Attitudes of maternal-fetal specialists concerning maternal-fetal surgery

OBJECTIVE

We examined the attitudes of members of the Society for Maternal-Fetal Medicine regarding the clinical, scientific, ethical, and policy issues in maternal-fetal surgery.

STUDY DESIGN

A 43-question survey was distributed to all members of the Society for Maternal-Fetal Medicine. Two mailings and one electronic mail reminder were sent, each with instructions to submit the survey either via US mail or the Internet. The survey included questions in six categories: physician demographic data, experience with maternal-fetal surgery, views on innovative therapies, scientific validation of currently used and proposed procedures, ethical issues, and future directions in public policy.

RESULTS

Of the 1639 United States members sent questionnaires, 943 replied (response rate = 59%). Forty-seven percent had referred patients for open fetal surgery for nonlethal conditions, and 69% believed physicians were obligated to inform patients of this option. Seventy-eight percent believed that innovative therapies should be performed only under institutional review board-approved protocols. Although the majority of respondents believed that certain proposed benefits of open fetal surgery for myelomeningocele could offset the risks, the majority (56%) also indicated that the procedure has not been validated. Fifty-seven percent believed that a moratorium should be imposed on open fetal surgery for nonlethal conditions, such as myelomeningocele, until a multicenter-controlled clinical trial is completed.

CONCLUSIONS

The use of maternal-fetal surgery for nonlethal conditions is highly controversial. The majority of maternal-fetal specialists we surveyed support further research before such procedures are integrated into clinical practice.

Toward the ethical evaluation and use of maternal-fetal surgery

BACKGROUND

Important clinical, social, and ethical questions are associated with the evaluation and use of surgical approaches aimed at correcting fetal anatomic abnormalities. In particular, the expansion of maternal-fetal surgery to ameliorate nonlethal fetal conditions has intensified the need to address issues about the adequacy of technology assessment and the safety of those who undergo these novel procedures.

APPROACH

After discussions at a multidisciplinary conference, we reviewed the development and current practices of maternal-fetal surgery and analyzed the relevant ethical issues concerning the use of maternal-fetal surgery for nonlethal conditions, focusing on the correction of myelomeningocele.

FINDINGS

Characterizing nonvalidated maternal-fetal surgery procedures as "innovative therapy" blurs the boundaries between research and therapy and creates uncertainty about the obligations of clinicians and researchers. Further, maternal-fetal surgery raises ethical issues related to maternal risks and benefits, informed consent, distinguishing lethal from nonlethal conditions, withholding unproven treatments, entrepreneurship, and prioritization.

RECOMMENDATIONS

To help ensure that maternal-fetal surgery will be studied and eventually applied in a scientifically and ethically sound manner, we offer several recommendations. First, innovation in maternal-fetal surgery should be conducted and evaluated as research. Second, women must be considered research subjects in these trials. Third, the informed consent process must ensure adequate comprehension and genuine voluntariness in those considering participation. Fourth, discriminatory and fearful attitudes toward individuals with disabilities should be addressed explicitly prior to making a decision to proceed with maternal-fetal surgery in an attempt to correct such disabilities. Fifth, maternal-fetal surgery should not be performed for cosmetic indications unless and until there is reliable evidence that maternal-fetal surgery can be performed safely and that long-term side effects on women and their offspring are minimal. Sixth, centers of excellence should be established for conducting research and providing maternal-fetal surgery. Seventh, funding for research on maternal-fetal surgery should be considered in the context of societal needs.

Preconceptional health care model

During the last 10 years, there has been a movement to expand the definition of prenatal care to encompass preconceptional counseling. Major organizations throughout the world have endorsed preconceptional counseling as an integral component of care for all women contemplating pregnancy. This article will assist health care providers who interact with women of reproductive age to understand the potential benefits and limitations of preconceptional counseling and to develop an approach to that service relating to nutrition, infections, and metabolic diseases as they impact on reproductive outcome. Although there are many potential benefits of the preconception health care model, barriers to its implementation remain.

Central hemodynamic effects of oxytocin and interaction with magnesium and pregnancy in the isolated perfused rat heart

OBJECTIVE

Our purpose was to determine the cardiac effects of oxytocin in the isolated perfused rat heart model and to see whether pregnancy or pharmacologic levels of magnesium modifies the hormone's action.

STUDY DESIGN

Hearts were excised from 30 female Sprague-Dawley rats (15 pregnant, 15 nonpregnant) and attached to a Langendorf's apparatus. Heart rate, left ventricular systolic pressure, and contractility were measured. Hearts were exposed serially to 2, 4, and 6 mU/ml concentrations of oxytocin. The experiment was repeated in 15 pregnant animals at a magnesium level of 5 mEq/L.

RESULTS

Hearts from pregnant rats had lower heart rates than did hearts from nonpregnant animals. Oxytocin exposure diminished heart rate but increased left ventricular systolic pressure and contractility in a dose-dependent manner. Pregnancy did not alter this response. Magnesium levels of 5 mEq/L reversed the effects of oxytocin on contractility and left ventricular systolic pressure.

CONCLUSION

Oxytocin is a negative chronotropic and positive inotropic agent in hearts from pregnant and nonpregnant rats. Magnesium reserves the positive inotropic effects of oxytocin.

Central hemodynamic effects of recombinant human relaxin in the isolated, perfused rat heart model

OBJECTIVE

To determine the cardiac effects of relaxin in the isolated, perfused rat heart model, and to see if pregnancy modifies the hormone's actions.

METHODS

Hearts were excised from 18 female Sprague-Dawley rats (ten pregnant, eight nonpregnant) and attached to a Langendorff apparatus. Left ventricular systolic pressure, heart rate, and contractility were measured. Hearts were exposed serially to 0.5, 1.0, 2.0, 4.0, 8.0, and 16.0 ng/mL concentrations of recombinant human relaxin.

