Management of severe postpartum hemorrhage with a prostaglandin F2 alpha analogue.

Presented is a three-year study using a 15-methyl analogue of prostaglandin F2 alpha, in the management of severe postpartum hemorrhage due to uterine atony in patients who were unresponsive to conventional therapies. Fifty-four patients were entered into the study, but 51 were analyzed for efficacy. Successful control of postpartum hemorrhage occurred in 86%. Of the seven in whom therapy failed and who subsequently required surgical therapy, four had chorioamnionitis. Six subjects had intramyometrial injection of the agent, with dramatic results in five. Mild transient side effects occurred in less than 10% of subjects.

Management of severe postpartum hemorrhage due to uterine atony using an analogue of prostaglandin F2 alpha.

Twenty patients with severe postpartum hemorrhage due to uterine atony who were unresponsive to conventional therapy were treated with 0.25-mg intramuscular injections of (15-S)-15-methyl prostaglandin F2 alpha-tromethamine. A rapid and successful response was obtained in 18 patients. Two patients required surgical procedures to control bleeding. Both patients with treatment failure had chorioamnionitis. Side effects of the prostaglandin therapy included nausea, vomiting and diarrhea, a transient mild temperature elevation, and a transient moderate blood pressure elevation. Those subjects with preeclampsia did not demonstrate a serious elevation of blood pressure. The prostaglandin F2 alpha analogue appears to be very effective in the treatment of postpartum hemorrhage due to uterine atony.

Use of ultrasound biparietal diameter in timing of repeat cesarean section.

The aim of the study was to evaluate the use of ultrasound biparietal diameter (BPD) in the timing of elective repeat cesarean section on a large indigent service. One hundred sixty-five patients were evaluated over 2 years. If the BPD was 9.3 cm or more at or later than 38 weeks' gestation, a repeat procedure was undertaken without further testing of fetal maturity. This occurred in 55% of the study group. None of these neonates developed hyaline membrane disease (HMD). The remainder of the study group either did not attain a BPD of 9.3 cm by term, were diabetic, or had other factors to determine timing of delivery. Of this group, 50% underwent amniocentesis for a lecithin:sphingomyelin ratio. Three patients had fetal bleeding, 1 had rupture of membranes, and 1 began labor following amniocentesis. All neonates were healthy except 1 who had mild HMD. That neonate had not reached 9.3 cm BPD. Ultrasound has allowed development of a management program for elective repeat cesarean section that is reliable, cost-effective, and beneficial to the mother and neonate.

Impetigo herpetiformis as a cause of postpartum fever.

Impetigo herpetiformis is a rare and often serious pustular dermatosis of pregnancy. The usual course of impetigo herpetiformis is one of continued progression throughout pregnancy with rapid resolution during the puerperium. This patient is the first reported case, to the authors' knowledge, of impetigo herpetiformis presenting during the puerperium, a time usually associated with the disease's remission. This suggests that impetigo herpetiformis should be included in the differential diagnosis of puerperal fever, particularly in those cases associated with dermatoses.

Cocaine blocks extraneuronal uptake of norepinephrine by the pregnant human uterus.

Premature labor is one of the most common complications associated with cocaine abuse during pregnancy. Still, the effect of cocaine on the pregnant uterus is largely unknown. Although inhibition of neuronal uptake is the most important effect of cocaine in most tissues, after mid-pregnancy, the uterus has few functioning adrenergic nerve endings. To determine whether cocaine has any effect on uptake during pregnancy, we evaluated the ability of the term pregnant human uterus to take up [3H]-norepinephrine (9 x 10(-8) mol/L) and the ability of cocaine (10(-6)-10(-8) mol/L) to block this uptake. Because d-propranolol has been shown to block the direct effects of cocaine on the pregnant rabbit uterus, we also evaluated the ability of d-propranolol (2 x 10(-6) mol/L) to block the effect of cocaine on catecholamine uptake. The ability of the Uptake 2 inhibitor hydrocortisone (2 x 10(-5) mol/L) to block catecholamine uptake was also studied. We found that [3H]-norepinephrine was taken up by both the pregnant myometrium and endometrium, and that cocaine blocked this uptake by up to 55% at concentrations as low as 10(-7) mol/L. D-propranolol had no effect on the ability of cocaine to block catecholamine uptake. Hydrocortisone blocked uptake by the endometrium by 15% but did not block uptake by the myometrium. We conclude that the pregnant human uterus at term retains the ability to take up catecholamines and that cocaine blocks this extraneuronal uptake. This may explain, in part, the association of cocaine use with premature labor.

