Safety of Cimetidine in Obstetric Patients

Cimetidine has been suggested as a new approach to the prevention of the acid pulmonary aspiration syndrome in obstetric anaesthesia. In 20 patients in labour cimetidine 200 mg intravenously did not prolong labour or alter the pattern or strength of uterine contractions. The fetal heart rate did not show any alteration in rate or pattern and it was confirmed that cimetidine crosses the placenta. These findings suggest that further studies of cimetidine in obstetric patients would be safe.

Plasma Amino Acids and Glucose Levels in the Rat Fetus and Dam after Chronic Maternal Alcohol Consumption

To evaluate the effect of chronic maternal alcohol consumption on plasma amino acid and glucose levels in both the fetus and the mother, female Sprague-Dawley rats were divided into 3 dietary treatment groups. Group 1 (alcohol) was fed ad libitum a stock diet plus 20% alcohol in drinking water for at least 4 weeks before mating and 30% alcohol during gestation. Group 2 was pair-fed the stock diet plus corn starch calorically equivalent to the amount of alcohol consumed by group 1 animals. Group 3 (control) received the stock diet and water ad libitum. On day 21 of gestation the fetuses of alcohol-treated dams weighed significantly less than those of the control and pair-fed groups. Fetal plasma glucose levels were significantly lower in the alcohol group when compared to those of the pair-fed and control groups, while the maternal glucose levels were similar in all three treatment groups. Plasma amino acid concentrations showed no corresponding trends in mother and fetus. Only proline was significantly reduced and alpha-amino-n-butyric acid elevated in the alcohol-treated dams when compared to the pair-fed and control rats. In the fetal plasma, only aspartic acid was significantly lower in the alcohol group when compared to the other two groups. A moderate degree of dehydration occurred in the alcohol-treated dams, but plasma albumin was within normal levels. It is concluded that the marked decrease in the concentration of plasma glucose in alcohol-exposed fetuses may be partially responsible for their retarded growth.

Serum T4, T3, r-T3, TSH and Tg Levels in Cord Blood and Maternal Circulation at the Time of Delivery

The concentrations of T4, T3, r-T3, TSH and Tg were determined in parallel in maternal serum at the time of delivery and in cord blood. The serum T3 concentration in cord blood was significantly lower than that in the serum of the mother. However contrary to T3, r-T3 in cord serum was significantly higher than in maternal serum. Also, the level of TSH in cord blood was considerably higher than in maternal serum. The concentrations of total T4 in maternal and cord serum did not differ markedly, even though the values (mean and individual) were somewhat lower in the cord serum. The concentrations of Tg in cord and maternal serum varied widely, although the mean value for Tg in cord serum was somewhat higher than in maternal serum. No correlation was found between Tg concentration and TSH level in cord or maternal serum.

The Characterization of Hemoglobin Manitoba or α2102(G9)Ser→Argβ2and Hemoglobin Contaldo or α2103(G10)HIS→ARGβ2By High Performance Liquid Chromatography

Hb Contaldo with a His----Arg substitution at position 103(G10) of the alpha chain is a newly discovered unstable Hb variant observed in an Italian child. Its instability is probably due to the disruption of the hydrogen bond between alpha 103(G10)His and beta 108(G10)Asn. The structural variation in the core segment was determined through analysis of tryptic peptides from digests of the alpha X and oxidized alpha X (with performic acid) chains, which were separated by HPLC. Similar analyses were made for the alpha X chain of the rare Hb Manitoba in which alpha 102(G9) Ser is replaced by Arg. This variant was observed for the first time in an Italian patient, and was also studied in a member of a previously described Canadian family.

HB Cordele α247(CE5)ASP→ALAβ2A Mildly Unstable Variant Observed in Black Twins

Hb Cordele, which has an Asp----Ala substitution at position 47 (CE5) of the alpha chain, was discovered in Black twins living in Cordele, Georgia. The structure of this variant was elucidated through analyses of tryptic peptides of the alpha chain which were isolated by high performance liquid chromatography. At birth, Hb Cordele accounted for about 21-23% of total hemoglobin, and for 30.4% in one of the babies at age 3.5 months. Hb Cordele has a normal oxygen affinity, but is mildly unstable at 60 degrees C. Some of its properties have been compared with those of Hb Kokura (alpha 47 Asp----Gly), Hb Hasharon (alpha 47 Asp----His), and Hb Arya (alpha 47 Asp----Asn). Studies on an adult carrier of Hb Cordele were not possible.

Ferastral, an iron-poly (sorbitol-gluconic acid) complex, in the treatment of severe iron-deficiency anaemia in pregnancy

Thirteen pregnant women with iron-deficiency anaemia have been treated with Ferastral. In a further seven women, Ferastral was given 24 hours before delivery, when induction of labour was indicated, to investigation of iron concentration in maternal serum, cord blood and amniotic fluid simultaneously. The efficacy of Ferastral was demonstrated by a significant increase in haemoglobin and haematocrit. No serious reactions occurred and no evidence was found of disturbance of liver or renal function. It was shown that Ferastral does not pass the placental barrier and that no direct transport takes place through the uterine wall or amnion. No effects on the newborn were demonstrated.

