High-Dose Intravenous Immunoglobulin Treatment of a Pregnant Patient with an Antiphospholipid Syndrome: Immunological Changes Associated with a Successful Outcome

A patient with a history of habitual abortion, deep venous thrombosis, thrombocytopenia, high titer IgG anticardiolipin antibodies and a clearly positive lupus anticoagulant, was treated during her seventh pregnancy with high-dose intravenous immunoglobulins (IVIg) from the third month onwards. Every month, a daily infusion of 400 mg immunoglobulins per kg body weight was given during five consecutive days. The patient’s pregnancy ended preterm with a live birth, delivered by caesarian section because of a placental abruption. The 1070 g (P20-P25) weighing girl was in good health, apart from a bradycardia, due to dysfunction of the atrioventricular conduction.

Each treatment with IVIg resulted in a slight reduction of both anticardiolipin antibodies and lupus anticoagulant levels and in an increase in platelet count. During the six-month observation period, a gradual decline in antiphospholipid antibodies and an increase in platelet count was found. The potential role of anti-idiotypic antibodies, present in the IVIg used for treatment, was studied. In vitro, IVIg were able to reduce the binding of the patient’s anticardiolipin antibodies to cardiolipin coated microtiter plates. The presence of anti-idiotypic antibodies in IVIg was further documented by affinity chromatography and by realtime biospecific interaction analysis (BIA) on a BIA-core instrument. Affinity purified anticardiolipin antibodies were retarded on a column of insolubilized IVIg and a weak interaction was found between IVIg and affinity purified patient antiphospholipid antibodies, coupled to the BIA-core biosensor. In addition, the same technology revealed increased levels of anti-antiphospholipid antibodies in the patient’s plasma following IVIg therapy. The partial and transient reduction of anti-phospholipid antibody levels observed immediately following each treatment course seems compatible with low affinity complexation of idiotype-antiidiotypes, resulting in an accelerated clearance of the autoantibodies. Despite the low affinity for the patient’s idiotypes, the beneficial long term effects observed could be related to an immune regulatory role of these anti-idiotypic antibodies on the synthesis of antiphospholipid antibodies.

Fibrinolytic Response to Venous Occlusion and Fibrin Fragment D-Dimer Levels in Normal and Complicated Pregnancy

The fibrinolytic response to venous occlusion was assessed in 29 women with normal or complicated pregnancy, by measurements of total t-PA and free t-PA with specific ELISAs. The release of t-PA from the vessel wall was 11±9 ng/ml in nonpregnant women (mean ± SD, n = 6) but was markedly reduced throughout pregnancy. Following venous occlusion, free t-PA increased by 12 ± 11 ng/ml in non-pregnant women but remained below the detection limit of 2 ng/ml towards the end of pregnancy. A markedly reduced t-PA release with absence of free t-PA was also observed during late pregnancy in patients with insulin-dependent diabetes mellitus, intra-uterine growth ietaida-tion and pre-eclampsia.

Plasma levels of fragment D-dimer of cross-linked fibrin were measured with a specific FITS A in 79 pregnant women. D-dimer levels were 129 ± 36 ng/ml (mean ± SD, n = 8) in non-pregnant women and increased to 400 ± 170 ng/ml (n = 25) and 440 ± 220 ng/ml (n – 22) during the second and third trimester of pregnancy respectively. Significantly higher levels than observed in uncomplicated third trimester pregnancies were found in 3 out of 6 diabetic and in 2 out of 7 pre-eclamptic women.

It is concluded that the t-PA release after venous occlusion is significantly reduced during pregnancy. In addition, released t-PA is rapidly inhibited. The levels of fragment D-dimer increase during pregnancy, suggesting that, notwithstanding the marked impairment of the fibrinolytic response to venous occlusion, the fibrinolytic system remains functionally active.

[Influence of the seasonal variation on the prevalence of pre-eclampsia in Kinshasa]

OBJECTIVES

The present study aims at determining the influence of the seasons on the occurrence of pre-eclampsia in the county city of Kinshasa (DR Congo).

PATIENTS AND METHOD

A multicentric descriptive study was carried out in three great maternity hospitals of this city between 2003 and 2007. The registers and files of the maternity wards and the units of intensive care were used for the gathering of medical data. The geographical data on the seasonal changes were provided by two great weather stations, which receive the satellite data on the town suit. These data include the temperature, the percentage of humidity and the rate of precipitation. This information allowed to define for each year the dry season and the season of rains.

RESULTS

Overall, 17,592 pregnant women were studied. Among these, we could find 1492 (8.5 %) cases of pre-eclampsia and 319 (1.8 %) cases of eclampsia. The distribution of these pregnant women according to two seasons revealed that 11,358 (64 %) pregnancies were seen during the season of rain and that among these, 681 (6 %) were complicated by pre-eclampsia. During the dry season, 6234 (36 %) pregnancies occurred and among these we found 811 (13 %) cases of pre-eclampsia.

DISCUSSION AND CONCLUSION

The seasonal distribution reveals that the incidence of pre-eclampsia is significantly higher during the dry season than during the rainy season, but probably is not directly related to meteorological factors but rather on the nutritional deficiencies caused by the low rate of precipitations.

Differential effects of inducers of syncytialization and apoptosis on BeWo and JEG-3 choriocarcinoma cells

BACKGROUND

The interactions of trophoblasts with the cytokine network at the fetomaternal interface determine the pathway the cell undertakes, e.g. proliferation, differentiation and apoptosis.

METHODS

We used cultures of fusigenic BeWo and non-fusigenic JEG-3 choriocarcinoma cells to study the effects of inducers of syncytialisation (forskolin) and apoptosis [tumour necrosis factor-alpha (TNFalpha)] on differentiation, viability, proliferation and apoptosis.