RESULTS

Hearts from pregnant rats had lower heart rates than those from nonpregnant animals. Relaxin increased heart rate, left ventricular systolic pressure, and contractility in a dose-dependent fashion. Pregnancy did not modify this response.

CONCLUSION

Recombinant human relaxin is a potent inotropic and chronotropic agent. The effects coupled with the physiologic increase of relaxin during human pregnancy indicate that relaxin may be involved in the cardiovascular changes of pregnancy.

The impact of a preconceptional health promotion program on intendedness of pregnancy

The objective for this study was to determine whether a brief preconceptional health promotion program for low-income women attending family planning clinics impacts on intendedness of pregnancy. In this prospective study, we examined data on 1378 women presenting for prenatal care at three local health departments. Each of the departments offers a standardized preconceptional health promotion program in its family planning clinics. Comparisons were undertaken for 456 women who had been exposed to the family planning preconception program, 309 women who had attended the family planning clinics but had not been exposed to the program, and 613 women who were unknown to the health department before beginning prenatal care. Women exposed to information on preconceptional health during routine family planning visits, the experimental group, had a 51.8% (p = 0.064) greater likelihood of identifying their pregnancies at intended than a group known to the local health departments' family planning programs but unexposed to the intervention. Furthermore, the experimental group had a 64.2% (p = 0.0009) greater likelihood of intendedness than a comparison group not known to the health departments before the initiation of prenatal care. Our study indicates that an introductory program of preconceptional health promotion which is targeted to women not planning a pregnancy in the immediate future is associated with a higher rate of intendedness in subsequent pregnancies. Expansion of similar preconceptional programs in family planning clinics may prove a useful approach for promoting intendedness of pregnancy in low-income women.

Effects of cocaine administration during early organogenesis on prenatal development and postnatal growth in mice

Cocaine use has been associated with adverse developmental effects in humans. However, clinical reports both confirm and deny an association between cocaine use and malformations. Similarly, differences in species and strain, as well as route and timing of cocaine administration, have added to the difficulties in determining the teratogenicity of cocaine in animal models. This study was undertaken to compare the effects of dose, route, and timing of cocaine administration in ICR mice during early organogenesis. A single intraperitoneal (ip) administration of cocaine ( > or = 60 mg/kg) on Day 9 of gestation (plug day = 1) produced maternal lethality. The predominant developmental effect of cocaine administration was an increase in the percentage of litters exhibiting an enlarged renal pelvis. Despite a high incidence of affected pups at these doses, the enlargement was not severe. These results, in agreement with previous reports, provide further evidence that the developing urogenital system is sensitive to cocaine administration. When cocaine was administered using a subcutaneous route, pup weights were greater and the incidence of enlarged renal pelvis was lower than when an ip route was used. To better mimic human binge cocaine abuse, the toxicity of a "split dose" was determined. A 60 mg/kg dose was administered using one administration of 60 mg/kg, two treatments of 30 mg/kg, or three administrations of 20 mg/kg with 1 hr separating the treatments. The incidence of enlarged renal pelvis was similar when cocaine was administered as one or two but was decreased when cocaine was administered as three treatments. Both the route and split-dose studies suggest that high-peak serum concentrations are required to perturb development. There were no differences in the incidence or severity of enlarged renal pelvis when cocaine was administered on Day 8, 9, or 10 or on all 3 days of gestation. This suggested that the increase in enlarged renal pelvis may not be a specific teratogenic effect of cocaine administration but may be a delay of normal development induced by cocaine exposure during this early period of organogenesis. To address this hypothesis, cocaine was administered on Day 9 using an ip route and the pups were allowed to be naturally born. In pups whose mothers received cocaine there was an increase in postnatal deaths and a trend toward a reduction in pup body weight/litter at Postnatal Day 21. However, when renal morphology was assessed on Postnatal Day 21 no abnormal kidneys were seen. This supports the hypothesis that enlarged renal pelvis produced by cocaine administration during early organogenesis represents a developmental delay and not a persistent teratogenic defect. These studies suggest that high peak cocaine concentrations are required to delay normal kidney morphogenesis in mice.

Breast-feeding education of obstetrics-gynecology residents and practitioners

OBJECTIVE

Our purpose was to assess breast-feeding education, knowledge, attitudes, and practices among resident and practicing obstetrician-gynecologists.

STUDY DESIGN

A mailed survey was administered to a national sample of resident and practicing obstetrician-gynecologists.

RESULTS

Response rates were 64% for residents and 69% for practitioners. Residency training included limited opportunity for direct patient interaction regarding breast-feeding; 60% of practitioners recommended that training devote more time to breast-feeding counseling skills. Only 38% of residents reported that obstetric faculty presented breast-feeding topics; more common sources were nursing staff and other residents. Practitioners rated themselves as more effective in meeting the needs of breast-feeding patients than were residents; prior personal breast-feeding experience was a significant influence on perceived effectiveness. Almost all respondents agreed that obstretician-gynecologists have a role in breast-feeding promotion, but significant deficits in knowledge of breast-feeding benefits and clinical management were found.

CONCLUSION

Residency training and continuing education programs should create opportunities to practice breast-feeding promotion skills and emphasize management of common lactation problems.

Preconception care: a means of prevention

Preconceptional health promotion should provide a prevention framework for interactions with all women of childbearing potential. Preconceptional counselling is properly directed by specialists in the field of obstetrics and gynaecology, but a multispecialty effort may be needed to achieve adequate information for decision-making. Preconceptional health care offers an important opportunity for physicians involved in women's health to expand a primary care and a primary prevention focus. The obstetrician or gynaecologist is not only involved in acute diagnosis and treatment plans but also in disease prevention, risk and behaviour modification and counselling, which are integral parts of primary prevention and co-ordinated women's health care.