Cohort study of silastic obstetric vacuum cup deliveries: I. Safety of the instrument.

A prospective study was undertaken to determine the safety of the Silastic vacuum extractor. Between November 1982 and July 1983, a cohort of 84 successful vacuum extractor deliveries was examined, using the next sequential forceps delivery and spontaneous vaginal delivery as controls. In addition to routine neonatal morbidity measures, Scanlon early neonatal neurobehavioral scale and a modified Sarnat encephalopathy staging examination were used to critically assess neurologic functioning; a cranial ultrasound scan was performed to look for intracerebral hemorrhage, and an indirect ophthalmologic examination was done to assess the incidence of retinal hemorrhage. The study yielded no significant increase in maternal vaginal trauma for vacuum extractor versus spontaneous vaginal delivery, but there was a significantly greater incidence for forceps delivery (60%) versus vacuum extractor (25%) and more associated blood loss for forceps delivery (P less than .01). There was no significant increase in neonatal morbidity for vacuum extractor compared with forceps delivery nor in serious morbidity compared with spontaneous vaginal delivery. Specifically, for vacuum extractor versus forceps delivery there was no difference in one- and five-minute Apgar scores, extent of resuscitation, cosmetic injury, jaundice, mean neonatal intensive care unit stay, or incidence of retinal hemorrhage. Notably, there was no mortality related to delivery method, but there were two unrelated deaths. There were no cases of intraventricular or subgaleal hemorrhage on clinical or ultrasound examination, but one stillborn infant, who succumbed to a generalized coagulation defect, had a subarachnoid hemorrhage. Finally, there was no significant difference in Sarnat encephalopathy staging or Scanlon neurobehavioral assessment between spontaneous vaginal, forceps, and vacuum extractor deliveries.(ABSTRACT TRUNCATED AT 250 WORDS)

Cohort study of Silastic obstetric vacuum cup deliveries: II. Unsuccessful vacuum extraction.

In a cohort analysis of Silastic vacuum extractor deliveries, 65% were completed with the vacuum extractor alone, 24% with outlet forceps, 3% with midforceps, and 7% with cesarean section (vacuum extractor-cesarean). Control groups were formed by using the next sequential forceps delivery, spontaneous vaginal delivery, and every second cesarean section after a trial of labor. The infants were examined using a neurobehavioral scale, an encephalopathy assessment, cranial ultrasound, and indirect ophthalmoscopy. In the combined vacuum extractor and forceps delivery subgroup (vacuum extractor-forceps), all but 3% were converted from a high mid-forceps delivery to outlet forceps by the initial vacuum extractor procedure, thus eliminating many difficult midforceps deliveries. The study yielded no significant difference in maternal morbidity between vacuum extractor-forceps and forceps delivery, no difference in vaginal trauma for vacuum extractor-cesarean versus vacuum extractor delivery, and no greater hospital stay, infection rate, or need for transfusion for either vacuum extractor-forceps versus forceps delivery or vacuum extractor-cesarean versus cesarean delivery. Neonatal morbidity did not differ between successful and unsuccessful trial of vacuum extractor, except for an increased frequency of retinal hemorrhage. The frequency of scalp trauma, including cephalohematoma, did not differ between vacuum extractor-forceps and forceps delivery, or between vacuum extractor-cesarean and vacuum extractor delivery. For vacuum extractor-forceps versus forceps delivery and vacuum extractor-cesarean versus cesarean section, there were no significant differences in neurobehavioral or encephalopathy scores, or in the frequency of neonatal jaundice, facial palsy, anemia, fractures, or mortality.(ABSTRACT TRUNCATED AT 250 WORDS)

Serial salivary estriol to detect an increased risk of preterm birth.

OBJECTIVE: To evaluate serial measurements of salivary estriol (E3) to detect increased risk of spontaneous preterm labor and preterm birth. METHODS: A masked, prospective, multicenter trial of 956 women with singleton pregnancies was completed at eight United States medical centers. Saliva was collected weekly, beginning at the 22nd week of gestation until birth, and tested for unconjugated E3 by enzyme-linked immunosorbent assay. Women were separated into high-risk and low-risk groups using the Creasy scoring system. RESULTS: A single, positive (at or above 2.1 ng/mL) salivary E3 test predicted an increased risk of spontaneous preterm labor and delivery in the total population (relative risk [RR] 4.0, P <.005), in the low-risk population (RR 4.0, P < or =.05), and in the high-risk population (RR 3.4, P =.05). Two consecutive positive tests significantly increased the RR in all study groups, with a dramatic improvement in test specificity and positive predictive value but only a modest decrease in sensitivity. In women who presented with symptomatic preterm labor, salivary E3 identified 61% of those who delivered within 2 weeks, using a threshold of 1.4 ng/mL. CONCLUSION: Elevated salivary E3 is associated with increased risk of preterm birth in asymptomatic women and symptomatic women who present for evaluation of preterm labor.

