabetogenic metabolic stress and macrosomy. Evaluation of the course of birth revealed a distinctly raised risk of asphyxia with restriction of the vitality index and increase of abnormal internal and neurological features especially for the neonates with a weight of 4500 g and more. Our goal must therefore be to diagnose macrosomy better than so far by foetal biometry in order to counteract the risks described by prospective control of pregnancy and delivery.

[Clinical study of the labour inhibiting effects an side effects of acetylsalicylic acid (ASA) (author's transl)]

In 37 pregnancy women preterm labour was inhibited with intravenous administration of ASA. 20 patients (Group I) had a combined treatment of ASA and Fenoterol. 7 pregnant women (Group II) without successful labour inhibition under Fenoterol were treated with ASA subsequently. In a third group of 10 women we administered ASA alone. The treatment was considered as successful if signs of preterm labour stopped and pregnancy maintained for 7 days or more. In the first group 16, in the second group all patients had been treated successfully. In group III we succeeded in labour inhibiting for more than 7 days in 6 cases. An initial loading dose of 5.5 to 7.0 mn/min ASA had been infused for 24 hours. If preterm labour was stopped, the dosage had been reduced. In all patients dose related but reversible symptoms of vertigo, tinnitus, headache and hyperventilation were seen. Furthermore we found a non-dose-dependent prolongation ( by 30% or normal) of bleeding time. In the fetus respectively the newborn an affection by this ASA treatment could be excluded. We propose inhibition of preterm labour by i.v. ASA administration in all pregnant women if beta-mimetic drugs are not successful or an intolerance is diagnosed. Contraindications for ASA therapy are mentioned.

[Dosage related effect of fenoterol on fetal hemoglobin oxygen affinity (author's transl)]

Fenoterol induced displacements of the fetal oxygen dissociation curve were investigated in animal experiments by determining the oxygen halfsaturation pressure (P 50). At term pregnant rabbits were infused intravenously over 3 hours with an increasing Fenoterol dosis (10 to 30 microgram/kg/min) up to a dosis level which produced complete labour inhibition. By cesarean section fetal aortic blood was collected and the oxygen halfsaturation pressure (P 50) was determined as described by Lichtman et al. (14). All P 50 values were corrected to so-called standard conditions (pH: 7.4; PCO2: 40 mmHg; t: 37 degrees C). Likewise, in a second series P 50 values were measured in newborn rabbits which received Fenoterol subcutaneously as a single shot injection. In the first series standardized P 50 significantly fell from 20.9 to 15.0 mmHg and in the second series it fell from 20.9 to 14.4 mmHg. This raised oxygen hemoglobin affinity, i.e. leftward shift of the fetal oxygen dissociation curve, is probably due to a Fenoterol induced diminution of the red cell 2.3-DPG concentration. In all cases of severe fetal hypoxia a beneficial effect on O2-transport is discussed whereas at normoxia or mild hypoxia a rightward shift of the oxygen dissociation curve would be more favourable.

[Examinations on the pathomechanism of severe cardio-pulmonary hazards under i.v. tocolytic treatment with beta-adrenergic drugs (author's transl)]

Lungs edemas in five pregnant women under i.v. tocolytic treatment with betaadrenergic drugs between the 28.--33. week of gestation are reported. Additionally, in all cases Betamethasone was given to prevent fetal lungs dysmaturity. Within less than 72 hours the occurrence of lungs edema was observed when both drugs were given simultaneously. These findings are in agreement with those of other authors, who observed similar symptoms in as well clinically healthy pregnant women under the same therapy. As the underlying pathomechanism the coincidence of the following factors are discussed: 1. An increased pressure in the pulmonary circulatory system as found in current, not yet published heart catheter investigations. 2. A reduced colloidosmotic pressure caused by Beta-methasone.