Pregnancy in a patient with eosinophilic granulomatosis of the lung: a case report

BACKGROUND

There are three syndromes of histiocytosis X: eosinophilic granulomatosis of the lungs, Hand-Schüller-Christian disease, and Letterer-Siwe disease. Although there have been five case reports of Hand-Schüller-Christian disease in pregnancy, we found none describing pregnancy in patients with eosinophilic granulomatosis.

CASE

We present a report of eosinophilic granulomatosis of the lungs in pregnancy. The patient's pregnancy was complicated by fetal growth retardation (FGR) and oligohydramnios, but resulted in the delivery of a healthy infant. Her pulmonary disease remained stable.

CONCLUSION

Pregnancy does not appear to exacerbate pulmonary eosinophilic granulomatosis. In this patient, pregnancy was complicated by FGR and oligohydramnios. This case report may be valuable in counseling patients with eosinophilic granulomatosis who are currently pregnant or contemplating pregnancy.

Estrogen mediates the pregnancy-enhanced cardiotoxicity of cocaine in the isolated perfused rat heart

OBJECTIVE

To determine whether pregnancy enhances cocaine toxicity in the isolated perfused whole rat heart model and whether this enhanced toxicity can be simulated by pre-treatment with either estrogen or progesterone.

METHODS

Hearts excised from 65 female Sprague-Dawley rats were attached to a Langendorff apparatus for measurement of left ventricular systolic pressure, heart rate, and contractility. Before excision, the animals were assigned to one of five groups: 1) nonpregnant, 2) pregnant, 3) nonpregnant pretreated with progesterone, 4) nonpregnant pretreated with estrogen, and 5) nonpregnant pretreated with estrogen and progesterone. Each group was exposed serially to the following cocaine concentrations: 5 x 10(-6), 1 x 10(-5), and 6 x 10(-5) mol/L.

RESULTS

Heart rate declined at all doses of cocaine (9.2, 6.9, and 31.0%, respectively). The lowest dose of cocaine had positive inotropic effects, with a 23.2% increase in left ventricular pressure and a 15.3% increase in contractility. Exposure to the two higher doses resulted in negative inotropic effects (a 24.8% decrease in left ventricular pressure and a 39.7% decrease in contractility for the highest dose). Although pre-treatment with estrogen, alone or with progesterone, resulted in responses similar to those seen in pregnant animals, progesterone pre-treatment alone failed to do so.

CONCLUSIONS

Cocaine displayed cardiotoxicity in isolated rat hearts similar to that in other animal models. This toxicity was enhanced by pregnancy. We were able to simulate changes by pretreating the animals with estrogen. Perhaps the enhanced cardiotoxicity of cocaine in pregnancy is partially mediated by estrogen.

Group B streptococci: results of a protocol of antepartum screening and intrapartum treatment

OBJECTIVE

Our purpose was to evaluate and report the results of a protocol for the identification and treatment of all group B streptococcal carriers.

STUDY DESIGN

In 1991 we instituted a protocol of antepartum cultures for group B streptococci on all pregnant women who attended clinics at the University of North Carolina Hospitals. Cultures were obtained from the lower third of the vagina and rectum at 24 to 28 weeks' gestation. Women with positive cultures were treated with intravenous antibiotics in labor. Women with signs of chorioamnionitis (through intrapartum assessment) were also treated in labor, regardless of carrier status.

RESULTS

During the first 2 years of this protocol 1681 women were delivered. Forty percent of the women were from the private practice, 32% were black, and 62% were married. The group B streptococcal carriage rate was 14%. During the period of evaluation there were no infants infected with group B streptococci and no adverse reactions or complications among women who were treated with antibiotics.

CONCLUSION

We found antepartum screening and intrapartum chemoprophylaxis of all group B streptococcal carriers to be an acceptable and effective protocol for reducing perinatal group B streptococcal infections.

Central hemodynamic effects of cocaine and ritodrine in the isolated, perfused rat heart

OBJECTIVE

To explore the cardiac interactions of cocaine and ritodrine in pregnancy.

METHODS

Using the isolated, perfused rat-heart model, hearts from pregnant Sprague-Dawley rats were exposed to increasing concentrations of ritodrine: 25, 50, 100, and 250 ng/mL. Hearts of half of the animals, the experimental group, were exposed to cocaine (5 x 10(-6) mol/L). Left ventricular systolic pressure, heart rate, and contractility were measured.

RESULTS

Ritodrine had marked positive inotropic and chronotropic effects. Cocaine exposure resulted in smaller increases in all indices.

CONCLUSION

Cocaine blunted but did not obliterate the cardiac stimulatory effects of ritodrine in this model.

The bioethics of human fetal tissue research and therapy: moral decision making of professionals

OBJECTIVE

We investigated the decision making of professionals regarding the ethical acceptability of using human fetal tissue from elective abortion for research or therapy.

STUDY DESIGN

We surveyed 390 professionals from 20 European countries on their ethical beliefs regarding the scientific and medical use of human fetal tissue from elective abortion. We assessed the importance of basic medical ethics and beliefs regarding the morality of abortion and fetal rights to their decision making.

RESULTS

Sixty-six percent of 198 responding professionals believed that use of fetal tissue from elective abortion was ethically acceptable. Beliefs regarding the morality of elective abortion and fetal exploitation overwhelmingly influenced individual ethics regarding fetal tissue research or therapy.

CONCLUSION

Ethical decision making is a dynamic process and individuals are not altogether consistent in their beliefs. The important public policy issues raised in this study concern the rights of the dead fetus, whether these rights are exploited through fetal tissue therapy, and whether women's right of authority over the disposition of aborted fetal tissue is abdicated.