RESULTS

E-cadherin immunostaining showed that syncytium formation was confined to BeWo and not JEG-3 cells, while secretion of hCG was promoted by forskolin in both cell types implying a 'dissociation' between morphological and biochemical differentiation. Forskolin also had differential effects on cell viability (MTT reduction test) and proliferation (Ki67 immunostaining with MIB-1 monoclonal antibody), both decreasing in BeWo and increasing in JEG-3 cells. TNFalpha increased apoptosis (cytokeratin neo-epitope immunostaining with M30 monoclonal antibody) in both cell types, an effect which was blocked by epidermal growth factor selectively in JEG-3 cells.

CONCLUSION

Our results suggest that the differential responses of BeWo and JEG-3 cells to inducers of syncytialization and apoptosis might be related to their fusigenic capacity. Caution is needed when extrapolating results obtained by these models to normal trophoblast populations. However, we speculate that these models can help identify key factors involved in trophoblast differentiation at the placental bed.

[Trauma during pregnancy]

In the past 60 years trauma has become the most important cause of morbidity and mortality in pregnancy. Motor vehicle accidents are the most common cause of abdominal trauma and lead to the highest mortality. The typical anatomical and physiological changes occurring during pregnancy demand a specific resuscitation procedure in which stabilization of the mother hemodynamically has to be done first. During the secondary survey the mother and fetus have to be examined thoroughly. The correct use of safety belts is an essential part of prevention.

Low-dose combined spinal-epidural anaesthesia vs. conventional epidural anaesthesia for Caesarean section in pre-eclampsia: a retrospective analysis

BACKGROUND AND OBJECTIVE

Epidural anaesthesia is the preferred technique of anaesthesia for Caesarean section in pre-eclampsia. Spinal anaesthesia is considered by some as a safe and effective alternative, which is especially useful in emergency situations. Combined spinal-epidural anaesthesia, using low doses of local anaesthetics with opioids, is effective and reduces the incidence of hypotension in normal pregnancy. We performed a retrospective chart analysis to evaluate the effects of combined spinal-epidural anaesthesia on maternal haemodynamics and fetal outcome compared to conventional epidural anaesthesia.

METHODS

A retrospective anaesthesia chart analysis of all pre-eclamptic patients who underwent Caesarean section over a 4 yr period was performed. Patient characteristic, obstetric, haemodynamic, fetal and neonatal data were gathered and analysed according to the anaesthetic technique used.

RESULTS

Seventy-seven pre-eclamptic parturients undergoing Caesarean section were identified (26 women were severely pre-eclamptic and 51 demonstrated mild pre-eclampsia). Epidural anaesthesia was performed in 62 patients and combined spinal-epidural anaesthesia was performed in 15. No differences in patient characteristic and obstetric data were noted. Highest mean arterial pressure prior to anaesthesia was comparable between the groups (epidural: 106 +/- 12 vs. combined spinal-epidural anaesthesia: 109 +/- 18 mmHg) as well as the lowest recorded mean arterial pressure following anaesthesia (epidural: 93 +/- 13 vs. combined spinal-epidural anaesthesia: 98 +/- 17 mmHg). In the combined spinal-epidural anaesthesia group more ephedrine was used compared to the epidural group (14.6 +/- 4.4 vs. 3.6 +/- 4.6 mg, P < 0.05). However, more lactated Ringer's was used in the epidural group. Umbilical artery pH was lower in the epidural group (7.26 +/- 0.01 vs. 7.29 +/- 0.02, P < 0.05). Similar results were noted in 26 severely pre-eclamptic patients. Seven women underwent combined spinal-epidural anaesthesia and 19 underwent epidural anaesthesia in the severely pre-eclamptic group. Also more ephedrine was used in the combined spinal-epidural anaesthesia group. A tendency towards a lower umbilical artery pH was observed in the epidural group but this difference did not reach statistical significance.

CONCLUSIONS

Combined spinal-epidural anaesthesia appears to be safe as anaesthetic technique for pre-eclampsia and severe pre-eclampsia. However, it is important to consider the retrospective design of the study and the large number of epidural anaesthetics performed.

Delivery related rupture of the gravid uterus: imaging findings

Rupture of the gravid uterus is a rare, life-threatening obstetric complication. Major symptoms are hypovolemic shock and abdominal pain during late pregnancy or after vaginal delivery. Immediate surgical therapy is required. We report a case of uterine rupture after vaginal delivery diagnosed by means of ultrasonography and computed tomography.

Color Doppler imaging is a valuable tool for the diagnosis and management of uterine vascular malformations

OBJECTIVE

The aim of this study was to assess the spontaneous outcome of uterine vascular malformations detected with ultrasonography and color Doppler, and to investigate the predictive value of color Doppler imaging as to which patients require invasive treatment.

METHODS

This was a prospective observational study conducted between January 1999 and February 2001 comprising all consecutive patients diagnosed with a uterine vascular malformation by ultrasonography and color Doppler imaging. Spectral analysis included measurement of flow velocities, pulsatility index (PI) and resistance index (RI). Close follow-up was arranged in all cases and the outcomes were recorded.

RESULTS

A total of 30 consecutive patients with uterine vascular malformations were included in the study. Spectral analysis of the vessels in the vascular malformations within the myometrium and endometrium revealed the presence of a low-impedance and high-velocity flow. The average values for PI, RI, peak systolic velocity (PSV) and time-averaged maximum velocity (TAMXV) were 0.50, 0.38, 0.63 m/s and 0.46 m/s, respectively. Eight patients (27%) eventually required embolization of the uterine arteries and three of them had true arteriovenous malformations confirmed at angiography. PSV values of >/= 0.83 m/s were associated with higher probabilities of further treatment, such as an embolization, whereas no vascular malformation with a PSV value < 0.39 m/s required embolization.

CONCLUSION

Conservative management is possible in more than two-thirds of patients presenting with uterine vascular malformations diagnosed by color Doppler sonography. Despite considerable overlap, PSV values appear to be useful in distinguishing between low- and high-risk patients.

