The effect of rest and intravenous infusion of hypertonic dextrose on subnormal estriol excretion in pregnancy

Urinary oestriol assay for monitoring fetoplacental function

During the years 1971-1984 urinary oestriol excretion was tested in 51,427 patients (group 1). One or more low oestriol value was found in 10.7% of patients; in this group the stillbirth rate was 6.8 times higher, the neonatal death rate 3.8 times higher, and fetal growth retardation rate 3.5 times higher than in patients with normal oestriol values (all p less than 0.00001). During the years 1985-1989 a further 20,635 patients were tested (group 2) and 7.6% had one or more low oestriol value. The perinatal mortality rate in patients with normal oestriol excretion fell from 0.8% in group 1 to 0.5% in group 2 (p less than 0.005), and in patients with low oestriol excretion from 4.2% in group 1 to 2.4% in group 2 (p less than 0.002). However, patients in group 2 with low oestriol values still had significantly unfavourable results, compared to those with normal oestriol values--stillbirth rate 3.3 times higher, neonatal death rate 4.6 times higher, and fetal growth retardation rate 3.2 times higher (all p less than 0.00001). Intravenous dextrose and aminoacid infusions were given to 967 patients who had persistently low oestriol values in spite of rest in hospital, in an attempt to correct fetoplacental function; the perinatal mortality rate was 0.9% in the 660 (68.3%) who responded favourably, and 9.8% in the 307 (31.7%) who did not respond (p less than 0.0001).

Infant development following the use of intravenous nutrition to women with persistently low urinary oestriol excretion

During the 6-year period 1971 to 1976, 10,545 patients had urinary oestriol determinations during pregnancy and 333 (3.2%) had persistently low values. Of the 335 resultant infants 206 were from patients treated with intravenous dextrose and/or amino-acids (treated group) and 129 from nontreated patients (nontreated group). The stillbirth rate was 2.4% in the treated group and 11.6% in the untreated group (p greater than 0.001), and the neonatal death rates were 2.9% and 4.7% respectively (p = NS). Assessment of the surviving infants to 7 years of age revealed no significant differences in growth between treated and nontreated groups. There was no increase in the incidence of major neurological abnormalities in the treated infants (2.9%) when compared to those from nontreated pregnancies (1.3%) (p = NS), nor was there a significant difference in the incidence of minor neurological abnormality or findings on psychological assessments. We conclude that dextrose and/or amino-acid infusions given to pregnant women with low oestriol excretion reduced the perinatal mortality rate without significant compromise to subsequent development of surviving infants.

Quality of survival of infants with critical fetal reserve detected by antenatal cardiotocography

During the 8-year period 1973 to 1980, antenatal cardiotocographic monitoring was performed on 3,006 high-risk pregnancies selected from a total obstetric population of 37,856 patients. A critical fetal reserve was detected in 72 patients (2.3%) whose pregnancies resulted in 20 perinatal deaths and 52 infants who survived the neonatal period; 45 of these infants have been assessed at ages ranging from 2 months to 8 years, 9 months. Growth was below the tenth percentile in 25.0% for weight, 23.3% for length, and 22.5% for head circumference at the review examination. Neurological abnormalities were detected in 12 infants but the abnormality was major in only four, including one who has familial interstitial polyneuropathy. The quality of survival of infants delivered of pregnancies complicated by critical fetal reserve is satisfactory; 93.2% had no neurological impairment likely to interfere with quality of life and indeed 13.5% had superior intelligence. Cardiotocographic evidence of critical fetal reserve does not signify that the fetus is doomed; delivery by cesarean section is indicated if the fetus is viable and has no ultrasonic evidence of untreatable major malformation.