Do nifedipine and verapamil potentiate the cardiac toxicity of magnesium sulfate?

We hypothesized that verapamil and nifedipine would potentiate the cardiac toxicity of magnesium in a dose-dependent manner. The hypothesis was tested in the isolated perfused rat heart model (Langendorff's apparatus) with Sprague-Dawley rats. After excision of hearts, each heart was exposed to increasing doses of verapamil and nifedipine followed by magnesium sulfate. Heart rate, contractility, and left ventricular systolic pressure were measured. Nifedipine and verapamil infusion in this model caused dose-dependent decreases in all three parameters measured (p values 0.05 to 0.01). The addition of magnesium sulfate potentiated these dose-dependent decreases (p values 0.01 to 0.0002). Nifedipine and verapamil caused similar depression at equivalent doses. Nifedipine and verapamil cause dose-dependent cardiac depression that is potentiated by the addition of magnesium sulfate in the isolated perfused rat heart. Caution is called for when magnesium sulfate and calcium channel blockers are administered in combination.

Spontaneous resolution of hypofibrinogenemia in a triplet gestation associated with second trimester in utero death of two fetuses

Multiple gestations are increasing in frequency secondary to assisted reproductive technologies; therefore, it will become increasingly important to know how to manage a multiple pregnancy in which an in utero fetal death has occurred. This case report describes the spontaneous resolution of maternal hypofibrinogenemia associated with the deaths of two fetuses in a triplet gestation. A 29-year-old woman with a triplet gestation had in utero death of two monoamniotic fetuses between 15 and 17 weeks' gestation. Maternal plasma fibrinogen levels were obtained weekly and were initially in the normal range for pregnancy. At 31 weeks' gestation, the fibrinogen level decreased to 239 mg/dl and reached a nadir of 150 mg/dl 11 days later. Although the patient received no treatment, her fibrinogen level increased to 307 mg/dl over the next 4 days and then remained above 260 mg/dl for the rest of her pregnancy. At 35 weeks' gestation, a healthy 2090 gm female was delivered. The infant is alive and well and developing normally. When there is an in utero death of one fetus of a multiple gestation in the second or early third trimester, some authors advocate heparinization to reverse maternal coagulopathy; others describe spontaneous resolution of hypofibrinogenemia. The role of heparin in treating hypofibrinogenemia remains unclear. Hypofibrinogenemia may resolve spontaneously without exposing the patient to the potentially serious risks associated with heparin therapy.

The pharmacokinetics of recombinant human relaxin in nonpregnant women after intravenous, intravaginal, and intracervical administration

The pharmacokinetics of recombinant human relaxin (rhRlx) after intravenous (iv) bolus administration and the absorption of rhRlx after intracervical or intravaginal administration were determined in nonpregnant women. The study was conducted in two parts. In part I, 25 women received 0.01 mg/kg rhRlx iv. After a minimum 7-day washout period, these women were dosed intracervically (n = 10) or intravaginally (n = 15) with 0.75 or 1.5 mg rhRlx, respectively, in 3% methylcellulose gel. Part II was a double-blind, randomized, three-way crossover study in 26 women. At 1-month intervals, each woman received one of three intravaginal treatments consisting of 0 (placebo), 1, or 6 mg rhRlx in 3% methylcellulose gel. The serum concentrations of relaxin following iv administration were described as the sum of three exponentials. The mean (+/- SD) initial, intermediate, and terminal half-lives were 0.09 +/- 0.04, 0.72 +/- 0.11, and 4.6 +/- 1.2 hr, respectively. Most of the area under the curve was associated with the intermediate half-life. The weight-normalized clearance was 170 +/- 50 mL/hr/kg. The observed peak concentration was 98 +/- 29 ng/mL, and the weight-normalized initial volume of distribution was 78 +/- 40 mL/kg, which is approximately equivalent to the serum volume. If central compartment elimination was assumed, the volume of distribution at steady state (Vss/W) was 280 +/- 100 mL/kg, which is approximately equivalent to extracellular fluid volume. Vss/W could be as large as 1300 +/- 400 mL/kg without this assumption.(ABSTRACT TRUNCATED AT 250 WORDS)

Thermoregulation of pregnant women during aerobic exercise on land and in the water

Seven women in their 25th week of pregnancy exercised for 20 minutes on a cycle ergometer at 70% of their maximal heart rate on land and in the water (30 degrees C) to compare thermoregulatory responses. Rectal temperatures increased 0.5 +/- 0.1 degrees C during the land trial and only 0.2 +/- 0.1 degrees C during the water trial (p < 0.05). Mean body temperature rose 0.6 +/- 0.2 degrees C during the land trial, but declined -0.3 +/- 0.1 degrees C during the water trials (p < 0.05). Land exercise caused greater heat storage and sweat loss. The results suggest that normal pregnant women can maintain thermal balance during 20 minutes of exercise at 70% maximal heart rate, whether on land or in the water. Thus, for normal, average fit, pregnant women who wish to participate in a moderate exercise program, heat stress is probably not a major concern.

Prenatal diagnosis and caring

Although the science of prenatal diagnosis is rapidly expanding, the art of caring for these patients is poorly understood and taught. Prenatal diagnosis programs must acknowledge the psychosocial consequences of electing to undergo prenatal testing, receiving either normal or abnormal test results, and choosing to continue or terminate a pregnancy with an identified fetal defect. There are suggestions from the literature of interventions to assist families under these circumstances (Table 3). Prospective studies of patient adaptation are needed; however, on the basis of the retrospective studies and common sense, a reasonable plan for patient support and care can be established. Prenatal diagnosis programs must demand not only excellent medical knowledge and technical expertise but also compassionate and continued care for the patient, her partner, and family.

