Intravascular coagulation in gestational hypertension and pre-eclampsia: the value of haematological screening tests

Routine investigations designed to detect excessive intravascular coagulation in patients with gestational hypertension and pre-eclampsia have been analysed in 936 cases. Reticulocyte counts did not differ significantly from those in normal controls and abnormal red cell morphology was detected in only two patients. Fibrinogen degradation products and thrombocytopenia were found in about 10% of all hypertensive women and macrothrombocytosis in 32%. Neither reticulocyte counts nor the scanning of stained blood films for evidence of microangiopathic haemolysis have a place in the routine investigation of pre-eclampsia and it is doubtful whether any of the other screening tests can influence the management of patients with uncomplicated gestational hypertension. In fully developed pre-eclampsia, macrothrombocytosis is found in about 50% of patients, fibrinogen degradation products and thrombocytopenia in about 15%. All three parameters reflect the degree of clinical severity of the disease.

Maternal hypertension with superimposed pre-eclampsia: effects on child development at 71/2 years

Children born to women participating in a prospective study of hypertension during pregnancy were followed up from birth. Data on growth and development at the age of 71/2 years of 56 children whose mothers had superimposed pre-eclampsia are compared with results of 176 children whose mothers had only hypertension. Perinatal mortality in the hypertension-only group was similar to that for the hospital population in general at the time of their birth; but in the group who developed preeclampsia it was significantly higher. At the age of 71/2 years no differences were found in the frequency of health, handicap, sight and hearing problems, weight, height, head circumference, and standing and supine blood pressures. For six aspects of intellectual development children in the pre-eclampsia group had slightly higher mean scores; and in one of these, "perceptual matching' the difference was significant after adjustment had been made for confounding variables. Pre-eclampsia superimposed on hypertension does not increase the likelihood of impaired growth and development among children who survive the perinatal period.

Risk indicators of reduction limb defects

The birth of a child with a reduction limb defect (RLD) was evaluated in relation to vaginal bleeding, threatened abortion, and other complications of pregnancy, placental weight, birth weight, family history, parental age, and the outcome of previous pregnancies. The material consisted of 453 cases of reduction limb defect and an equal number of non-malformed controls matched for time and place. The children were born in Finland during 1964-77. The cases with reduction limb defect without additional malformations were analysed separately. Statistically significant associations were found between the occurrence of reduction limb defect and the following risk indicators: vaginal bleeding, threatened abortion, duration of gestation under 37 weeks, placental weight 400 g or less, birth weight 2500 g or less, and any type of malformation in the relatives. Vaginal bleeding indicated the risk of reduction limb defect to be increased about fourfold; short gestation indicated about twofold risk of reduction limb defect as an isolated malformation. Both low placental weight and low birth weight were associated to a threefold risk of an isolated reduction limb defect. These factors of an abnormal pregnancy indicated even higher risk of reduction limb defect with additional malformations. Preliminary genetic analysis suggests that hereditary factors play no major part in the aetiology of reduction limb defects.

Prognostic aspects of aplastic anemia in pregnancy. Experience on six cases and review of the literature

Our resent experience on six cases of aplastic anemia complicated with pregnancy is described. In addition, 43 similar cases were collected from the literature and reviewed to analyze some prognostic aspects of this relatively rare but potentially serious complication. Clinical and hematological data were treated to extract some clinically meaningful factors in relation to the success and failure of pregnancy. Among initial hematological parameters, no significant difference was found between successful and unsuccessful cases with an exception of hemoglobin concentration. The patients diagnosed as aplastic anemia prior to conception demonstrated an better outcome of pregnancy as well as survival rate of mother when compared with those diagnosed during pregnancy. Mortality has apparently improved after the late 1950's. Success rate of pregnancy before 1958 was 21%, while it was 67% and 71% in the era of 1959-1969 and after 1970, respectively. However, hemorrhage and infection remained to be two major causes of maternal death in both eras. Based on these observations, the currently recommendable attitude to this complication is discussed.

Further investigation on the predictive value of human placental lactogen in high-risk pregnancies

Blood samples were taken from 254 women with pregnancies with various complications and 119 completely normal pregnant women for measurement of serum human placental lactogen (hPL) during the third trimester. The value of this test in the management of these pregnancies was retrospectively evaluated through details of outcome. Serum hPL and urinary estriol were compared as tools for assessment of fetal condition. Serum hPL was found to be very efficient in the prenatal diagnosis of intrauterine growth retardation associated with maternal hypertension. Low hPL levels were recorded in all severely hypertensive patients who were delivered of small-for-dates infants (a 100 per cent prediction rate), while 30 per cent of these patients had normal estriol values. Prediction rate of postmature infants by serum hPL level was 70 per cent as compared to 50 per cent by urinary estriol level. The diagnostic significance of low hPL levels is emphasized, with stress upon its value in early detection of unfavorable intrauterine environment. The importance of preterm deliveries in pregnancies involving intrauterine growth retardation and low hPL levels is discussed and demonstration cases are presented.

Maternal primary hyperparathyroidism of pregnancy. Successful treatment by parathyroidectomy

Primary hyperparathyroidism of pregnancy may result in spontaneous abortion, neonatal hypocalcemia, or neonatal tetany if appropriate treatment is not instituted. Of great importance in prevention of these complications is an awareness by physicians that this disease exists and is of clinical importance. Parathyroidectomy performed during the second trimester of pregnancy offers the best chance for fetal and neonatal survival. This operation results in little risk to either the mother or the fetus. Normal calcium homeostasis is restored to the fetus and the risk of hypocalcemia in the neonatal period is virtually eliminated.