Continuous spinal analgesia for labor pain in a parturient with aortic stenosis

Aortic stenosis in pregnancy carries a high fetal and maternal morbidity and mortality. Spinal analgesia/anesthesia is considered by many to be contraindicated in these patients. The rapid onset of sympathetic block induces hypotension, which can result in myocardial hypoperfusion and myocardial ischemia. We describe a case of moderate to severe aortic stenosis, diagnosed during pregnancy, in which pain relief during labor and delivery was managed using a continuous spinal catheter. Pure intrathecal opioid analgesia was used initially to maintain hemodynamic stability. However after two bolus administrations of sufentanil, analgesia was further maintained using ropivacaine and sufentanil. A spinal catheter was chosen to provide reliable anesthesia, which could be extended rapidly for cesarean section.

Vascular malformations in the uterus: ultrasonographic diagnosis and conservative management

OBJECTIVE

To investigate the presence and outcome of uterine vascular malformations in women with abnormal premenopausal bleeding.

STUDY DESIGN

In this observational study 265 consecutive patients with abnormal premenopausal bleeding were examined by the same ultrasonographer with transvaginal gray-scale ultrasonography and color Doppler imaging. A final diagnosis of uterine vascular malformation was based on ultrasonographic findings, hysteroscopy or histological findings. Patients suspected of uterine vascular malformations at ultrasonography were closely monitored.

RESULTS

In nine patients (3.4%) we found ultrasonographic features of uterine vascular malformations. Color Doppler imaging showed hypervascularity, marked turbulence, and low-impedance, high-velocity flow. In six patients the condition resolved spontaneously. Two patients with hydatiform mole needed chemotherapy and their condition normalized. One patient underwent a selective embolization of the uterine artery. Subsequently, five patients had uncomplicated pregnancies after resolution of the vascular malformation.

CONCLUSION

Uterine vascular malformations are more common than previously thought. We conclude that conservative management is a valuable option in many of the acquired pregnancy-related cases that are diagnosed with color Doppler imaging.

Relationship of bacterial vaginosis and mycoplasmas to the risk of spontaneous abortion

OBJECTIVE

This study was undertaken to investigate a possible link between first-trimester diagnosis of bacterial vaginosis and cessation of pregnancy at < or =20 weeks' gestation.

STUDY DESIGN

Women (n = 228) who received routine prenatal care in Flanders, Belgium, during the first trimester (14 weeks' gestation) and had a living singleton fetus were examined for microbiologic flora of the vagina. Bacterial vaginosis was assessed either clinically (Amsel et al criteria), microscopically (clue cells), or by culture of bacterial vaginosis-associated bacteria. Data were analyzed univariately (relative risk) and multivariately.

RESULTS

The presence of bacterial vaginosis at the first prenatal visit was strongly associated with subsequent early pregnancy loss (relative risk, 5.4; 95% confidence interval, 2.5-11). After multivariate analysis bacterial vaginosis, Mycoplasma hominis, and Ureaplasma urealyticum but not other microorganisms remained associated with an increased risk of miscarriage.

CONCLUSION

Bacterial vaginosis and mycoplasmas may play causative roles in spontaneous abortion and early pregnancy loss.

Rupture of membranes before 26 weeks of gestation: outcome of 148 consecutive cases

AIMS

To assess the outcome of preterm prelabor rupture of the membranes (PPROM) before 26 weeks of gestation and to develop a prediction model for survival.

METHODS

148 consecutive cases of PPROM before 26 weeks of gestation, collected between 1988 and 1996, were retrospectively analyzed. A multivariate analysis (generalized estimating equations) of 21 process and 5 short and long term outcome variables was performed.

RESULTS

40 out of 148 children (27%) died before or during birth, 57 (38.5%) of the children survived more than 28 days, from which still 5 died after one month. Amongst the 52 survivors (35.1%), the Bayley Mental Development Index and Psychomotor Development Index at a corrected age of 7 months was normal in respectively 85.7% and 75.5% of the cases. At 6-7 years of age, 24 out of 33 children (73%) performed adequately at school. Sex, gestational age at PPROM, birth weight, the administration of steroids and interactions of steroid administration with sex and with gestational age at the time of PPROM largely determined the chances of survival.

CONCLUSIONS

Overall fetal survival after PPROM before 26 weeks of gestation was 35.1%. Survival can be predicted with an accuracy of 75%, a sensitivity of 85% and a specificity of 60%. More than 70% of the survivors behaved and performed adequately at school age, but 27% require special long-term attention and care.

Wet mount microscopy reflects functional vaginal lactobacillary flora better than Gram stain

AIM

The status of vaginal lacto-bacillary flora, an indicator of possible genital infection and pregnancy complications, can be assessed on wet mount or Gram stained specimens. The former is quick, the latter more routine. The accuracy of the two preparative techniques to detect normal vaginal lacto-bacillary microflora was compared for 646 patients. The effect of delay in transport medium before Gram staining was also investigated.

METHODS

Patients presented with infectious vaginitis or for a routine prenatal visit. After placement of a speculum, duplicate smears were taken from the upper vaginal vault and examined fresh or after Gram staining. Lacto-bacillary grades from both methods were compared with lactate concentration in vaginal rinses. In a subgroup of 238 patients, Gram staining was performed both on fresh smears and those that had been transported in Stuart's growth medium.

RESULTS

Higher lacto-bacillary grades (more disrupted flora) were diagnosed 2.9 times more frequently on Gram stained specimens than on wet mounts (p < 0.0001), a difference even more pronounced after transport in Stuart's medium (relative risk, 4.2; p < 0.0001). Lacto-bacillary grades assessed on wet mounts correlated better with vaginal lactate concentration than those assessed on Gram stains.

CONCLUSIONS

Easier recognition of lacto-bacillary morphotypes on wet mounts than on Gram stains might result from the loss of lactobacilli by the process of fixation or Gram staining. Wet mount microscopy of vaginal smears for assessment of lacto-bacillary grades, rather than Gram staining, is strongly recommended.