The value of screening tests for glucose-6-phosphate dehydrogenase deficiency

The performances of two commercial screening tests for glucose-6-phosphate dehydrogenase deficiency (Sigma fluorescent spot test and Sigma colorimetric method) were assessed in order to determine their usefulness in a routine haematology laboratory. As a first step, three ranges for enzyme activity were determined as follows: a 'normal' range determined from the 95% confidence limit of assays carried out on 114 normal adult males, a deficient range calculated as 25% of the upper limit of normal or less, and an intermediate range between the lower and upper values of these ranges. These values were 4.9-11.8 u/g Hb, 0-2.9 u/g Hb and 3.0-4.8 u/g Hb respectively. A separate normal range was also determined for females and was 5.5-12.8 u/g Hb. The two screening tests were then assessed against these values and the kits were found to be equally reliable at predicting normals and deficients but less reliable at detecting all female heterozygotes. The criteria for using the different procedures were evaluated. It is concluded that screening procedures are useful only when a large number of tests are routinely performed or in the absence of facilities for assays, as they offer no advantage in cost or time over the assay procedure. The colorimetric test (single vials) is easier and cheaper to use if isolated tests are performed, whereas the fluorescent spot test (with some modifications) is more useful for carrying out numerous tests simultaneously.

Inherited metabolic disease: prospects for the future in both basic and clinical research

The birth of a child with an inherited disorder is often the beginning of a life-long problem for the whole family. About 8.5% of paediatric deaths and 4.7% of paediatric hospital admissions are due to autosomal and sex-linked recessive diseases. These figures are likely to be erroneously low because of incomplete ascertainment. The inherited metabolic diseases therefore merit study on economic as well as humanitarian grounds. Investigations of the disorders of purine metabolism have been conducted for more than a century and a half in the borderland between biochemistry and medicine, illuminating both disciplines and reflecting their separate developments. These studies are a general model for work in other branches of human intermediary metabolism. It is hoped that the basic study of the inborn errors or metabolism will expand our knowledge of the defective gene and of its product, the enzyme protein. Clinical studies should aim to improve the prenatal, postnatal and carrier-state diagnosis of these disorders, and to improve their treatment by methods which can be made practicable and generally available at the clinical level. There may be some hope for enzyme replacement in certain circumstances. The prospect for genetic modification at the clinical level is almost infinitely far away, where many would say that is should remain.

Metabolic events associated with the preparation of the fetus for independent life

The metabolic changes late in fetal development that are essential for neonatal survival are discussed. In many species gluconeogenesis develops before birth but provides substrate for intracellular biosynthesis and not for glucose production because of low activities of glucose 6-phosphate translocase. At the time of glycogen deposition in species with a relatively mature brain at birth the translocase develops and glucagon and adrenaline can stimulate glucose production and synthesis to elevate blood glucose concentrations both pre- and postnatally. The other metabolic fuel accumulated before birth, fat, can also be mobilized prenatally and in fetuses that are relatively mature at birth it may be used as an alternative fuel. The fetal rat brain can oxidize fatty acids and the brain of fetuses such as that of the guinea-pig and man can oxidize ketone bodies before birth. The timing and degree of oxidation of ketone bodies relates to the timing of myelination and protects the brain against hypoglycaemia. These late changes in development are associated with a sharp increase in plasma cortisol and adrenaline concentrations and a high fetal insulin concentration.

The development of fetal adrenal function

The response profiles of fetal sheep adrenals to tropic stimulation have been examined ih vivo and in vitro. Isolated adrenal cells from sheep fetuses in early pregnancy (Day 50) reduced cortisol in response to ACTH, dibutyryl cyclic AMP and GTP. The response was minimal on Day 100, but reappeared near term. 17 alpha-Hydroxyprogesterone was converted to cortisol by adrenals of all ages, but pregnenolone and progesterone were converted to cortisol only in early and late, but not mid-pregnancy. These studies suggested that the mid-gestation loss of fetal adrenal responsiveness was associated with post-receptor/adenylate cyclase events and involved loss of 17 alpha-hydroxylase activity. Fetal adrenal function was activated by exogenous ACTH in vivo, and was reflected in an increase in the ratio of cortisol to corticosterone in fetal plasma and in augmented cortisol output in vitro from dispersed fetal adrenal cells. The results were consistent with an effect of ACTH administration on 17 alpha-hydroxylation. Fetal pituitary cells, prostaglandin E2, alpha-MSH and term placental extract are other potential (sources of) corticotropins, although further studies are required to delineate the nature and origin of the active substances, and/or their primary sites of action.

Fetal cortisol and the initiation of labour in the human

The role of the fetal adrenal activity in the initiation of parturition in the human has been investigated. Women were studied in the last trimester of pregnancy during treatment with betamethasone for prevention of the idiopathic respiratory distress syndrome. Although betamethasone caused a considerable drop in the cortisol concentrations of fetal plasma and amniotic fluid, the time to spontaneous delivery in this group was similar to that in matched controls. Moreover, cortisol in fetal scalp blood at the onset of parturition in untreated women did not differ between those with spontaneous and those with induced labour. Evidence is given that increase of circulating cortisol in the fetus during the course of parturition predominantly reflects a rise in maternal cortisol under the influence of labour. The strain of labour seems to partly override the betamethasone-induced inhibition of maternal cortisol release. The possible ability of the fetal adrenals to respond to stimuli is illustrated by comparison of cortisol concentrations in cord plasma after various forms of complicated deliveries.