Mortality and morbidity of fetal growth retardation

This study reports the fetal outcome in 500 pregnancies when the baby weighed less than the 10th centile for gestational age at birth, compared with that in a series of 500 pregnancies where there was a normal weight for gestation. Fetal growth retardation (0-9th centile) had a significant positive association with perinatal mortality (5.2% versus 1.2%, P greater than 0.001) and low oestriol excretion (42.4% versus 15%, P greater than 0.001), but not with major fetal malformations or fetal asphyxia. In the study group, 20 of the 26 perinatal deaths were associated with subnormal oestriol excretion. When severe fetal growth retardation was considered (less than the 5th centile), the associations with perinatal mortality (19%) and subnormal oestriol excretion (63%) were stronger and a significant correlation with major malformations emerged (17%, P greater than 0.001). Detection of subnormal oestriol excretion allows identification and appropriate treatment of severe fetal growth retardation which should improve survival and neurological development in these infants. This study confirms that birth-weight below the 10th centile is an appropriate definition of fetal growth retardation in terms of perinatal mortality and morbidity.

Perinatal deaths in twin pregnancy. A five-year analysis of statewide statistics in Missouri

Analysis of computer-stored State of Missouri birth and death records over a 5 year period revealed 3,594 twin pregnancies (1.02% of all pregnancies), which accounted for 10.1% of the perinatal deaths. The mean birth weight according to weeks of gestation was computed for the pregnancies with no complications noted prior to labor and the perinatal mortality rate was determined. Complications of pregnancy were evaluated. Low birth weight appears to be the major factor in the elevated perinatal death rate in twin pregnancy, with a significant elevation of the perinatal death rate noted with labor prior to 36 weeks, any episode of hemorrhage, or premature rupture of membranes. A more liberal use of cesarean section currently shows no effect in altering the perinatal mortality rate. Programs are suggested to increase early detection and appropriate consultation and referral of multiple pregnancies in a statewide comprehensive effort to decrease the perinatal mortality rate in twin pregnancy.

The significance of abnormal glucose tolerance (hyperglycaemia and hypoglycaemia) in pregnancy

Maternal hypoglycaemia (plasma glucose below 5th centile) had a highly significant association with fetal growth retardation, and perinatal mortality was significantly increased in the presence of both hypoglycaemia and hyperglycaemia (plasma glucose above 95th centile) when pregnancy outcome was analyzed in 5000 consecutive patients who had a glucose tolerance test performed during the third trimester of pregnancy. This study confirms the significance of abnormal glucose tolerance as a causative factor of feto-placental dysfunction. The flat glucose tolerance test pattern had no significance beyond the presence of associated hypoglycaemia, but reactive hypoglycaemia, and persistent abnormalities of plasma glucose levels during the test, were associated with higher incidences of complicated outcome. Hypertonic dextrose therapy administered to the patient with persistently subnormal urinary oestriol excretion was less likely to cause a favourable response in oestriol excretion if glucose tolerance was abnormal, perhaps because the adverse influences of abnormal glucose tolerance were not reversible by the third trimester of pregnancy. Hypoglycaemia and hyperglycaemia, additional to diabetes mellitus, are significant factors in the aetiology and diagnosis of abnormal pregnancy, and point to the need to investigate therapeutic measures.

The recurrence rate and significance of low oestriol excretion in successive pregnancies

A total of 440 women who had low oestriol excretion in a previous pregnancy was investigated by urinary oestriol assays in one or more subsequent pregnancies. The incidence of low oestriol excretion in the subsequent pregnancy was 29.1 per cent, or more than double that in the total obstetric population (13.4 per cent; p less than 0.001). Patients with persistently low oestriol excretion had a 40.8 per cent recurrence rate in subsequent pregnancies. When oestriol excretion was low in successive pregnancies it retained a significant association with increased incidences of stillbirths, neonatal deaths and fetal growth retardation. It was concluded that low oestriol excretion in a previous pregnancy is a definite indication to test fetoplacental function in subsequent pregnancies even when the clinical findings are normal.