Pathogenesis of abnormal vaginal bacterial flora

OBJECTIVE

This study was undertaken to determine the relationships between microscopy findings on wet mounts, such as lactobacillary grade or vaginal leukocytosis, and results of vaginal culture, lactate and succinate content of the vagina, and levels of selected cytokines.

STUDY DESIGN

In a population of 631 unselected women seeking treatment at an obstetrics and gynecology outpatient clinic, vaginal fluid was obtained by wooden Ayre spatula for wet mounting and pH measurement, by high vaginal swab for culture, and by standardized vaginal rinsing with 2 mL 0.9% sodium chloride solution for measurements of lactate, succinate, interleukin 1beta, interleukin 8, leukemia inhibitory factor, and interleukin 1 receptor antagonist concentrations. Lactate and succinate levels were measured by gas-liquid chromatography and the cytokine concentrations were measured by specific immunoassays. Both univariate analysis (Student t test, Welch test, chi(2) test, and Fisher exact test) and multivariate regression analysis (Cox analysis) were used.

RESULTS

Increasing disturbance of the lactobacillary flora (lactobacillary grades I, IIa, IIb, and III) was highly correlated with the presence of Gardnerella vaginalis, Trichomonas vaginalis, enterococci, group B streptococci, and Escherichia coli. Vaginal pH and interleukin 8 and interleukin 1beta concentrations increased linearly with increasing lactobacillary grade, whereas lactate concentrations and the presence of epithelial cell lysis decreased. A similar pattern of associations with increasing leukocyte count was clear, but in addition there was an increase in leukemia inhibitory factor concentration. Multivariate analysis of vaginal leukocytosis, lactobacillary grades, and the presence of positive vaginal culture results showed that interleukin 1beta concentration was most closely related to the lactobacillary grade, leukemia inhibitory factor concentration was most closely related to the lactobacillary grade and positive culture results, interleukin 8 concentration was most closely related to positive culture results, and interleukin 1 receptor antagonist concentration was most closely related to vaginal leukocytosis and positive culture results. The concentration ratio of interleukin 1beta to interleukin 1 receptor antagonist remained stable, except when vaginal leukocytosis increased. In its most severe form, with >10 leukocytes per epithelial cell present, a decompensation of the vaginal flora with a collapse in interleukin 1beta and interleukin 1 receptor antagonist concentrations was seen, but there was a concurrent sharp increase in leukemia inhibitory factor concentration. This pattern was completely different from the course of the cytokine concentrations associated with a lactobacillary grade increase.

CONCLUSION

Both disturbed lactobacillary grade and the presence of increasing vaginal leukocytosis were correlated with lactobacillary substrate (lactate) concentration, pH, and the concentrations of a variety of cytokines. There was a remarkably linear increase in these cytokines as either leukocytosis or lactobacillary grade became more severe. In circumstances in which leukocytosis was extreme, however, interleukin 1beta was no longer produced but leukemia inhibitory factor concentrations increased. We speculate that in extreme inflammation the body tries to limit the damage that can be done by exaggerated cytokine production.

Maternal serum levels of macrophage colony-stimulating factor are associated with adverse pregnancy outcome

OBJECTIVE

The aim of this study was the measurement of maternal serum levels of M-CSF throughout pregnancy, in a low risk obstetrical population, to examine the relationship of M-CSF and pregnancy outcome.

STUDY DESIGN

Maternal serum was obtained at various stages of pregnancy and post partum, M-CSF levels were measured by ELISA, pertinent clinical data tabulated, and pregnancy outcome was determined.

RESULTS

In 564 pregnancies studied, 22% of 260 nulliparous pregnancies and 10% of 304 multiparous pregnancies were hypertensive. Preeclampsia occurred in 1.5% of nulliparous and in 1% of the multiparous women. In apparently normal pregnancies with good outcome, M-CSF levels rose throughout pregnancy. No cases of preeclampsia occurred if maternal serum M-CSF levels increased more than 100% throughout pregnancy.

CONCLUSIONS

This study suggests that absolute levels and relative changes in maternal serum M-CSF levels during pregnancy are associated with adverse pregnancy outcomes.

Accuracy of rapid antigen detection test for group B streptococci in the indigenous vaginal bacterial flora

OBJECTIVE

To test the sensitivity of the rapid group B streptococci (GBS) antigen test ICONR and compare its accuracy in women with vaginal enterococci or with non-specific disturbance of the lactobacillary flora.

STUDY DESIGN

The ICONR, aerobic culture and a microscopic wet mount evaluation were done on a vaginal sample in 254 unselected women presenting for routine gynecologic care in an academic hospital in Flanders, Belgium and tested by Chi2 [diagnostic odds ratio (DOR) and its 95 percent confidence limits].

RESULTS

Sensitivity of the test was 70%, specificity 99.5%. Prevalence of GBS was 10.6% overall, 23% in the group with abnormal vaginal flora and 7% in the normal group (p=0.002). Accuracy of the ICONR was not affected by abnormal vaginal flora, but was significantly lower in the presence of enterococci: the DOR decreased from 490 to 58, and the positive predictive value from 94 to 80%.

CONCLUSION

With a sensitivity of 70% the enzyme immunoassay ICONR does not appear to be suitable as a practical screening tool for detecting GBS carriage in normal or preterm laboring women. In the presence of enterococci the test performed less well, with a DOR falling by 8 to 9 fold. We presume this is due to lower specificity in vivo in the presence of enterococci, as non-specific disturbance of the lactobacillary flora did not interfere with test results.

Misoprostol compared with methylergometrine for the prevention of postpartum haemorrhage: a double-blind randomised trial

OBJECTIVE

To compare the efficacy and side effects of misoprostol, compared with methylergometrine, for the prevention of postpartum haemorrhage.

DESIGN

A double-blind, randomised clinical trial of 200 women with apparently normal pregnancies.

SETTING

University teaching hospital.

PARTICIPANTS

Two hundred women with apparently normal pregnancies.