Effect of daily immersion on the edema of pregnancy

To evaluate whether pregnant women become refractory to the effects of immersion, we studied 11 healthy women from 26 to 38 weeks' gestation, immersed in 34 degrees C shoulder-deep water for 4 or 5 consecutive days. The daily immersion diuresis showed no change throughout the study (p = 0.98: mean, 145 ml, 159 ml, 159 ml, 173 ml, 184 ml, day 1 through day 5, respectively). The range of urine volumes was broad, 35 to 675 ml, depending on the subject's degree of edema. Immersion produced a significantly larger diuresis compared with preimmersion values, 162 ml versus 110 ml. Maternal blood pressure and heart rate consistently fell during immersion, and this effect was maintained for each day studied. The subjects' hematocrit, hemoglobin, and total protein were unchanged from a preimmersion sample on day 1 to a postimmersion sample on the last day of the study. The results of this study indicate that pregnant women do not become refractory to the hemodynamic and diuretic effects of immersion.

Elemental mercury exposure in early pregnancy

We present a case of first-trimester elemental mercury exposure and review the literature to demonstrate that the reproductive toxicity of mercury varies depending on the form of mercury to which one is exposed. It appears that elemental mercury exposure poses less of a reproductive threat than the well-known hazards of exposure to organic mercurials. It is critical to determine the form of exposure when counseling patients at risk.

Immune thrombocytopenic purpura in pregnancy: a reappraisal of management

Management and, particularly, mode of delivery of the pregnant patient with immune thrombocytopenic purpura (ITP) are controversial. We reviewed our experience with 31 pregnancies in 25 women with ITP over a 10-year period. Fourteen infants were born vaginally and 18 by cesarean. Six major complications occurred among mothers delivered by cesarean, whereas none occurred among those born vaginally (P = .028). Three of 32 infants were born with moderate thrombocytopenia (platelet count 51-100 x 10(9)/L) and two with severe thrombocytopenia (platelet count 50 x 10(9)/L or less); there were no clinically significant complications in these infants. No maternal characteristic could be used to predict the neonatal platelet count. In an analysis of 474 infants of mothers with ITP reported in the literature and including the present series, 10% were born with moderate thrombocytopenia and 15% with severe thrombocytopenia. The overall rate of intracranial hemorrhage in newborns with moderate or severe thrombocytopenia was 3%. No significant association was found between the rate of intracranial hemorrhage and delivery mode for moderately and severely thrombocytopenic neonates together (weighted odds ratio 1.69, 95% confidence interval 0.14-44.6) or for those with severe thrombocytopenia (crude odds ratio 1.38, 95% confidence interval 0.07-84.67). We conclude that the mode of delivery may not affect the rate of intracranial hemorrhage in thrombocytopenic newborns.

Characteristics of neonatal intensive care unit patients in North Carolina: a cross-sectional survey

A shortage of neonatal intensive care facilities has been encountered in some areas of the country including North Carolina. To examine possible solutions to this health care delivery problem, a cross-sectional survey of all the neonatal intensive care units in North Carolina was performed to examine characteristics of patients occupying the beds in these facilities. It was found that a substantial amount of chronic care is now occurring in neonatal intensive care beds, with 38% of occupants of neonatal intensive care beds being 31 days of age or older and 3% being mechanically ventilated at 91 days of age or older. In addition, according to criteria established for this study, a substantial number of "convalescent" patients (32%) were occupying beds in neonatal intensive care units. It is concluded that an increase in both intermediate/convalescent care beds and establishment of chronic care facilities in North Carolina, rather than an increase in intensive care beds in these units, would alleviate the shortage of neonatal intensive care facilities. Further, the characteristics of the population occupying neonatal intensive care unit beds should be considered by health planners in addition to occupancy rate, when new facilities are being established.

Unexplained elevations of maternal serum alpha-fetoprotein

Alpha-fetoprotein (AFP) is a commonly used prenatal screening test for congenital anomalies. However, when anomalies are excluded after high resolution ultrasound and/or amniocentesis, an elevated maternal serum AFP (MSAFP) has been found to be associated with a 2- to 4-fold increase in low birthweight resulting from both preterm delivery and intrauterine growth retardation. Unexplained MSAFP elevations are also associated with up to 10-fold increase of placental abruption and a 10-fold increase in perinatal mortality. Results from studies of over 225,000 screened pregnancies indicate that 20 and 38 per cent of women with an unexplained MSAFP elevation may have an adverse pregnancy outcome. Twin gestations with MSAFP elevations greater than four multiples of the median are associated with similar constellations of pregnancy complications. Maternal serum AFP elevations in women with pregnancy complications are most likely the result of a leak of AFP across the placenta. Optimum management of women with unexplained elevations has not yet been established; however, evaluation of fetal growth throughout gestation is important in these patients.

The thermoregulation of pregnant women during aerobic exercise in the water: a longitudinal approach

Twelve women early in their pregnancies were recruited to examine thermoregulation during immersion and exercise in the water (30 degrees C). Their responses were compared at 15, 25 and 35 weeks of pregnancy as well as 10-12 weeks post pregnancy to determine whether the responses differ between the gravid and non-gravid woman or were modified during pregnancy. Rectal temperature, mean skin temperature, heat storage, and evaporation were similar during immersion or exercise during the 15th, 25th and 35th weeks of pregnancy. Compared to 10 weeks post partum, pregnancy reduced heat storage, lowered skin temperature and increased evaporative heat loss during immersion and exercise (P less than 0.05). The results suggest that pregnancy causes subtle changes in the mechanism of thermoregulation which tend to increase heat production and improve heat conservation.