The uptake of tritiated diethylstilbestrol by the brain, pituitary gland, and genital tract of the fetal macaque: a combined chromatographic and autoradiographic study

To examine the possible sites of action of the synthetic estrogen diethylstilbestrol (DES) in the developing primate, [3H]DES (250 mu Ci, iv, or 500 mu Ci, sc) was administered directly into two rhesus and nine cynomolgus macaque fetuses at about 122 days gestation (range, 121-124 days). The location of cells accumulating radioactivity 60 min later was examined by autoradiography in two males and two females. In females, labeled neurons were observed in the hypothalamus, preoptic area, and amygdala, but not in the cerebral cortex. In one male a similar pattern of uptake was observed, but percentages of labeled neurons were lower, and in the other male very little labeling was observed in any region. The chemical identity of the radioactivity in cell nuclei was determined by high performance liquid chromatography in three males and four females. Concentrations of radioactivity in nuclear pellets were highest in the hypothalamus and lowest in the cerebral cortex. This regional variation was highly significant (P less than 0.001), but there was no significant difference between nuclear concentrations of radioactivity in males and females. In supernatant fractions, concentrations of radioactivity showed no significant variation between brain regions and after 60 min, 52-67% of the extracted radioactivity was no longer in the form of [3H]DES. Nuclear levels of radioactivity in pituitary glands and genital tracts of both male and female fetuses were 2-5 times higher than those in hypothalamus. The results demonstrated a direct interaction between DES and cell nuclei from specific regions of the brain, pituitary gland, and genital tract at this stage of gestation in a primate.

Limited role of fetal blood sampling in prediction of outcome in intrauterine growth retardation

Fetal acid-base status was evaluated on 66 blood samples taken for rapid karyotyping from 58 growth-retarded fetuses. Before blood sampling, doppler blood flow studies of the umbilical artery showed end-diastolic frequencies to be absent in 32 fetuses (group 1) and present in 26 (group 2). Fetuses with chromosomal (n = 4) or structural (n = 8) abnormalities were excluded from subsequent analysis. Gestational age at blood sampling (27.8 [95% CI 26.5-29.1] vs 32.2 [30.4-34.1] weeks) and time from sampling to delivery (median 2 (range 0-35] vs 14 [0-77] days) were significantly lower in group 1 than group 2. There were no perinatal deaths in group 2 whereas mortality in group 1 was 65.4%. There were significant differences between the groups at blood sampling in pH, pO2, pCO2, base equivalents, and nucleated-red-cell count, but within group 1 these measurements were similar in surviving fetuses and those who died perinatally. Since acid-base determination does not predict perinatal outcome in growth-retarded fetuses, fetal blood sampling has a limited role in monitoring fetal wellbeing.

Intrauterine diagnosis and treatment of fetal goitrous hypothyroidism

Newborn screening programs for the detection of congenital hypothyroidism have dramatically shortened the time before treatment is begun. However, concern still exists about central nervous system sequelae which may persist due to a period of untreated intrauterine hypothyroidism. Presence of polyhydramnios led to the ultrasound diagnosis of a fetal goiter. Hypothyroidism was confirmed at 34 weeks gestation by percutaneous fetal blood sampling, which revealed an elevated TSH (186 mU/L) and a low T4 (19.3 nmol/L). Intraamniotic fluid injections of 500 micrograms levothyroxine sodium (T4) every 10-14 days increased fetal serum T4 (59.2 nmol/L), decreased fetal serum TSH (14 mU/L), decreased amniotic fluid TSH, and decreased the size of the fetal goiter. The infant was born at term without perinatal complications. Thyroid function studies on cord blood were normal (T4, 109.4 nmol/L; TSH, 1.3 mU/L), and the infant was discharged on oral T4. Follow-up examination at age 6 weeks revealed that the infant was developmentally normal and clinically and chemically euthyroid. Intrauterine T4 therapy can suppress fetal TSH and treat fetal hypothyroidism despite hypothyroid levels of serum T3. Highly sensitive TSH assays may allow the use of amniotic fluid TSH as a marker for fetal hypothyroidism.

Intrapartum asphyxia in pregnancies complicated by intra-amniotic infection

Intra-amniotic infection has been reported to be associated with intrapartum asphyxia; however, the criteria used to define asphyxia have been imprecise. In the present study of 123 women with intra-amniotic infection and 6769 women without infection, the mean umbilical artery pH was 7.28 in both groups. The frequency of acidemia (umbilical artery pH less than 7.20) was not significantly different between the infection group and controls (15 versus 10%; P = .12). Likewise, there was no significant difference between the groups when a lower umbilical artery pH value (less than 7.15) was used to define acidemia. None of the infants from infected mothers had metabolic acidemia with a pH of less than 7.15 and none had a pH of less than 7.00. Significantly more (P less than .05) infants in the infected group did have low 1-minute (20 versus 5%) and 5-minute (3 versus 1%) Apgar scores of 6 or less, criteria often used to define asphyxia. However, none of the newborns from the infected group had recently proposed criteria for the diagnosis of birth asphyxia (ie, leading to neurologic impairment) such as metabolic acidemia, seizures in the immediate newborn period, and low Apgar scores (3 or less). Birth asphyxia is rarely associated with intra-amniotic infection, and in the absence of other signs of fetal jeopardy such as an ominous fetal heart rate pattern, an immediate cesarean to prevent asphyxia does not appear justified once the diagnosis of chorioamnionitis is made.