METHODS

After the baby had been born, all women received two capsules by mouth and the contents of an ampule by intravenous injection. Each woman only received one active product. The capsules contained either a total of 600 microg misoprostol or placebo, and the ampule 200 microg of methylergometrine or placebo.

MAIN OUTCOME MEASURES

Need for further oxytocic drugs, blood pressure, the presence of side effects, mean haemoglobin and haematocrit three days after delivery.

RESULTS

Two hundred women completed the study (100 received methylergometrine and 100 misoprostol). Postpartum haemorrhage occurred in 4.3% of the methylergometrine group and 8.3% of the misoprostol group (P = 0.57). The need for further oxytocic drugs was 4.4% and 12.8% after methylergometrine and misoprostol, respectively (P = 0.065). One hour after the birth of the baby there was no difference in the mean systolic blood pressure (117 +/- 12 mmHg versus 115 +/- 11 mmHg) (P = 0.26) or the mean diastolic blood pressure (72 +/- 10 mmHg versus 71 +/- 11 mmHg for the groups receiving methylergometrine or misoprostol, respectively) (P = 0.97). The mean temperature in the misoprostol group rose to 37.4 degrees C, compared with 37 degrees C in the methylergometrine group (P < 0.0001). In the misoprostol group 34% developed fever (> 38 degrees C) compared with 3% in the methylergometrine group (P < 0.0001). Shivering (visual analogue score > or = 8) also occurred more often after misoprostol (42%) than after methylergometrine (8.5%) (P < 0.0001). The haemoglobin level (g/dL) on the third postpartum day was similar for both groups ( 11.0 and 11.2 for methylergometrine and misoprostol, respectively) (P = 0.39).

CONCLUSIONS

This study suggests that although protection from postpartum haemorrhage using parenteral methylergometrine and oral misoprostol is nearly equal, misoprostol is associated with more side effects.

Gastric emptying in hyperemesis gravidarum and non-dyspeptic pregnancy

BACKGROUND

Emesis and hyperemesis are significant problems associated with early pregnancy. However, gastric emptying of solids has never been studied during early pregnancy in humans.

AIM

To investigate gastric emptying of solids in patients recovering from hyperemesis gravidarum and in non-dyspeptic pregnant women and to compare these results with a group of healthy non-pregnant women.

METHODS

Fourteen patients with hyperemesis gravidarum, 10 non-dyspeptic pregnant women and 36 non-pregnant women in the first half of the menstrual cycle underwent a gastric emptying study. Seven non-pregnant women repeated the test in the post-ovulatory period.

RESULTS

Gastric emptying of solids was not significantly delayed in non-dyspeptic pregnant women compared with non-pregnant women. The emptying rate tended to be impaired in the post-ovulatory period of the menstrual cycle. Solid emptying was significantly accelerated in patients recovering from hyperemesis gravidarum, correlating well with thyroid function in the latter group.

CONCLUSION

Pregnancy in humans is not associated with decreased solid gastric emptying. In subjects recovering from hyperemesis gravidarum, solid emptying is increased, correlating well with thyroid function abnormalities. Nausea and vomiting in hyperemesis are therefore probably not due to upper gastrointestinal disorders.

Experience with fetoscopic cord ligation

OBJECTIVE

In the case of a monochorionic multiple pregnancy with one non-viable fetus who compromises its co-twin, fetoscopic cord ligation may be performed. We describe our fetoscopic cord ligation technique and discuss the efficacy of cord ligation for salvaging the co-twin, based on available data.

STUDY DESIGN

Descriptive case series of four cases and review of the cases published up to 1996.

RESULTS

We performed four successful ligations. Of the 23 reported cases, which include the present series, two ligations failed. Four fetuses died in utero, and 17 were born alive at a mean of 8 weeks following the procedure. Two babies died in the perinatal period, a third after 60 days. Preterm uterine contractions do not seem to be a clinical problem. Preterm prelabour rupture of the membranes (PPROM) complicates about 40% of cases, the majority occurring prior to 32 weeks.

CONCLUSION

Fetoscopic cord ligation is a feasible procedure with a 71% survival rate and a high risk for PPROM.

[Prematurity: current role of prostaglandin synthesis inhibitors]

Prostaglandins seem to play a significant role in labor initiation; it is not surprising therefore that inhibitors of prostaglandin synthesis have been studied for the treatment of premature contractions. Controlled studies confirmed the tocolytic effect of indomethacin which is better tolerated than other drugs used in the same indication. Possible foeto-neonatal complications prevent a wider use of indomethacin. If it is given before the 32nd week of pregnancy and for less than 72 hours, the risks are acceptable. In other cases, the expected advantages and possible hazards should be carefully weighed and intensive foeto-neonatal care is required. Characterization of the phospholipases and cyclo-oxygenases specific to preterm labor will undoubtedly allow to design, in the future, a more appropriate therapeutic approach.

Postpartum hyperprolactinemia and hyporesponsiveness of growth hormone (GH) to GH-releasing peptide

Human PRL and GH as well as their respective receptors have closely related origins. In peripartal women, physiological hyperprolactinemia is associated with a pronounced hyposomatotropism that remains to be fully characterized. Through paracrine mechanisms, PRL-secreting "pregnancy cells" may modulate the secretory function of somatotropes, which are known to express PRL receptors. Within a randomized, placebo-controlled design, we examined GH responsiveness in 10 nonpregnant women and in 58 mothers either in early (median, 48 h; range, 42-54 h after delivery; all lactating) or late postpartum (median, 10 weeks; range, 3-25 weeks; lactating and nonlactating subgroups), using GH-releasing peptide-1 (GHRP-1; 100-micrograms i.v. bolus) as the GH secretagogue. Baseline serum PRL concentrations were low and similar (median, 5 micrograms/L) in nonpregnant controls and nonlactating, late postpartum women and were elevated in lactating women, particularly in the early postpartum period (median, 102 micrograms/L), compared to those in the late postpartum period (median, 27 micrograms/L). GHRP-1 elicited GH responses in all study groups; lactation was associated with lower and slower GH responses. Serum GH concentrations (20 min after GHRP-1 treatment) in controls (median, 78 micrograms/L) were 7- and 5-fold higher than those in lactating women studied, respectively, early or late postpartum. Baseline prolactinemia presented an inverse correlation with GH responsiveness; the higher baseline PRL concentration, the lower and the slower the GH response to GHRP-1. GH hyporesponsiveness in postpartum women is herewith further characterized to include the GHRP pathway. The inverse relationship between baseline prolactinemia and GH responsiveness is consistent with the concept that pregnancy cells may exert, either directly or indirectly, an inhibitory effect on the secretory capacity of somatotropes.