Nifedipine enhances the cardiac toxicity of magnesium sulfate in the isolated perfused Sprague-Dawley rat heart

Magnesium sulfate is commonly used in tocolytic regimens and as prophylaxis against seizures. Nifedipine may be used simultaneously in either situation. With the isolated perfused rat heart model (Sprague-Dawley rats), we investigated the effects of these agents on cardiac function. Whereas each agent alone depressed cardiac performance, the two drugs together had maximal depressive effects on the heart.

Terms of confinement

Through habit we have chosen words to describe antepartum, intrapartum, and postpartum events that are domineering and restricting and that are consistent with imprisonment. We must be cognizant of the potential impact of our language.

Nonweightbearing exercise during pregnancy on land and during immersion: a comparative study

Seven women at 25 weeks' gestation exercised on land and in the water at 70% maximum oxygen capacity (VO2max) on a bicycle ergometer. Women had significantly lower heart rates and lower systolic blood pressures during immersion exercise. Women had a mean diuresis of 207 ml (6.5 ml/min) during water exercise compared with 98 ml. (2.4 ml/min) during land exercise. Fetal heart rates showed a tendency toward being higher after land exercise compared with water exercise. Six of seven fetuses displayed tachycardia after land exercise compared to one of seven after water exercise. Exercise on land and during immersion at 70% VO2max was well tolerated. However, exercise during immersion offers several physiologic advantages during pregnancy.

Magnesium sulfate tocolysis in selected patients with symptomatic placenta previa

Tocolysis can be used to arrest contractions in selected patients with placenta previa if the maternal condition is stable. Over a 5-year period, 41 patients with symptomatic placenta previa were treated, of whom 18 were given magnesium sulfate therapy for tocolysis. The mean prolongation of gestation was 18.5 days, and tocolysis was successful in 17 of 18 cases. Since betamimetic drugs used for tocolysis may mask or blunt maternal cardiovascular responses to volume depletion, magnesium sulfate is a better choice to inhibit contractions in patients with symptomatic placenta previa whose bleeding is mild or moderate.

Renal responses to immersion and exercise in pregnancy

Twelve healthy pregnant women were studied at 15, 25, and 35 weeks' gestation and at 8 to 12 weeks postpartum. Women were immersed for 20 minutes at 30 degrees C. They then exercised at 60% maximum oxygen capacity on a modified ergometer. Substantial diuresis and natriuresis occurred without changes in osmolarity or serum sodium. The diuresis was significantly greater during pregnancy than postpartum. The natriuresis was similar. Diuresis and natriuresis were greater than would be expected from investigations in nonpregnant subjects. This study suggests that immersion may be a beneficial therapy for edema without decreasing plasma volume.

Epidural analgesia and autonomic hyperreflexia: a case report

Autonomic hyperreflexia is a serious complication for paraplegic patients. A paraplegic woman in early labor presented with autonomic hyperreflexia. After epidural analgesia was established, hyperreflexia resolved. When the analgesic wore off, hyperreflexia returned. Continuous epidural analgesia may be helpful for pregnant women who are susceptible to autonomic hyperreflexia.

A comparison of bed rest and immersion for treating the edema of pregnancy

Bed rest and immersion both lead to a mobilization of extravascular fluid and thus reduce edema. This study compared three treatments for edema in healthy pregnant women in the third trimester: lateral supine bed rest at room temperature, sitting in a bathtub of waist-deep water at 32 +/- 0.5C with legs horizontal, and sitting immersed in shoulder-deep water at 32 +/- 0.5C with legs extended downward. Post-treatment diuresis was selected as the indicator of extravascular fluid mobilization. The mean (+/- SD) diuresis was 105 +/- 48, 161 +/- 155, or 242 +/- 161 mL/hour for bed rest, bathtub, and immersion tank, respectively (P less than .008, tank versus bed rest; P less than .05, tank versus bath). In all treatments, mean arterial pressure (MAP) declined from a baseline value of 88 +/- 9 to 77 +/- 10 mmHg 25 minutes into treatment and 77 +/- 11 mmHg at 50 minutes (both P less than .0001 compared with pre-treatment). Shoulder-deep immersion produced the greatest decline in MAP. Sodium clearance increased from 0.7 to 1.0 mEq/minute in all treatments (P less than .01). Serum sodium, potassium, creatinine, osmolarity, total protein, 6-keto prostaglandin F1 alpha, and plasma volume did not change significantly after the treatments. Serum prolactin declined significantly from 137.8 +/- 44 to 124 +/- 31 ng/mL after treatment; there was no difference among treatments. Immersion appears to be a safe and more rapid method than bed rest to mobilize extravascular fluid during pregnancy.

The effects of immersion and exercise on prolactin during pregnancy

Prolactin is an important hormone during pregnancy, affecting mother, fetus, and amniotic fluid volume. Immersion is known to affect prolactin levels significantly. To determine the effect of immersion and exercise on the prolactin response during pregnancy, we examined serum prolactin levels at 15, 25, and 35 weeks' gestation and 10 weeks post partum. Twelve women completed 20 min land rest, 20 min immersion in 30 degrees C water to the xiphoid, and 20 min exercise in the water at 60% VO2max. Resting prolactin levels were 1.91 +/- 0.32, 4.55 +/- 0.5, and 5.85 +/- 0.27 nmol.l-1 +/- standard error of the mean at 15, 25, and 35 weeks' gestation, respectively. Postpartum lactating women had a resting mean prolactin level of 3.95 +/- 1.6 versus 0.22 +/- 0.4 nmol.l-1 in non-lactating women. Prolactin levels declined significantly during immersion even after correction for dilution by plasma volume shifts. The immersion response was inversely related to the duration of pregnancy with 29%, 22%, and 12% drops during 15-, 25- and 35-week trials, respectively. Compared to rest, exercise prolactin levels remained depressed during the 15th and 25th week trials. We hypothesize that immersion in water caused prolactin levels to decline.

