[B-Lynch suture in post partum hemorrhage]

Post partum hemorrhage is a major cause of maternal morbidity and mortality. We describe a case of a woman with post partum hemorrhage due to uterine atony, successfully treated with B-Lynch suture. The authors review the causes and risk factors, and the range of medical and surgical options that may be considered for the management of post partum hemorrhage.

Vesicouterine fistula after manual removal of placenta in a woman with previous cesarean section

Vesicouterine fistula is one of the less common acquired urogenital fistula and a rare event in obstetrics. We report a case which occurred after a vaginal delivery followed by manual removal of placenta in a woman who had a previous cesarean section. The fistula was successfully repaired 5 weeks after delivery.

Spontaneous ovarian hyperstimulation and primary hypothyroidism with a naturally conceived pregnancy

BACKGROUND

Ovarian hyperstimulation syndrome, not related to ovulation induction, is rare. A MEDLINE search from 1987 to 1997 using the key words "spontaneous ovarian stimulation," "pregnancy," and "hypothyroidism" revealed only five cases: three associated with pregnancies and two with primary hypothyroidism.

CASE

A 25-year-old white gravida 2, para 1, at 11-12 weeks' gestation presented with mild distension of a nontender abdomen, myxedematous facies, and large bilateral, multilobulated ovarian cysts. Conception had occurred spontaneously. Thyroid stimulating hormone was elevated, and free triiodothyronine and free thyroxine were low. Hypothyroidism, associated with spontaneous ovarian hyperstimulation syndrome, was diagnosed, and oral levothyroxine (0.10 mg/day) was started. With TSH still elevated at 21 weeks, levothyroxine was increased to 0.20 mg/day, and by 24 weeks, TSH and ovarian size were normal. Vaginal delivery of a 1120 g male infant occurred at 28 weeks.

CONCLUSION

A case of naturally conceived pregnancy associated with spontaneous ovarian hyperstimulation and primary hypothyroidism is reported.

Bartter's syndrome and pregnancy

Bartter's syndrome is a rare renal tubular disorder and few cases are reported associated with pregnancy. We describe a case of long standing disease with a good obstetric outcome in which the main concern was to maintain normal potassium serum levels.

Unusual case of severe cholestasis of pregnancy with early onset, improved by ursodeoxycholic acid administration

An exceptional case of early onset and prolonged postpartum course of intrahepatic cholestasis of pregnancy is described. Contrary to other drugs tested, ursodeoxycholic acid administered after the 29th week of gestation improved pruritus and decreased bile acid levels both in serum and amniotic fluid. Labour was induced at 36 weeks, and a female weighing 2.050 g and with an Apgar score of nine was born. Ursodeoxycholic acid, by decreasing the passage of bile acids to the foetus, may have improved the outcome of the pregnancy.

Correction of maternal serum bile acid profile during ursodeoxycholic acid therapy in cholestasis of pregnancy

BACKGROUND/AIMS

Intrahepatic cholestasis of pregnancy is characterized by pruritus and increased levels of serum bile acids, and is often associated with premature delivery, fetal distress, and perinatal mortality. The aims of the present study were: (i) to better define the serum bile acid profile in intrahepatic cholestasis of pregnancy and its potential usefulness for differential diagnosis; (ii) to investigate the effect of ursodeoxycholic acid treatment on the bile acid pool; and (iii) to investigate possible adverse effects of therapy.

METHODS

Fifteen patients with intrahepatic cholestasis of pregnancy were enrolled in this study. Ursodeoxycholic acid (14 mg/kg body weight per day) was administered for 13 +/- 5 days. Twenty normal pregnant women served as controls. Serum bile acid profile was analyzed by high-performance liquid chromatography.