The biophysical profile in labor

To determine whether the biophysical profile would be a valuable intrapartum addition to fetal heart rate monitoring in predicting umbilical arterial acid-base status at delivery, 95 patients at term had serial studies during labor and umbilical artery blood gas analysis. There was no significant association between biophysical profile score and cord blood pH, nor was there a difference in scores between the acidemic and nonacidemic groups. Of the five components of the initial biophysical profile, only a nonreactive nonstress test (NST) was associated with both pH 7.20 or less (P = .019) and metabolic acidemia (P = .016). None of the individual variables of the final examination correlated with a pH of 7.20 or less. However, a nonreactive NST was associated with metabolic acidemia (P = .03), as was the presence of breathing (P = .03). Of the ten infants with pH 7.20 or less, eight had an initial and five had a final biophysical profile score of 8 or higher. Of the five whose pH was less than 7.15, four had an initial and three a final score of 8 or more. Finally, of the five with metabolic acidemia, four had an initial and two a final score of 8 or higher. Half of the acidemic fetuses had final biophysical profile scores of 8 or higher, suggesting that this score in labor is not reliable to rule out acidemia at delivery.(ABSTRACT TRUNCATED AT 250 WORDS)

Transplacental passage of insulin in pregnant women with insulin-dependent diabetes mellitus. Its role in fetal macrosomia

BACKGROUND AND METHODS

Fetal macrosomia occurs despite nearly normal maternal blood glucose levels in women with diabetes treated with insulin. We examined the hypothesis that it may be caused by insulin transferred as an insulin-antibody complex from the mother to her fetus. We adapted and validated a method based on high-performance liquid chromatography and used it to quantitate insulin in small volumes (0.5 to 1.0 ml) of cord serum from 51 infants born to mothers with insulin-dependent diabetes mellitus.

RESULTS

In mothers receiving only human insulin (n = 6), only human insulin was detected in cord serum. Of the remaining 45 infants, whose mothers received animal insulin during pregnancy, 28 (group 1) had levels of animal (bovine or porcine) insulin (mean [+/- SE], 707 +/- 163 pmol per liter) that constituted 27.4 +/- 2.5 percent of the total insulin concentration (2393 +/- 500 pmol per liter) measured in the cord serum. The cord-serum insulin concentration in the remaining 17 infants (group 2), in whom only human insulin was detected (381 +/- 56 pmol per liter), was only 15 percent of that in group 1 (P less than 0.001). There was a significant correlation between the maternal and the cord-serum concentrations of anti-insulin antibody and the concentration of animal insulin in the baby (r = 0.77, P less than 0.01, and r = 0.76, P less than 0.001, respectively), suggesting that the animal insulin was transferred as an insulin-antibody complex. In group 1 the mean concentration of animal insulin in cord serum was higher in the 12 infants with macrosomia than in the 16 infants without the condition (1113 +/- 321 vs. 402 +/- 110 pmol per liter; P less than 0.05), and the concentration of animal insulin in cord serum correlated with birth weight (r = 0.39, P less than 0.05). The maternal glycosylated hemoglobin values and the incidence of respiratory distress syndrome were similar in groups 1 and 2.

CONCLUSIONS

Considerable amounts of antibody-bound insulin are transferred from mother to fetus during pregnancy in some women with insulin-dependent diabetes mellitus; the extent of transfer correlates with the maternal concentration of anti-insulin antibody. The correlation between macrosomia and the concentrations of animal insulin in cord serum indicates that the transferred insulin has biologic activity and suggests that the formation of antibody to insulin in the mother is a determinant of fetal outcome independent of maternal blood glucose levels.

The detection of hemoglobin variants by isoelectrofocusing using EDTA-collected and filter paper-dried cord blood specimens

A comparative study was conducted aimed at the detection of abnormal hemoglobin conditions (mainly AS, SS, AC, CC, SC, AE, AD, Hb Bart's or gamma 4) by isoelectrofocusing of cord blood samples stored as liquid blood and as dried hemoglobin on filter paper. Analyses were made within four to six days after the collection of the samples; storage conditions mimicked those of testing programs using liquid blood samples (as in Georgia) or dried blood filter paper samples (as in several other states). During analysis of hemoglobin solutions extracted from dried blood samples, considerable difficulties were encountered in detecting significant hemoglobinopathies such as SS and SC, whereas even simple abnormalities such as AS, AC, AD, and AE were also often not diagnosed. Detection of the fast-moving variant Hb Bart's or gamma 4 was not possible. These results again cause doubt regarding the general use of dried blood filter paper samples in newborn hemoglobin testing programs. Perhaps special precautions--such as speed in analyzing the samples, storage at -20 degrees C (or perhaps 4 degrees C) instead of at room temperature, and removal of unstable hemoglobin from the filter paper extract by centrifugation--might eliminate some of the problems that were observed.

Perinatal growth hormone (GH) physiology: effect of GH-releasing factor on maternal and fetal secretion of pituitary and placental GH

To study regulation of the secretion of human pituitary GH (hGH) and placental GH (hPGH) in the pregnant woman and human fetus, the GH-releasing factor Sermorelin [GRF-(1-29)-NH2] was administered to pregnant women at term (n = 5), just before elective cesarean section; saline was administered in control studies (n = 5). The effects of GRF-(1-29)-NH2 administration on maternal and fetal serum concentrations of hGH and GRF-(1-29)-NH2 and maternal serum levels of hPGH were evaluated at birth. The mean time span between injection and birth was 20 min (range, 15-25 min). Cord serum hGH concentrations were similar in infants of GRF-(1-29)-NH2-injected mothers and control infants. GRF-(1-29)-NH2 elicited a consistent but small rise in maternal hGH serum concentrations (P = 0.08), whereas hPGH concentrations remained unaltered. Finally, GRF-(1-29)-NH2 concentrations were undetectable in cord serum, but readily detectable in concomitantly obtained maternal serum. In conclusion, these data suggest that hGH secretion in the pregnant woman at term is suppressed at the pituitary level, that GRF does not affect hPGH secretion, and that fetal hGH secretion is independent of circulating maternal GRF, probably because of lack of transplacental GRF passage.