An epidemiologic study of contraception and preeclampsia

The primary hypothesis of this study was that contraceptive methods that prevent exposure to sperm and seminal fluid (condoms, diaphragms, spermicides, withdrawal) are associated with an increased risk of developing preeclampsia during the subsequent pregnancy. A case-control study was conducted comparing the contraceptive and reproductive histories of 110 primiparous women with preeclampsia with 115 pregnant women without preeclampsia, aged 15 to 35 years, who gave birth at North Carolina Memorial Hospital, Chapel Hill, between 1984 and 1987. Controls were frequency matched to cases by age, race, and distance from the hospital. Unconditional logistic regression analysis indicated a 2.37-fold (95% confidence interval, 1.01 to 5.58) increased risk of preeclampsia for users of contraceptives that prevent exposure to sperm. A dose-response gradient was observed, with increasing risk of preeclampsia for those with fewer episodes of sperm exposure. These results were supportive of the hypothesis that birth control methods that prevent sperm exposure may play a role in the etiology of preeclampsia.

The zygote: to be or not be a person

It is no longer possible to claim that the biological characteristics of the future adult are already determined at conception. After all, a zygote may develop into a hydatidiform mole rather than into a human being. The development of an individual human person is determined by genetically and non-genetically coded molecules within the embryo, together with the influence of the maternal environment. Consequently, it is an error to regard the zygote's chromosomal (and other) DNA as sufficient to determine the uniqueness of the future individual.

Pseudotumor cerebri and pregnancy

We reviewed 11 pregnancies complicated by pseudotumor cerebri over a 6-year period for an incidence of approximately 1 in 870 births. No pregnancy was adversely affected, but symptoms of pseudotumor increased in 9 of 11 pregnancies. All patients were managed medically, 9 of 11 with analgesics and diuretics. Two cases required steroid therapy.

Hypersensitivity to magnesium sulfate

Two patients who were labor and delivery nurses were treated with intravenous magnesium sulfate because of preterm labor. Both patients had a rapid and sudden onset of an urticarial eruption. The eruption cleared when magnesium sulfate was discontinued. The reactions did not affect the mothers or fetuses, but other therapies to stop labor were necessary.

Pregnancies among physicians. A historical cohort study

Sixty-seven pregnancies in practicing physicians were compared with 201 pregnancies in nonphysicians in a historical cohort study. All subjects were cared for and delivered by the same obstetricians. Physician and nonphysician pregnancies of similar socioeconomic status were matched for age, race and parity. After statistically controlling for alcohol and tobacco use and adequacy of prenatal care, physicians had a 1.86 (1.00, 3.46) relative risk of an adverse pregnancy outcome. Physicians were at a 4.0 (1.58, 10.1) and 2.33 (0.93, 5.8) times higher risk for preterm labor and delivery than were nonphysicians. Pregnancies in physicians were found to be similar to those in nonphysicians in the use of obstetric technology except for an increased number of ultrasound examinations among physicians. These results suggest that physicians are at increased risk for an adverse pregnancy outcome and should be considered and treated as a high-risk obstetric group.

Effects of terbutaline sulfate on fetal cardiac function

An isolated heart preparation was used to study the effects of terbutaline sulfate (Brethine) on fetal cardiac function. Pregnant guinea pigs received daily subcutaneous injections of terbutaline for 10 day, whereas a control group received placebo injections. Fetal guinea pig hearts were evaluated for cariodynamic and pathologic differences. Fetuses exposed to terbutaline demonstrated a higher mean heart rate (p less than 0.01), a higher mean heart weight (p less than 0.05), a higher mean heart weight/body weight ratio (p less than 0.01), and a trend toward higher left ventricular systolic pressure levels (p less than 0.1). These hemodynamic responses in fetuses exposed to terbutaline may result in increased functional demands that may predispose myocardial tissue to damage.

Maternal death from carotid artery thrombosis associated with the syndrome of hemolysis, elevated liver function, and low platelets

A case is presented of cerebral infarction secondary to carotid artery thrombosis in a patient with hemolysis, elevated liver function, and low platelets (HELLP) syndrome. The patient's rebound thrombocytosis may have contributed to a hypercoagulable state. Severe preeclamptic patients with HELLP syndrome who experience a reactive thrombocytosis may represent a subset of women who have postpartum thrombosis.

The use of fetal and anencephalic tissue for transplantation

Advances in transplantation have extended the life and relieved the suffering of thousands of individuals. The prospect of being able to use tissues from embryos, as well as from anencephalic newborns, offers the promise of further relief of suffering. However, these possibilities raise significant moral and public policy issues. The question arises of the extent to which those who disapprove of abortion may make use of tissues derived from abortion in order to treat serious diseases. This essay argues that, with proper safeguards, such tissue can be used without cooperating in abortion. That is, even those who oppose abortion can benefit from the use of tissue procured during abortion. Questions also arise regarding the probity of maintaining a pregnancy in order to produce an anencephalic newborn whose biological existence will be maintained so as better to secure organs once death is declared. It is argued that, since no harm can be done to a being that has neither a sense of self or the capacity to feel pain, and since women have a right to forego abortions, there is no legitimate ground for opposing women's seeking meaning in their pregnancy through maximizing the opportunity of others to use the organs of their anencephalic newborn once death has been declared. Finally, it is argued that, since the capacities for sentience, a minimal condition for personhood, are never realized by an anencephalic, the entity has never been alive as a person. Therefore, there should be no opposition in principle to aborting anencephalics nor, after proper declaration, to making their organs available as one would after whole-brain death, despite the continued functioning of the brain stem.