RESULTS

Patients with cholestasis of pregnancy showed significant alterations in the proportion of primary bile acids, with an increase in cholic acid (64.0 +/- 3.0% vs. 32.2 +/- 1.8%, p < 0.01), and a decrease in chenodeoxycholic acid (20.8 +/- 1.4% vs. 31.9 +/- 1.3%, p < 0.01), as compared to controls, resulting in a marked elevation in the cholic/chenodeoxycholic acid ratio (3.4 +/- 0.5 vs. 1.1 +/- 0.1, p < 0.01). The glycine/taurine ratio was reduced in cholestasis of pregnancy (0.8 +/- 0.1 vs. 1.4 +/- 0.1, p < 0.01). During ursodeoxycholic acid administration its proportion in serum increased from 1.4 +/- 0.6% (0.6 +/- 0.2 micromol/l) at baseline to 24.7 +/- 2.3% (5.9 +/- 1.9 micromol/l) with therapy (p < 0.01). This increment was accompanied by a significant decrease in the percentage of cholic acid (28.2 +/- 2.6%, p < 0.01) and an elevation in chenodeoxycholic acid proportion (25.0 +/- 1.9%, N.S.). Although lithocholic acid concentration in serum was maintained with treatment (1.2 +/- 0.2 micromol/l vs. 1.7 +/- 0.5 micromol/l), there was a significant increase in lithocholic acid proportion (p < 0.01) from 3.3 +/- 0.5% at baseline to 7.4 +/- 1.3% during therapy. The glycine/taurine ratio of serum bile acid pool returned to normal after ursodeoxycholic acid administration (1.7 +/- 0.3).

CONCLUSIONS

These results establish the importance of ursodeoxycholic acid treatment for the correction of maternal serum bile acid profile in cholestasis of pregnancy, indicating that ursodeoxycholic acid may improve fetal prognosis.

[Gaucher's disease in pregnancy]

A case of Gaucher's disease associated with pregnancy is reported. Although clinical symptoms were not present, portal hypertension was detected by ultrasound in the 13th week of pregnancy. Maternal anemia implied the use of erythropoietin from the 33rd week onwards. Good perinatal and maternal outcomes were achieved and there were no hemorrhagic complications.

[Hypertension associated with pregnancy. Epidemiologic study of 311 consecutive cases]

The epidemiologic aspects of 311 consecutive cases of hypertension associated with pregnancy seen in the Department of Obstetrics and Gynecology, Hospital de Santa Maria/University of Lisbon Medical School between January 1st 1988 and December 31st 1992, are reviewed. Seventeen cases were multifetal pregnancies. Using the criteria proposed by the American College of Obstetricians and Gynecologists the cases were classified as follows: Mild preeclampsia, 64 cases (7 in twins); severe preeclampsia 50 cases (5 in twins); chronic hypertensive disease, 81 (1 in twins); chronic hypertension with superimposed preeclampsia, 16 (all singleton pregnancies); transient hypertension of pregnancy, 84 (4 in twins); unclassified hypertension, 16 cases of singleton pregnancies. No maternal deaths occurred. The most frequent maternal complications (eclampsia, HELLP syndrome, abruptio placentae and acute renal failure) were seen in preeclampsia (mild and severe forms). Only 2 significant maternal complications were observed in the cases of superimposed preeclampsia on chronic hypertensive disease. In the other groups maternal complications were seldom seen. Excepting in transient hypertension, perinatal morbidity and mortality were frequent in all groups, specially in severe preeclampsia and superimposed preeclampsia, when the delivery occurred before 34 weeks; after that time of pregnancy there were no neonatal deaths in any of the groups and intrauterine growth retardation and fetal distress were the most common fetal complications in all groups. In the whole, uncomplicated chronic hypertension and transient hypertension of pregnancy were the clinical situations in which maternal and perinatal complications were milder and less frequent. No perinatal problems were found in the group of unclassified hypertension.

[Teratogenic effects of exogenous agents]

Since the identification of Thalidomide as a potent human teratogen, the possible effects of a large number of drugs, and chemical, physical and environmental agents, on the embryo and the fetus have been raised without support of scientific demonstration. During the last ten years, a large number of papers were published on this issue, making the understanding of teratogenic mechanisms and effects a new field for investigation. This review is to show the recent trends and concepts on human teratogenesis induced by extrinsic agents, making it clear that the majority of them can not be seen as harmful to humans.