Effect of antenatal thyrotropin-releasing hormone on uterine contractility, blood pressure, and maternal heart rate

OBJECTIVE

The goal was to study the effects on uterine contractility, blood pressure, and heart rate of thyrotropin-releasing hormone given antenatally in combination with glucocorticoids to accelerate fetal maturation.

STUDY DESIGN

A placebo-controlled, randomized, double-blind study was performed involving 30 women whose pregnancies were followed up at the University Hospital Gasthuisberg in 1994 and 1995.

RESULTS

Thyrotropin-releasing hormone induced a significant mean increase of nearly 6 mm Hg in systolic blood pressure and approximately 5 mm Hg in diastolic blood pressure. The duration of this raise was < 20 minutes. Thyrotropin-releasing hormone had no significant effect on maternal heart rate or uterine contractility: 4.2 +/- 1.6 contractions per hour before versus 4.7 +/- 1.7 contractions per hour after treatment.

CONCLUSIONS

Thyrotropin-releasing hormone induces a small (mean < 6 mm Hg) and brief mean (< 20 minutes) increase in blood pressure but appears to have no clinically detectable effect on uterine contractility.

Community control in a world of regional delivery systems

The pell-mell restructuring of health care into massive regional delivery systems has disrupted long-standing relationships between local leaders and residents and their community health care systems. This diminished role of communities in our new world of health care is ironic. As control within large regions in this country becomes concentrated within the operation of three or four health plans, we become increasingly dependent upon oligopolies for our market solutions. As economic arrangements, all that oligopolies can offer are indeterminate outcomes. Some may be good for consumers, others disastrous. Without the countervailing influence of nonmarket community interests, individuals may find their satisfaction with the health care system greatly diminished.

Hemodynamic effects of intravenous isoproterenol versus saline in the parturient

The use of epinephrine as a test dose for epidural analgesia in obstetrics remains controversial. Isoproterenol as a test dose may be efficacious in the parturient. However, the effects of isoproterenol on the uterine blood flow (UBF) and umbilical blood flow (UMB) in the parturient are unknown. In a randomized, double-blind study, the hemodynamic variables in 60 nonlaboring women at term were studied 5 min before and for 10 min after an intravenous injection of either 5 micrograms isoproterenol or 5 micrograms saline. The UBF was assessed in 35 women and the UMB in 25 women using a color Doppler technique. The results of 50 women were used for further analysis. Maternal heart rate (MHR) was measured continuously, and maternal mean arterial pressure was measured every minute. MHR did not change after saline but increased significantly after injection of isoproterenol. UBF also increased significantly after isoproterenol during the same time interval. UMB did not change. Other hemodynamic variables did not change. We conclude that isoproterenol, 5 micrograms, may be a suitable test dose for epidural analgesia in obstetrics.

Hepatic necrosis and haemorrhage in pregnant patients with antiphospholipid antibodies

Two case reports of pregnant patients with antiphospholipid antibodies and HELLP syndrome (hemolysis, elevated liver enzymes and low platelets) are presented. Attention is mainly drawn to the hepatic necrosis and the underlying pathophysiology.

Coccidioidomycosis in patients infected with human immunodeficiency virus: review of 91 cases at a single institution

We retrospectively evaluated the clinical manifestations, diagnosis, treatment, and outcome of coccidioidomycosis in 91 patients infected with human immunodeficiency virus (HIV) at a single institution. Coccidioidomycosis was the AIDS-defining illness in 37 patients. Fever and chills, weight loss, and night sweats were the most frequent symptoms. The lung was the most frequently involved organ (80%), followed by the meninges (15%). A diffuse reticulonodular infiltrate was seen in 59 patients (65%), and 13 (14%) had focal pulmonary disease; for 15 patients (16%), the chest radiograph was normal. Coccidioidal serologies were positive for 60 patients (68%), while for 23% with proven coccidioidomycosis such tests were negative Most patients were treated with systemic amphotericin B and then an oral azole. The mortality for the whole group was 60%. Patients with diffuse pulmonary disease had the highest mortality (68%), with a median duration of survival of 54 days (P < .05; 95% confidence interval, 147-175 days). The presence of diffuse pulmonary disease and a CD4 lymphocyte count of < 50/microL were independent predictors of death. In our experience, coccidioidomycosis is an important opportunistic infection that causes substantial morbidity and mortality among HIV-infected patients living in an area of endemicity.

Abdominal pain in the postpartum: role of imaging

The post-delivery evaluation of the obstetric patient presenting with severe abdominal pain can be a challenge to the obstetrician, the internist, and the radiologist. Besides non-pregnancy-related causes of abdominal pain, several pregnancy-related complications should be included in the list of differential diagnoses. Based on pathogenesis, these conditions can be divided in four categories: thromboembolic disease, infectious complications, mechanical complications, and complications of preeclampsia. Most disease processes can be adequately visualized with sonography. CT can be indicated for the evaluation of the extent of ovarian vein thrombosis and for depiction of deep abdominal collections in obese patients or in cases of abundant overlying abdominal gas. MRI can be useful to provide the specific diagnosis of hemorrhagic liver infarction in the clinical setting of a HELLP syndrome.