[Risk of prematurity and reported bleeding in pregnancy (author's transl)]

The analysis of 5.139 cases from the prospective study "Pregnancy and Childdevelopment" (supported by the Deutsche Forschungsgemeinschaft) showns that time and frequency of bleeding in pregnancy influence the risk of premature delivery. Every additional bleeding will increase the risk, especially if bleeding occurs in the second trimester. For example the risk of prematurity exceedes 25%, if bleeding occurs four times or more. After bleeding in early pregnancy the frequency of small for gestational age infants is not increased.

Hypertension in pregnancy: the use of ultrasound

Great advances in ultrasound instrumentation have enabled the physician to delineate subtle intrauterine changes. Not only can specific measurements of the fetal body be obtained but tissue textures within fetal organs can be appreciated. The perinatologist is constantly searching for ways to learn more about the fetus, and ultrasound has clearly become a major implement in this search. The following discussion will focus on information made available by ultrasound for aid in the modern management of hypertension, one of the most challenging conditions complicating pregnancy.

Respiratory distress syndrome of the newborn and complications of pregnancy

A group of 412 infants with birthweights between 501 and 2,500 gm and gestational ages of 36 weeks or less were studied for the influence of both prolonged ruputre of amniotic membranes and maternal hypertension on the incidence of idiopathic respiratory distress syndrome (IRDS). The occurrence of these complications was associated with a significant decrease in the incidence of IRDS only in infants with birthweights between 1,501 and 2,500 gm (37.4% in the no complications group versus 12.8% in the complications group; P less than .01) or gestational ages of 33 to 36 weeks (35.2% in the no complications group versus 13.1% in the complications group; P less than .01). In infants with birthweights of 1,500 gm or less or gestational ages of 32 weeks or less, the specific antecedent complications of pregnancy did not alter the incidence of IRDS. Rupture of the membranes for more than 72 hours had no greater effect on the incidence of IRDS than those lasting 24 to 72 hours.

An autopsied case of Eisenmenger syndrome complicated by recurrent thromboembolic phenomena in postpartal period

Dyspnea, back pain, edema, and cyanosis developed suddenly in a 23-year-old woman during the last trimester of her first pregnancy. Although she had been noticed to have the enlarged heart and exertional shortness of breath to a slight degree, she had been apparently in good condition without any significant heart murmurs. Clinically, recurrent episodes of disseminated intravascular coagulation, including pulmonary thrombosis, were thought to be superimposed to Eisenmenger syndrome associated with toxemia of pregnancy. Anticoagulant and fibrinolytic treatments were tried, but their effectiveness was limited by hemorrhagic diathesis. She died of respiratory and circulatory failure after delivery of a moribund baby. Autopsy revealed Eisenmenger complex (a defect in the membranous portion of the interventricular septum and pulmonary vascular disease) and many fresh hemmorrhages in both lungs with a lot of new and organized thrombi. Fresh thrombi were also seen in the heart, the pancreas and the kidneys. The high peripartal mortality in Eisenmenger syndrome could be attributed to pulmonary thrombosis, which may be related to DIC, as well as to peripartal changes in circulatory function.

Clinical experience with the oxytocin challenge test. II. An ominous atypical pattern

Three cases have been observed over the past 3 years at Los Angeles County-USC Medical Center, Women's Hospital, which have shown an unusual fetal heart rate response to induced uterine contractions during the antepartum period. All 3 cases resulted in perinatal death apparently due to asphyxia. This report describes this unusual pattern and presents a discussion of its possible significance.

Clinical and experimental studies of the congenital constriction band syndrome, with an emphasis on its etiology

The findings in fifty-nine patients with congenital constriction band syndrome and in experiments in which limb malformations resembling those of the human constriction band syndrome were successfully reproduced in rat fetuses by amniocentesis indicated that these malformations arise from excessive contraction of the uterine muscle during pregnancy, with resulting hemorrhages from the marginal blood sinuses of the digital rays. Such malformations in humans may arise during the fifth and sixth weeks counted from ovulation. It therefore was concluded that this syndrome is not hereditary but is produced by prenatal environmental factors.

Pulmonary edema and wheezing after pulmonary embolism

A young, pregnant woman with angiographically proved pulmonary emboli developed pulmonary edema and wheezing without evidence of left ventricular failure. This cast study points out the unusual association of pulmonary embolism with pulmonary edema, wheezing, and hyper-reactive airways in a patient with a positive family history of allergy, but no antecedent history of bronchospasm. Mechanisms for the occurrence of noncardiogenic pulmonary edema and wheezing after pulmonary embolism are reviewed.

Amniotic fluid creatinine in pregnancies complicated by diabetes

Amniotic fluid (AF) creatinine concentrations, determined in 353 samples from 167 pregnancies complicated by maternal diabetes, are similar to those found at comparable gestation in uncomplicated pregnancy. Added maternal vascular disease significantly raises AF creatinine to such a degree that overestimation of fetal (renal) maturity is a clinical hazard if based solely on this parameter. Relative concentrations of creatinine in AF and maternal plasma (AF/MP ratio) are related to gestational age. Failure of AF creatinine to rise consistently on successive serial samples accompanies an increased risk of perinatal death in the pregnancy complicated by diabetes, four of five deaths in the present series following declines in this measurement.

Maternal cardiomyopathy of pregnancy causing stillbirth

Cardiomyopathy of pregnancy developed in a healthy primigravida at 34 weeks gestation and was followed two weeks later by the spontaneous delivery of a fresh stillbirth. An immunological basis underlying both the mother's condition and the fetal death was suggested by the presence of myocardial antibodies in maternal and cord blood. Reference is made to two other cases in which a similar pathological process may have occurred.