[The clinical implications of the characteristics of uteroplacental flow in pregnancy complicated by hypertension]

The study of the relationship between maternal and perinatal outcome with uterine blood flows using a continuous wave Doppler unit, in hypertensive patients was the aim of our work. One hundred and thirty seven pregnant hypertensive women seen and delivered at the Department of Obstetrics, Santa Maria Hospital, Lisbon, were included in the study. Blood flows were classified as abnormal if and when the systolic/diastolic ratio was > 2.8 and/or a diastolic notch was seen in one or both uterine arteries. The cases were divided in 2 groups (normal/abnormal) according to the uterine blood flow and correlated with maternal and perinatal outcomes. Twenty-three of 26 maternal complications occurred in cases with abnormal uterine artery blood flow; we also found the large majority of perinatal complications within this group (100% perinatal deaths, 88% of the intrauterine growth retardation, 92% preterm deliveries, 93% fetuses with absent or reverted diastolic umbilical flow, 88% cardiotocographic patterns of fetal distress and 84% of the newborns admitted to the neonatal care unit). In conclusion, in pregnancies complicated by hypertension, uterine artery blood flow evaluation by continuous wave Doppler may identify a set of patients needing closer prenatal surveillance.

[Deep venous thrombosis during pregnancy]

Deep vein thrombosis is a rare event during pregnancy. A case which occurred in a 27-year-old nullipara at 36 weeks of pregnancy is reported. Related literature is reviewed, specially in what concerns diagnosis and therapy.

[Trial of labor after cesarean section. Two years' experience]

A retrospective study was undertaken to evaluate the incidence of vaginal delivery in women that previously undergone a cesarean section; in addition, incidence of complications such as uterine rupture and scar dehiscence were evaluated. During the two years reviewed, 251 out of 324 women with a previous cesarean section were allowed to labor; 64.1% had a vaginal delivery. Uterine rupture occurred in 0.8% of the patients of the trial of labor group: no other significant maternal and/or fetal complications were seen; scar dehiscence occurred in 3.3%. Statistical analysis didn't show any increase in complications when oxytocin was used to stimulate uterine activity. It is concluded that trail of labor and delivery after cesarean section is a safe option in a large number of patients.

[The HELLP syndrome in pregnancy-related hypertension]

During a 5-year period, 13 cases of HELLP syndrome were seen in hypertensive patients in the Obstetrics Department, Santa Maria Hospital, Lisbon. In 7 cases the syndrome occurred antepartum and in 6 during early early puerperium; gestational age and clinical features were very different from case to case. Four cases of eclampsia and 2 cases of acute renal failure occurred in 5 patients; there were 2 intrauterine deaths. Maternal mortality was nil. HELLP syndrome always implicates an important hepatic involvement with deleterious effects on the clinical status of the patients. Since the syndrome is often diagnosed in the puerperium and major complications seen in our study group occurred in that period, we conclude that all hypertensive patients must be closely monitored during the first 48 hours after delivery.

[Myasthenia gravis and pregnancy]

Four cases of pregnancy in patients with Myasthenia Gravis are presented. No significant pregnancy complications occurred; labour/delivery and puerperium did not present many differences from those expected in healthy women. The review of the literature along with our short experience allows us to conclude that pregnancy in myasthenic patients is a high risk situation, but must be seen with optimism.

[Umbilical flowmetry in twin pregnancy. A method for identifying discordant fetal growth?]

Umbilical artery velocimetry was performed in 33 twin gestations to evaluate the predictivity of the test (umbilical artery S/D difference between the pair > 0.4) in the screening of discordant fetal growth. Four out of 10 cases of discordant fetal growth were identified by the test and it was abnormal in 1 out of 23 concordant twins. The sensitivity was 40%, specificity 95%, positive predictive value 80% and negative predictive value of 79%. In spite of its low sensitivity the test can be useful in detecting discordant fetal growth in twin pregnancies.