Hyperkalemia after irradiation of packed red blood cells: possible effects with intravascular fetal transfusion

Plasma potassium, calcium, and albumin concentrations in irradiated blood, and in fetal blood before and after transfusion, were measured. Dangerously high plasma potassium levels were observed in some units of irradiated packed red blood cells (range, 13.9 to 66.5 mEq/L; mean, 44.7 mEq/L) and could be one possible explanation for the high incidence of fetal arrhythmia associated with fetal intravascular transfusion. There are many factors operative in the preparation of irradiated packed red blood cells that may predispose to high potassium levels: the age of the red blood cells, the number of procedures used to concentrate the blood, the duration of time elapsed from concentration, the duration of time elapsed from irradiation, and the hematocrit. Use of fresh blood, avoidance of multiple packing procedures, limiting the hematocrit in the donor unit to less than or equal to 80%, and minimizing the time between concentration, irradiation and transfusion may minimize the potassium levels, and therefore making an additional washing procedure unnecessary.

Maternal alcohol abuse is associated with elevated fetal erythropoietin levels

The erythropoietin levels in mixed cord serum of 40 infants born to drinking women were compared with those of 24 infants born to abstinent women. Twenty infants born to drinkers had signs of fetal alcohol effects. Thirty-five percent of the erythropoietin levels in mixed cord serum of infants of drinking mothers were above the normal range. Further, the elevation in fetal erythropoietin level correlated with maternal alcohol intake; infants of mothers consuming at least 300 g of ethanol weekly (28) had significantly higher (P less than .025) umbilical erythropoietin levels (median 66 mU/mL, range 10-2500) compared with infants of mothers consuming 150-300 g of ethanol weekly (median 37 mU/mL, range 23-215) or infants of control women (median 32 mU/mL, range 11-73). The subgroup analysis between infants with and without fetal alcohol effects showed no differences in umbilical erythropoietin levels. Maternal alcohol ingestion during pregnancy is associated with elevated umbilical erythropoietin levels, but whether this is a direct effect of ethanol or is induced by chronic fetal hypoxemia remains unclear.

Cord blood red-cell enzymes and reduced glutathione in Indian neonates, normal and with pathologic jaundice

Red-cell enzymes and reduced glutathione (GSH) were assayed on cord blood in 307 Indian neonates. On follow-up, 20 of them developed pathologic jaundice. Of these, six had red-cell enzyme/GSH deficiency, seven had associated non-enzymatic causes of jaundice, and in the remaining seven the cause could not be diagnosed. In 41 other neonates, there was enzyme/GSH deficiency without pathologic jaundice. The degree of enzyme deficiency had no relation with jaundice. Red-cell enzyme/GSH deficiency state in neonates was associated with pathologic jaundice more frequently (six of 47; 12.8%) than in the absence of such deficiency (14 of 260; 5.4%). None of the jaundiced patients had very high levels of bilirubin nor needed exchange blood transfusion. There was no reduction in haemoglobin level in the enzyme/GSH deficient group with jaundice in comparison with non-deficient jaundiced neonates or normal subjects. The incidence of red-cell enzyme/GSH deficiency appears to be high in Indian neonates; however, the majority of them do not precipitate pathologic jaundice.

Relationship of fetal biophysical profile and blood gas values at cordocentesis in severely growth-retarded fetuses

In 14 severely growth-retarded fetuses the biophysical profile score was analyzed in relation to blood PO2, pH, oxygen saturation, and oxygen content in samples obtained by cordocentesis. The data suggest that the biophysical profile score can predict the degree of fetal acidemia.

Topical prostaglandin E2 gel for cervical ripening and closure of the ductus arteriosus in the newborn

The closure time of the ductus arteriosus was investigated in 29 full term babies born vaginally after induction with prostaglandin E2 and in 22 controls. Serial Doppler echocardiography studies showed a significantly prolonged closure time in babies induced by prostaglandin E2. Whether the difference is related to changes in fetal prostaglandin E2 concentration remains to be established.

Fetofetal transfusion syndrome: do the neonatal criteria apply in utero?

Thirteen fetuses (five twin, one triplet) were compromised by fetofetal transfusion syndrome in six pregnancies, five in the mid trimester, and one in the third trimester. This diagnosis, which was suspected because of ultrasound findings of discordant growth, discordant amniotic fluid volumes, concordant external genitalia, and monochorial placentation, was confirmed postnatally in each. Nine fetuses underwent blood sampling to aid diagnosis and assessment of fetal wellbeing. In contrast to fetofetal transfusion syndrome investigated postnatally, a difference in haemoglobin concentration of 50 g/l or more in utero was found in only one pregnancy, which was near term, although all had fetal erythroblastaemia and a difference in weight of 20% or more. In vivo confirmation of shared circulation was achieved in two pregnancies by transfusing adult Rh negative red cells into the smaller fetus and then detecting them by Kleihauer testing in blood aspirated from the larger. Invasive procedures also yielded information on fetal blood gas measurements (acidaemia in four and hypoxaemia in six) and amniotic pressure (raised in two). We suggest that comparison of haemoglobin concentrations is inaccurate in fetofetal transfusion syndrome in utero, the diagnosis of which may necessitate detection of a shared circulation using a marker such as adult red cells.