Paediatric follow up of pregnancies complicated by subnormal oestriol excretion. Interim report

In 92 pregnant women with low urinary oestriol excretion after 30 weeks' gestation, there was a higher incidence of fetal distress, premature delivery and induced labour, while resuscitation of the infant at birth was required more often than in controls. The birth weights, head circumference, and body lengths of the infants were significantly lower than those of the controls. In the 26 cases where maternal oestriol levels were persistently low, three were associated with placental sulphatase deficiency, and three infants died postnatally. Four infants had evidence of neurological defects on follow up, as did four infants in the control group. The low head circumferences, weight, and length were still present at two years of age. It is concluded that, although low oestriol excretion during pregnancy is associated with increased risk to the fetus, it is not associated per se with permanent neurological damage, provided the infant is born alive, and is congenitally normal. However, many infants remain smaller than average, at least for the first years of life.

Non-pregnant maternal plasma volume and fetal growth retardation

The hypothesis that low maternal blood volume is an aetiological factor in fetal growth retardation was considered. It was found that a high proportion of women who had repeatedly given birth to small-for-dates babies had a low non-pregnant plasma volume.

Trial of intravenous therapy in women with low urinary estriol excretion

Estriol excretion in pregnancy is favourably improved following administration of 25% dextrose to patients with persistently low estriol excretion. A double-blind controlled trial was undertaken in 60 patients to assess the efficacy of other regimens of infusion therapy with Hartmann's solution, aminofusin, 10% dextrose, or ritodrine in Hartmann's solution. Estriol excretion rose above the lower limit of normal in 69% of the patients treated. There was no significant difference in success rates between the four solutions studied when subjected to analyses of variance and covariance. Fetal and placental weights were directly related to estriol excretion. Influences of the various therapeutic regimens on metabolic acidosis have been considered and possible reasons for therapeutic success discussed.

A randomized controlled trial of bed rest and sedation or normal activity and non-sedation in the management of non-albuminuric hypertension in late pregnancy

One hundred and thirty-five patients took part in a randomized controlled trial designed to determine whether bed rest and sedation are of any general benefit to either the mother or the baby in pregnancies complicated by mild non-albuminuric and non-symptomatic hypertension after the 28th week. The results suggest that they are not.

Incidence of anencephaly and other major malformations when oestriol excretion is very low

A study of 533 women with very low urinary oestriol excretion during the third trimester of pregnancy showed an incidence of major fetal malformations among their infants of 7-1% and a perinatal mortality rate of 14-6%. Thirteen of the malformations were cases of anencephaly, and 26 of the 78 perinatal deaths were due to or associated with major fetal malformations. The incidence of these complications was higher when maternal oestriol excretion was lower. Routine screening by urinary oestriol assay, with fetal radiography when values below 20-8 mumol/24 hours (6 mg/24 h) are detected is the most reliable method of detecting anencephaly before birth.

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.

The influence of abnormal glucose tolerance (hyperglycaemia and hypoglycaemia) on pregnancy outcome when oestriol excretion is subnormal

Subnormal urinary oestriol excretion was present in 611 (13.9 per cent) of 4403 consecutive patients in whom a glucose tolerance test had been performed and urinary oestriol excretion measured during the third trimester of pregnancy. Hypoglycaemia (less than 5th centile) had a significant association with subnormal oestriol excretion. The perinatal mortality rate was significantly higher in the presence of abnormal glucose tolerance when oestriol excretion was low. Normoglycaemia was associated with a perinatal mortality rate of 1.7 per cent when oestriol excretion was persistently low, whereas in the presence of hyperglycaemia (greater than 95th centile) the perinatal mortality rate was 12.5 per cent (P less than 0.01) and when there was hypoglycaemia the rate was 14.8 per cent (P less than 0.001). Small-fordates babies occurred in 46.3 per cent of pregnancies complicated by hypoglycaemia and persistently subnormal urinary oestriol excretion. The advantage of routine urinary oestriol assay and glucose tolerance testing in pregnancy is emphasized.