[Doppler flowmetry of feto-maternal circulation: III --Absent and reverse diastolic flow in the umbilical artery]

Twelve cases of extreme umbilical blood flow impairement (8 cases with loss of end-diastolic blood flow and 4 cases with reversed flow) found among 658 pregnancies studied by continuous Doppler between April 1st 1989 and March 31st 1990, are reported. The findings were associated to intra-uterine growth retardation (92%), maternal hypertensive disease (50%) and perinatal death (33%); fetal Trisomy 21 was the sole problem in one of the cases with absent end-diastolic frequencies. Our results are discussed and compared to similar data reported recently. Clinical management is proposed, according to umbilical blood flow patterns, length of gestation and underlying clinical situations.

Acute effects of maternal cigarette smoking on fetal heart rate and fetal body movements felt by the mother

Acute effects of maternal cigarette smoking on fetal heart rate (FHR) and fetal body movements felt by the mother (FM) were studied in 51 pregnant volunteers. Thirty four were chronic smokers (6 or more cigarettes per day, with an average of 14 cigarettes/day) and 17 were sporadic smokers (1 to 5 cigarettes per day, with an averaged of 3 cigarettes/day). In both groups the number of FM, fetal reactivity and short-term FHR variability decreased significantly in the 20 minutes following cigarette smoking; a sustained FHR rise of 10 or more beats/min was also found after the cigarette in more than 50% of the cases in the 2 groups. No statistically significant differences were found among the 2 groups when the post-cigarette data were compared. We conclude that maternal cigarette smoking produces important acute effects upon FM and FHR regardless the average daily number of cigarettes smoked by the mother.

An approach to interpretation and classification of sinusoidal fetal heart rate patterns

Sinusoidal fetal heart rate (SHR) records were obtained in 8 cases, either antepartum (3 cases of fetal Rh disease) or intrapartum (one case with an acute episode of fetomaternal transfusion as possible cause, 2 after meperidine administration to the mother and 2 others without attributable causes). Characteristics of both SHR patterns and related clinical pictures are described and compared to similar cases published elsewhere. The possible underlying mechanisms of SHR are discussed. Two different profiles of SHR patterns (smooth and jagged waveforms) are characterized and correlated with their most usual clinical backgrounds and prognostic significance. A classification of SHR into 2 main types is proposed, with clinical use in mind.

Takayasu's arteritis and pregnancy: a case of deleterious association

The association of pregnancy with Takayasu's arteritis is almost always uneventful. A case with high values of maternal blood pressure (BP) and severe intra-uterine growth retardation (IUGR), submitted to aggressive management with the delivery of a live fetus at 30 weeks, is presented.

Modification of the fetal reactivity by an intravenous glucose load to the mother

The effect of an intravenous maternal glucose load upon fetal activity and FHR was studied 51 times in 48 pregnancies at 34 or more weeks, in which the fetuses were classified as non-reactive during the NST. The initiation of fetal muscular activity was observed in 44 instances (41 fetuses) approximately 6 minutes after a 6 grams glucose load to the mother, which lead to the diagnosis of a state of fetal well-being without the need of a CST. In the 7 cases which were not responsive to the load, CSTs were performed; of these, 5 were positive, 1 negative and 1 suspicious. These pregnancies resulted in one fetal death during the 12 hours following CST and 5 newborns showed an APGAR Score less than 4 at one minute, with 2 neo-natal deaths. The reason for the negative glucose load test with negative CST was probably related to hemodynamic changes induced by intra-amniotic bleeding following a bloody amniocentesis, and not to the lack of fetal energy substate. The proposed method may constitute a screening possibility for the clinical management and prognosis of the hypoactive fetus, because the glucose load to the mother may release the somatic activity of the non-hypoxemic fetus. A fetus unable to show any significant increase in glucose uptake, even with increasing maternal-fetal gradients, could be identified by the negative response to the test.