Plasma zinc and copper in pregnant Nigerian women at term and their newborn babies

The concentration of copper and zinc was determined by atomic absorption spectrophotometry in 26 normal Nigerian women at term and their newborn babies. Cord zinc was significantly greater than maternal zinc. In contrast, cord copper was lower than maternal copper. There was only a weak correlation between cord copper and maternal copper but none between cord zinc and maternal zinc. There was no correlation between maternal and cord zinc and neonatal birthweight. However, an inverse correlation was found between maternal and cord copper and neonatal birthweight. These results indicate that: (1) zinc has no effect on fetal growth in Nigerian women but (2) copper may have a negative effect on fetal growth.

Reference values of magnesium and potassium in mononuclear cells and erythrocytes of children

Reference values for magnesium and potassium contents of mononuclear cells and erythrocytes were estimated in cord blood and in children from infancy through adolescence. No differences were detected between results for boys and girls. The mononuclear magnesium content was independent of age and was within the adult range of values. No significant correlation was shown between magnesium in serum and in mononuclear cells. Mononuclear potassium also showed no age-related differences. The correlation between magnesium and potassium contents in mononuclear cells was significant: however, the correlation was lower when the magnesium and potassium contents were expressed in terms of protein potent: micromoles or millimoles per gram of protein, respectively. The concentration of magnesium in erythrocytes was significantly lower in cord blood and during the first month of life, compared with that at older ages, and showed no significant correlation with serum magnesium. The concentration of erythrocyte potassium was independent of age and showed a low but significant correlation with erythrocyte magnesium content.

The effect of ethanol on habituation and the cardiovascular response to stimulation in fetal sheep

Fetal cardiovascular (CVS) changes, forelimb movements (FM) and rates of habituation to repeated stimulation, with suffusions of cold saline over the skin, were measured in 12 chronically catheterized fetal sheep aged 130-145 days. Stimulation of the fetuses caused a significant rise in heart rate (HR) (p less than 0.01) and blood pressure (BP) (p less than 0.001) and FM (p less than 0.01). When the ewe was given an intravenous (i.v.) infusion of ethanol which produced fetal ethanol levels of 87 +/- 1.1 mg/100 ml, the number of spontaneous FM decreased (p less than 0.05). After i.v. ethanol, repeated stimulation of the fetuses still caused an increase in FM (p less than 0.01) and a rise in HR (p less than 0.05) and BP (p less than 0.02) but the fetuses habituated more rapidly (7.25 +/- 1.28 stimuli) compared to control experiments performed prior to (21.5 +/- 3.57 stimuli) or after the ethanol (17.75 +/- 5.83, p less than 0.01). Fetal exposure to low concentrations of ethanol does affect the patterns of response and habituation of the developing fetal central nervous system.

Oral supplementation of vitamin K for pregnant women and effects on levels of plasma vitamin K and PIVKA-II in the neonate

Levels of plasma vitamin K1 (VK1) and vitamin K2 (VK2) and protein-induced vitamin K absence-II (PIVKA-II) were measured in Japanese mothers and their newborn (N = 33). Twenty milligrams of VK1 (N = 11) or VK2 (N = 12) were given orally to randomly selected mothers 7 to 10 days prior to delivery. Means of plasma VK1 and VK2 concentrations were significantly higher in VK1 (p less than 0.01) and VK2 (p less than 0.01) treated mothers than in the controls at delivery, respectively. Similarly, these levels were significantly elevated in cord plasma in VK1 (p less than 0.05) and VK2 (p less than 0.05) treated groups, compared with findings in the control group, although there was a large concentration gradient between maternal and cord plasma (mostly less than one-tenth). A significant positive correlation was found in VK1 concentration between maternal and cord plasma (N = 33, p less than 0.01), and the proportion of PIVKA-II-positive infants was significantly lower in the VK treated groups than in the control group at birth (p less than 0.05). On the fifth postnatal day, mean levels of VK1 (p less than 0.01) and VK2 (p less than 0.01) in breast milk were significantly higher in the VK1 and VK2 treated mothers than in the control mothers, respectively. In the control group, 9 of 10 infants had a positive PIVKA-II, but no one in the treated groups was positive, thereby indicating significant differences between control and treated groups (p less than 0.01 and p less than 0.01, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

Maternal and fetal digoxin-like immunoreactive factor in elective cesarean sections and spontaneous vaginal delivery

The effect of mode of delivery on maternal and newborn plasma levels of total digoxin-like immunoreactive factor was evaluated. 32 healthy at term parturients with normal fetuses were studied. The cord blood level of digoxin-like immunoreactive factor of the 16 vaginally delivered infants was significantly higher than in the 16 matched controlled newborns delivered by an elective Cesarean section (1381 +/- 334 versus 1104 +/- 338 pg/ml, p less than 0.02). No differences were found between the maternal venous blood levels of digoxin-like immunoreactive factor of both study groups. The cord blood levels of this factor in the vaginal as well as the Cesarean section groups were significantly higher than the concentration in the corresponding maternal blood (p less than 0.001 and p less than 0.01, respectively). It is suggested that the changes in digoxin-like immunoreactive factor in the cord blood may reflect the stress of vaginal delivery on the fetus.

Icteric serum as an indicator of fetal vascular access during intravascular transfusion for hemolytic disease

Correct needle placement during intravascular transfusion of the fetus may be difficult with an anterior placentation. Elevated bilirubin levels due to red cell hemolysis in the fetus of an alloimmunized pregnancy will result in icteric serum. The findings of such serum in centrifuged capillary tubes can be used to confirm fetal vascular access.