Cardiovascular responses of pregnant women during aerobic exercise in water: a longitudinal study

To determine the effects of pregnancy on the cardiovascular responses to immersion and exercise in water, 12 women completed 20 min of immersion and 20 min of bicycle ergometry at 60% predicted VO2max in 30 degrees C water during their 15th, 25th, and 35th week of pregnancy as well as 8-10 weeks post partum. Immersion lowered the resting heart rate approximately 8 bts/min (P less than 0.05). Exercise in water also resulted in a lower heart rate as compared with the same level of exercise on land (132 +/- 4 vs 149 +/- 6 bts/min; P less than 0.05). Both the rest and exercise heart rate responses were independent of duration of pregnancy or pregnancy status. Post partum exercise cardiac output averaged 9.9 +/- 0.4 l/min, significantly lower (P less than 0.05) than the 15th (12.7 +/- 0.5), 25th (14.7 +/- 0.5), or 35th week (15.1 +/- 0.7 l/min). Total peripheral resistance was greatest (P less than 0.05) post partum (657 +/- 29 dyn.s/cm5) compared with either the 15th (515 +/- 27), 25th (407 +/- 18), or 35th week (450 +/- 23). The results indicate that exercise in water lowers the heart rate compared with land exercise at the same metabolic rate. The combined effect of exercise, water, and pregnancy may elevate the cardiac output more than expected on land, but the same general pattern of exercise response will be evident throughout the duration of pregnancy. The results further suggest that water alters the heart rate and blood pressure responses such that land-derived exercise target heart rates should not be used to prescribe exercise intensity in water.

Immunoglobulin levels in fetal anatomic compartments

Immunoglobulins G, M, and A were found in varying concentrations in four different human fetal anatomic compartments of 17 fetuses in the absence of apparent infection. The highest levels were noted in the thoracic cavity.

Elevated maternal serum alpha-fetoprotein with oligohydramnios: ultrasound evaluation and outcome

Nineteen pregnancies evaluated for elevated maternal serum alpha-fetoprotein levels were found to have moderate to severe oligohydramnios. There were no survivors among six fetuses with ultrasound-diagnosed urinary tract anomalies. We followed 11 of the remaining 13 pregnancies with serial ultrasound examinations. When the second ultrasound examination demonstrated severely decreased amniotic fluid, the outcome was always poor (intrauterine death, perinatal death, or fetal deformations). Of the five cases in which the second ultrasound showed normal to moderately decreased fluid, there were four surviving infants. When no primary malformations are seen on the initial ultrasound examination, serial ultrasound evaluations of amniotic fluid volume help predict the pregnancy outcome.

Fetal and uterine responses to immersion and exercise

We evaluated the responses of the fetal-maternal unit to immersion and exercise in the water at 15, 25, and 35 weeks' gestation. As seen by underwater ultrasound, fetuses demonstrated body, limb, and breathing movements. Fetal heart rates (FHRs) were normal, and unchanged from those at rest, during maternal exercise in the water at 60% VO2 maximum. In 21 of 23 cases, post-exercise nonstress tests were reactive within ten minutes. There was no uterine activity seen at either 25 or 35 weeks' gestation. Maternal serum alpha-fetoprotein was unaffected at all gestational ages. Neither maternal temperature nor calculated plasma volume changed during exercise. This general lack of effect contrasts with results from other studies involving similar levels of exercise on land. We speculate that the plasma volume expansion with immersion contributes to the normal FHR responses seen in this study.

Determinants of fetal heart rate response to vibroacoustic stimulation in labor

To determine whether the fetal heart accelerates in response to a sound stimulus in labor, 40 women at various stages of labor were chosen at random to receive either a vibroacoustic stimulus or sham stimulus over the fetal head. Subsequent fetal heart rate (FHR) accelerations occurred to a significantly greater extent in study patients. One hundred thirty-two high- and low-risk patients were studied to determine correlations between the acceleration response and other maternal and fetal variables. There was a statistically significant negative correlation between the heart rate response to stimulation and three maternal variables: the degree of cervical dilation, the presence of ruptured membranes, and use of epidural anesthesia. The degree of fetal response did not correlate significantly with fetal distress at delivery or abnormal FHR tracings at the time of stimulation. Fewer than one-fifth of the fetuses manifested variable heart rate decelerations after the stimulation. In light of possible risks, the clinical use of the fetal acoustic stimulation test in labor should wait until its diagnostic value is better defined.

The effect of pregnancy on metabolic responses during rest, immersion, and aerobic exercise in the water

To examine the effects of advancing pregnancy on metabolic responses, 12 women, who were recruited early in pregnancy, were studied during 20 minutes of immersion in 30 degrees C water, followed by 20 minutes of exercise in the water (60% of predicted maximal capacity) and 20 minutes of lateral supine recovery. Each subject completed the trials during the fifteenth, twenty-fifth, and thirty-fifth weeks of pregnancy, as well as a control period 8 to 10 weeks post partum. Resting oxygen uptake increased with advancing pregnancy. Resting oxygen uptake was higher in the water than on land but was not altered by pregnancy. Exercise oxygen uptakes were similar for all trials, but the work load required to elicit the VO2 decreased during the thirty-fifth week of pregnancy. Exercise heart rates followed the same pattern as oxygen uptake. Lactate concentrations declined with advancing pregnancy after exercise. Blood glucose levels were normal for pregnancy but declined slightly during exercise. Blood triglyceride levels were elevated with exercise, with a tendency to increase with advancing pregnancy. Resting plasma cortisol concentrations increased with pregnancy but remained lower during immersion and exercise. These results suggest that pregnancy significantly alters metabolic responses to exercise in the water.