High-dose intravenous immunoglobulin treatment of a pregnant patient with an antiphospholipid syndrome: immunological changes associated with a successful outcome

A patient with a history of habitual abortion, deep venous thrombosis, thrombocytopenia, high titer IgG anticardiolipin antibodies and a clearly positive lupus anticoagulant, was treated during her seventh pregnancy with high-dose intravenous immunoglobulins (IVIg) from the third month onwards. Every month, a daily infusion of 400 mg immunoglobulins per kg body weight was given during five consecutive days. The patient's pregnancy ended preterm with a live birth, delivered by caesarian section because of a placental abruption. The 1070 g (P20-P25) weighing girl was in good health, apart from a bradycardia, due to dysfunction of the atrioventricular conduction. Each treatment with IVIg resulted in a slight reduction of both anticardiolipin antibodies and lupus anticoagulant levels and in an increase in platelet count. During the six-month observation period, a gradual decline in antiphospholipid antibodies and an increase in platelet count was found. The potential role of anti-idiotypic antibodies, present in the IVIg used for treatment, was studied. In vitro, IVIg were able to reduce the binding of the patient's anticardiolipin antibodies to cardiolipin coated microtiter plates. The presence of anti-idiotypic antibodies in IVIg was further documented by affinity chromatography and by realtime biospecific interaction analysis (BIA) on a BIA-core instrument. Affinity purified anticardiolipin antibodies were retarded on a column of insolubilized IVIg and a weak interaction was found between IVIg and affinity purified antiphospholipid antibodies, coupled to the BIA-core biosensor. In addition, the same technology revealed increased levels of anti-antiphospholipid antibodies in the patient's plasma following IVIg therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Increased thromboxane formation in diabetic pregnancy as a possible contributor to preeclampsia

OBJECTIVE

Because pregnant women with diabetes have an increased risk of preeclampsia, we tested the hypothesis that urinary excretion of thromboxane metabolites is increased in diabetic pregnancies without evidence of preeclampsia at the time of testing.

STUDY DESIGN

Urinary excretion of thromboxane A2 metabolites (either 2,3-dinor-thromboxane B2 or 11-dehydro-thromboxane B2) was measured in 24 type I pregnant diabetic individuals and in 20 women with normal pregnancies between 28 and 32 weeks' gestation.

RESULTS

The amount of 2,3-dinor-thromboxane B2 and 11-dehydro-thromboxane B2 in the urine of pregnant women with diabetes (1727 +/- 415 and 827 +/- 276 pg/mg creatinine) was significantly higher than in women with normal pregnancies (638 +/- 218 and 178 +/- 145 pg/mg creatinine) (p < 0.002 and p < 0.001).

CONCLUSION

Our findings support a role for thromboxane in the pathogenesis of preeclampsia.

Thromboxane synthetase inhibition as a new therapy for preeclampsia: animal and human studies minireview

The role of the eicosanoids in the pathophysiology of preeclampsia is reviewed, and the results of animal model and human studies with thromboxane synthetase inhibitors in preeclampsia are described. Potential benefits and limitations of therapy are discussed.

Effect of prenatal betamethasone/thyrotropin releasing hormone treatment on somatosensory evoked potentials in preterm newborns

The maternal administration of betamethasone and thyrotropin releasing hormone (TRH) to accelerate the maturation of the fetus is an increasingly adopted strategy to prevent neonatal morbidity in preterm infants. The effect of this prenatal treatment on the neural maturation of the infant was assessed by measuring somatosensory evoked potentials (SEP) in preterm infants (gestational age 29-36 wk) on the 1st postnatal day, at the age of 1 wk, and before discharge. The N1 latency values of the SEP obtained in 14 infants who were exposed prenatally to betamethasone/TRH were compared with the N1 latencies measured in 12 control infants. On the 1st postnatal day, the N1 latencies in the betamethasone/TRH-treated infants were strikingly shorter (p less than 0.01) than in the controls. However, at the age of 1 wk and at discharge, the N1 latency values of both groups were similar. In conclusion, the present study provides the first solid evidence for the concept that the prenatal exposure to betamethasone/TRH accelerates the SEP-assessed neural maturation of the human fetus, that this prenatal acceleration is followed by a compensatory relative deceleration during the early neonatal period, and that the subsequent SEP-assessed neural maturation proceeds at a normal velocity.

Platelet activation and vascular damage in gestational hypertension

Increased plasma fibronectin levels are a highly sensitive and specific predictor of gestational hypertension. Of a total of 105 apparently healthy normotensive primigravid women seen at the outpatient clinic, 10 with increased plasma levels of fibronectin (mean +/- 2 SD), were compared with 14 controls. Parameters of early vascular damage (laminin, preprocollagen III), platelet activation (beta-thromboglobulin, platelet factor 4), and coagulation (thrombin-antithrombin III complexes, fibrinopeptide A) were measured at regular (weekly or monthly) intervals. Abnormal values of laminin (p less than 0.005) and fibronectin (p less than 0.0001) were found up to 4 weeks before the onset of clinical disease. Levels of beta-thromboglobulin (p less than 0.0001) were also elevated at least 4 weeks before the appearance of clinical symptoms. Our results show that increased levels of laminin, fibronectin, and platelet activation, as indicated by beta-thromboglobulin levels, are preclinical features of gestational hypertension and indicate that vascular damage has occurred. Fibrin formation would appear to occur later.

Do biphasic uterine contractions imply poor uterine function?

In a retrospective study of 362 cardiotocographic recordings of primigravidae in labour we found 8% biphasic or coupled uterine contractions. In augmented labour, biphasic contractions occurred almost twice as often as in spontaneous and induced labour. The duration of labour complicated with biphasic contractions was increased significantly in all types of labour. Therefore biphasic contractions may reflect uneffective uterine function. Contrary to other studies, the appearance of biphasic contractions showed no correlation with epidural analgesia and the incidence of instrumental deliveries or caesarean sections was not increased.