Effects of exposure to PCBs and related compounds on growth and activity in children

Two hundred thirty-six children from two established cohorts at risk for exposure to polychlorinated biphenyls (PCBs) and related contaminants were evaluated at age 4 years. Prenatal exposure (assessed by cord serum PCB level) was associated with lower weight, an effect consistent with reports of growth retardation in laboratory rats and in children exposed at high levels in Taiwan and at general population levels in Japan. The highest exposed children weighed 1.8 kg less on the average than the least exposed. Contemporary body burden (assessed by 4-year serum PCB level) was associated with reduced activity based on composite ratings provided by the child's mother and two independent examiners. This effect, attributable to lactation exposure, was strongest among the offspring of women with above average milk PCB levels who breast fed for at least 1 year. While the weight deficit is consistent with previous data linking developmental effects of low-dose human PCB exposures specifically to the prenatal period, activity is the first domain found to be affected by lactation at contemporary levels of exposure.

High concentrations of plasma immunoreactive inhibin during normal pregnancy in women

The plasma inhibin concentrations in 190 normal pregnant women at 5-40 weeks gestation and in 4 puerperal women were measured by a specific RIA for human inhibin. The average plasma inhibin concentrations in pregnant women throughout pregnancy (minimum, 2.25 +/- 0.48 IU/mL at 17 weeks gestation; maximum, 24.15 +/- 6.99 IU/mL at 39 weeks gestation) were much higher than those in nonpregnant women with a normal menstrual cycle (0.46 +/- 0.04 IU/mL in the midfollicular phase and 2.02 +/- 0.47 IU/mL in the midluteal phase). The inhibin concentrations were already high at 5 weeks gestation (7.54 +/- 1.10 IU/mL) and rose to peak at 8-10 weeks gestation. The concentrations then decreased and remained relatively low during 14-30 weeks gestation, but rose again during the third trimester. The inhibin concentrations decreased to undetectable levels after delivery. Immunoreactive inhibin was demonstrated in the corpus luteum and term placental extracts, and the dose-response curves were parallel to an inhibin preparation from human follicular fluid. Immunoreactive inhibin concentrations were also high in both the umbilical vein and artery (7.77 +/- 0.80 and 7.84 +/- 0.78 IU/mL, respectively). These observations suggest that both the corpus luteum and placenta are likely sources of inhibin.

Detection of fetal blood contamination by amniotic fluid obtained during cordocentesis

When a fetal blood sample is obtained by cordocentesis it is important to know whether the sample is diluted with amniotic fluid. This study was designed to assess whether contaminated fetal blood samples could be discriminated from noncontaminated ones by the ferning test, and if so what is the minimum dilution ratio of amniotic fluid/fetal blood that is detectable. Fetal blood samples were diluted with amniotic fluid and were tested for ferning under the microscope after the plasma was separated from the cells. At a dilution ratio of 0.2 ml of amniotic fluid to 1 ml of fetal blood, 30% of the samples tested positive for ferning. A rate of 100% detection of ferning was achieved at a dilution ratio of 0.6:1. In conclusion, screening fetal blood samples for ferning can detect amniotic fluid contamination. The sensitivity of the test for ferning depends on the dilution ratio. The test cannot assess how much amniotic fluid was added to the blood sample.

Early neonatal predictors of neonatal hypocalcemia in infants of diabetic mothers: an epidemiologic study

Prematurity, neonatal asphyxia, hypomagnesemia, and advanced maternal diabetes are traditional risk factors for hypocalcemia in infants of diabetic mothers (IDMs). The aim of this study was to determine the relative contribution of these factors separately and combined in a cohort of diabetic pregnancies managed prospectively in the recent 9 years and to find accurate predictors of neonatal hypocalcemia in infants of diabetic mothers. We hypothesized that these factors plus low cord blood calcium (Ca) concentration allow prediction of IDMs who develop neonatal hypocalcemia. We studied 186 IDMs (White class B-RT); gestational age (GA, weeks) was by last menstrual period, confirmed +/- 2 weeks by Ballard score. The goals of glycemic control were: preprandial blood glucose less than 100 mg/dl and 90-minute postprandial blood glucose less than 140 mg/dl. Apgar scores, and cord, 24-, 48- and 72-hour serum calcium (Ca) (mg/dl) and magnesium (Mg; mg/dl) were determined. In univariate analysis, lowest serum Ca correlated with cord blood Ca (r = 0.48, p less than 0.001), GA (r = 0.37, p less than 0.001), and 1-minute Apgar score (r = 0.18, p = 0.09), but did not correlate with cord Mg or with advanced White class. In multiple regression, cord Ca and GA were dominant effects and other variables became insignificant. Lowest Ca (mg/dl) was predicted as follows: lowest Ca = 34.05 - 3.22 (Ca cord) - 0.84 (GA) + 0.10 (GA) (Ca cord). This equation predicts neonatal hypocalcemia (lowest Ca less than 8 mg/dl) with a sensitivity of 72% and a specificity of 75%. Thus, GA and cord Ca allow determination of IDMs at risk for neonatal hypocalcemia.

[Glucosylated proteins and perinatal growth]

The concentration of HbA1c and glycosylated serum proteins were measured colorimetrically in 30 and 29 newborn infants of various gestational age, at the postnatal age of 0-24 hrs and 19-23 days, respectively. No relationship was found either between the maturity and the prenatal and early postnatal growth of the studied infants or the concentration of glycosylated haemoglobin and serum proteins.