Measurement of individual plasma angiotensins in normal pregnancy and pregnancy-induced hypertension

Individual angiotensin peptides were measured by a high pressure liquid chromatography-RIA (HPLC-RIA) technique in the plasma of 20 nonpregnant women, 17 women with normal pregnancy, and 49 with pregnancy-induced hypertension. Immunoreactive angiotensin-II (ANG-II) consisted mainly of ANG-(1-8) octapeptide (greater than 65%), variable proportions (15-25%) of ANG-(4-8) pentapeptide, and small to negligible proportions of ANG-(2-8) heptapeptide and ANG-(3-8) hexapeptide. Levels of ANG-(1-8) were significantly higher in women with normal pregnancy than in both nonpregnant women (P less than 0.0006) and women with pregnancy-induced hypertension (P less than 0.008); in the latter, levels were lower with increasing severity of disease. Levels of ANG-(4-8) were higher in women with normal pregnancy than in women with pregnancy-induced hypertension or nonpregnant women. When expressed as a proportion of ANG-(1-8) levels, however, ANG-(4-8) levels were not higher in normal pregnancy than in women with pregnancy-induced hypertension or nonpregnant women. It is concluded that the well known increase in ANG-II levels in normal pregnancy relates predominantly to the active ANG-(1-8) octapeptide and to a far lesser extent to the smaller ANG peptides. Similarly, lower ANG-II levels in pregnancy-induced hypertension relate predominantly to lower ANG-(1-8) levels.

Angiotensin II levels in hypertensive and normotensive pregnancies

We measured circulating angiotension II by radioimmunoassay in women with pregnancy-induced hypertension (n = 54), and compared these values with those obtained in women with normal pregnancy (n = 18) and in non pregnant women (n = 20). Pregnant women had statistically significantly higher plasma angiotensin II [mean (SD): 41.3 (12.6) pg/ml] than non-pregnant women [29.2 (11.3) pg/ml; P less than 0.004]. Angiotensin II concentrations in women with pregnancy-induced hypertension [mean (SD): 31.7 (16.2) pg/ml] were, on average, 25% lower than in normal pregnancy (P less than 0.003) and resembled those obtained in non-pregnant women. The lowest angiotensin II levels were found in women with more severe forms of pregnancy-induced hypertension, such as proteinuric or superimposed pregnancy-induced hypertension. Review of the published studies on angiotensin II and our data suggest that the conflict among studies on angiotensin II levels in pregnancy-induced hypertension is largely due to the heterogeneity of the study populations in the various reports.

Low-dose aspirin. II. Relationship of angiotensin II pressor responses, circulating eicosanoids, and pregnancy outcome

Forty pregnant women (28 to 32 weeks' gestation) were given low-dose aspirin therapy (81 mg/day) from the time of enrollment until delivery; circulating eicosanoid levels and angiotensin II pressor responses were measured before and after 1 week of aspirin therapy. Subsequent clinical outcome was correlated with these results. All women had significant reductions in serum and plasma thromboxane B2 levels with aspirin treatment (p less than 0.01). Eleven women who remained sensitive to the pressor effects of angiotensin II (effective pressor dose less than 10 ng/kg/min) after 1 week of low-dose aspirin treatment exhibited significant decreases (p less than 0.05) in plasma 6-keto-prostaglandin F1 alpha (264 +/- 119 vs 161 +/- 31 pg/ml, mean +/- SD) and prostaglandin E2 (476 +/- 174 vs 351 +/- 112 pg/ml) levels. In contrast, patients who were either nonsensitive (refractory) to angiotensin II (n = 18; greater than or equal to 10 ng/kg/min) before aspirin or became nonsensitive after aspirin administration (n = 11) had no change in either plasma 6-keto-prostaglandin F1 alpha or prostaglandin E2 concentrations. The occurrence of pregnancy-induced hypertension was 100% in the women who remained angiotensin II sensitive during aspirin therapy as compared with 36% and 39% in the other two groups (x2 = 16.14; p less than 0.001). Thus during low-dose aspirin therapy a failure to develop refractoriness to infused angiotensin II is associated with a nonselective inhibition of eicosanoids and the almost certain development of pregnancy-induced hypertension. These observations may reflect a basic defect in vascular adaptation to pregnancy.

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.

Predictive value of increased plasma levels of fibronectin in gestational hypertension

Blood pressure, proteinuria, and plasma fibronectin and plasminogen activator inhibitor-1 levels were measured in 120 apparently healthy normotensive primigravid women during the first, second, and third trimesters of pregnancy and 2 days post partum. Thirty-two women developed hypertension (diastolic blood pressure greater than or equal to 90 mm Hg) that in 17 women was associated with proteinuria (greater than 0.3 gm/day). Fibronectin levels were 83% +/- 22% of normal (mean +/- SD) during the first trimester and 75% +/- 20% at term in the healthy women but increased from 94% +/- 36% to 187% +/- 36% in the women who developed gestational hypertension (with or without proteinuria) (p less than 0.0001). Plasminogen activator inhibitor-1 levels increased from 26 +/- 19 ng/ml to 110 +/- 86 ng/ml in healthy women and from 32 +/- 35 ng/ml to 290 +/- 90 ng/ml in hypertensive women (p less than 0.001). Increased levels of fibronectin at 25 to 36 weeks of pregnancy (greater than or equal to mean + 2 SD of the healthy women, or greater than 140%) were found in 31 of the 32 women with gestational hypertension with or without proteinuria and in 5 of the 88 healthy women (sensitivity 96%, specificity 94%). Fibronectin levels increased 3.6 +/- 1.9 weeks earlier than the onset of hypertension and/or proteinuria. Increased levels of plasminogen activator inhibitor-1 at 25 to 32 weeks (greater than or equal to 280 ng/ml) were found in 16 of the 32 women who developed gestational hypertension with or without proteinuria and in 4 of the 88 healthy women (sensitivity 50%, specificity 95%). We conclude that increased fibronectin levels are the best predictor of gestational hypertension with or without proteinuria and that its level in plasma increases several weeks before the development of hypertension.