[Vitamin K 1 concentration and vitamin K-dependent clotting factors in newborn infants after intramuscular and oral administration of vitamin K 1]

Serum concentration of vitamin K1 and activity of vitamin-K-dependent factors II, VII, IX and X were determined before and after vitamin K1 administration in infants. The babies received vitamin K1 intramuscularly or orally. 12 hours after vitamin K1 treatment the mean concentration was increased in the groups receiving vitamin K1 intramusculary or orally, respectively. Serum level of vitamin K1 fell exponentially, the mean half life was about 30 hours in both groups. Activity of vitamin K-dependent clotting factors did not change significantly after intramuscular or oral vitamin K1 administration during the first four-five days of life. It was no direct correlation between the concentration of vitamin K1 and the activity of vitamin-K-dependent clotting factors. This study suggest that oral administration of vitamin K1 is as effective as the intramuscular route.

Characterization of digoxin-like materials in human cord serum

Human cord serum contains substantial amounts of materials that cross-react in radioimmunoassays for digoxin. The average content of digoxin-like immunoreactivity in mixed cord serum is 0.3 +/- 0.05 ngE/ml compared to less than 0.05 ngE/ml in serum from normal adults. After solvent extraction, the major digoxin-like materials present in cord serum coelute on Sephadex LH-20 column with the steroid sulfate fraction. The steroid sulfates are digoxin-like materials because they cross-react in the digoxin RIA. If the amount of dehydroepiandrosterone sulfate, 16 alpha-hydroxydehydroepiandrosterone sulfate, and 15 beta-hydroxydehydroepiandrosterone sulfate present in cord serum and the amount of digoxin-like material present in the same serum are considered, then up to 90% of the digoxin-like materials present can be accounted for on the basis of the steroid sulfates present. However, although steroid sulfates contribute to the digoxin immunoreactivity in both serum and breast cyst fluid, digoxin-like materials are present in breast cyst fluid that are not present in cord serum.

Transplacental transfer of aflatoxin in humans

This study quantified aflatoxin (AFB1, AFG1 and AFQ1) by enzyme-linked immunosorbent assay in human cord sera obtained at birth and in serum obtained immediately after birth from the mother. The subjects of the study were residents of Songkhla, Thailand. Of the 35 samples of cord sera, 17 (48%) contained aflatoxin in concentrations from 0.064 to 13.6, mean 3.1 nmol/ml. By comparison only two (6%) of 35 maternal sera contained aflatoxin (mean 0.62 nmol/ml). These results demonstrate transplacental transfer and concentration of aflatoxin by the feto-placental unit which may be of biological importance. Aflatoxins are mutagenic, carcinogenic and teratogenic and cause immunosuppression in animals. The implications of these findings are potentially profound and deserve further study.

Screening for hemoglobins S and C in newborn and adult blood with a monoclonal antibody in an ELISA procedure

To facilitate the screening of blood for the presence of hemoglobins S or C, we devised an enzyme-linked immunoassay (ELISA). The ELISA procedure incorporated a murine monoclonal antibody (mAb), beta s-1, which recognized both Hb variants but did not react with Hb A, Hb A2 or Hb F. Hemoglobins in cord or adult hemolysates were coated on the surface of wells of polystyrene microtiter plates and treated with beta s-1 mAb, followed by goat anti-mouse IgG conjugated with horseradish peroxidase. After addition of tetramethylbenzidine substrate solution, a deep blue color developed, signifying the presence of Hb S or Hb C. The beta s-1 mAb ascites fluid could detect purified Hb S and Hb C when diluted to over 1/512,000 and cord blood hemolysates containing Hb/S or Hb C when diluted to 1/128,000. Although maximal reactivity was achieved using undiluted hemolysates, the ELISA system could easily detect Hb S and Hb C in cord blood hemolysates when diluted 10(-4). The sensitivity of the ELISA was 1%, which exceeds the lowest quantities of these variants normally found in cord blood. In addition, we found that the ELISA procedure was suitable for detecting Hb S/Hb C in whole blood as well. The entire assay could be conducted on multiple samples in less than 1 h, thus providing a specific, sensitive, rapid and simple screening technique for Hb S and Hb C in cord or adult blood.

[Cordocentesis: experience in 391 initial samples]

The first diagnostic cordocentesis was performed in our unit in october 1985. Our 4-year experience is reported: 391 cordocentesis were performed in 360 patients during gestational weeks 14 to 42. The first attempt was successful in 90% of the procedures, 4 samplings failed, there were 4 fetal deaths within one week after diagnostic cordocentesis, one of them appears to be directly linked to the punction. A transient fetal bradycardia was observed in 9.9% of the cases, bleeding occurred in 19% of the cases. The indications for cordocentesis were: risk of fetal infection, karyotyping, hemopathy, search for paternity, assessment of fetal acid-base status, biochemical dosage. Our data confirm that cordocentesis is a safe and reliable diagnostic procedure providing guidelines for management of the pregnancy.

Determination of ceftriaxone in biological material by differential-pulse adsorptive stripping voltammetry

Differential-pulse adsorptive stripping voltammetry was used to determine sub-micromolar concentrations of ceftriaxone in plasma. A hanging mercury drop electrode was chosen as the working electrode. A simple clean-up procedure was developed in which ceftriaxone was extracted from blood plasma with the non-ionic resin Amberlite XAD-2 and eluted with methanol. The recovery from plasma was 97.6% using a 1.52 x 10(-4) M stock ceftriaxone solution. The method was applied to caesarean cases, and total ceftriaxone levels were measured in the maternal and umbilical cord blood. The amount of ceftriaxone transmitted to the baby on administration of the drug to the mother before the caesarean operation was found to be in the range 0.067-0.17%.