Management of the pregnant patient with chronic hypertension.

Once the diagnosis of chronic hypertension in pregnancy has been made, many centers in the United States treat moderate to severe cases of chronic hypertension pharmacologically, hoping to delay or obviate the onset of superimposed preeclampsia and to improve perinatal outcome. Methyldopa, which is most often used, is the only antihypertensive drug for which there is no evidence of adverse effects in long-term follow-up studies of fetuses exposed to it. Newer beta-blocker drugs such as atenolol and labetalol are receiving much attention abroad. These newer drugs have fewer maternal side effects and, as yet, no adverse effects on fetuses have been seen. Clinical trials of labetalol will soon start in the United States.

Pituitary and testicular function in spontaneously hypertensive rats.

Levels of plasma gonadotropins, prolactin (PRL), and testosterone, and the testicular concentration, total content, and affinity of hCG binding sites were measured in male spontaneously hypertensive rats (SHR) and in genetically matched normotensive (WKY) rats. Hypertensive rats had higher plasma PRL and FSH levels and lower plasma testosterone levels. The affinity of testicular hCG binding sites was similar in SHR and WKY rats, but SHR had considerably lower concentration and total content of hCG-binding sites than did WKY animals. The comparison of these findings with those obtained previously with pituitary-grafted rats and with tumor-bearing rats indicates that the endocrine effects of hyperprolactinemia may vary depending on the rate and magnitude of the increase in peripheral PRL levels. Species differences in the response to hyperprolactinemia and differences between SHR and other rat strains suggest that hormonal responses to PRL elevation depend also on the genetic characteristics of the animal.

A competency based approach to comprehensive pregnancy care.

This paper assesses the quality and cost of a pregnancy care program based on explicit and achieved patient competencies. By using the USPHS Content of Prenatal Care (1989), key psychosocial/education elements of perinatal care were identified. The goal was a process of patient education that is competency based, integrated, and outcome oriented. Psychosocial assessment, patient education tools, criterion-based length of postpartum stay, and home nursing follow-up were implemented as part of a Comprehensive Pregnancy Program (CPP). Case-control and cohort survey methodology were used to evaluate outcome. There was a significant decrease in hospital length of stay for mothers and newborns after implementation of the CPP. Post-discharge maternal emergency room visits and/or readmits did not increase. Differences in newborn emergency room visits and/or readmits were non-significant. There was a marked reduction in hospital costs for mothers and newborns. Patient satisfaction remained high. Core competencies forming the basis of educational and assessment programs allow the focus of care to be optimal outcome, and provide a useful template against which to measure prenatal, intrapartum, and postpartum care.

A multicenter evaluation of intramuscular ritodrine hydrochloride as initial parenteral therapy for preterm labor management.

Ninety-four patients in documented preterm labor received three intramuscular injections of ritodrine hydrochloride over an interval of 6 hours. They subsequently received the tocolytic agent intravenously for a minimum of 6 hours. The effects of ritodrine on uterine activity and the cardiovascular system were determined. Intramuscular ritodrine hydrochloride elicited a prompt and sustained reduction in the frequency of uterine contractions. The transition to intravenous treatment was achieved without an increase in uterine activity. Seventy percent of the patients had a sustained interval of uterine quiescence, and 96% had at least a 24-hour delay in delivery. Initial parenteral therapy with intramuscular ritodrine hydrochloride is safe and effective and may provide an alternative to intravenous therapy and a means of managing preterm labor during interhospital transport of a patient.

Ultrasound uses in obstetrics.

Diagnostic ultrasound, particularly real-time, has significantly altered the management protocols for many obstetric problems. Often a clinical situation arises quickly where essential diagnostic information is needed as soon as possible in order to make a rational management decision. Thus, the need for a real-time ultrasound unit has become essential for the perinatal unit. With current rapid technical advancement, one should carefully determine the essential and desired elements of the apparatus and shop around. When planning a perinatal unit, planners should consider the layout of a diagnostic suite, a place for ultrasound scanning, and aminiocentesis procedures and consider both a free-standing and fixed ultrasound units.

Hemorrhagic shock in obstetrics.

Hemorrhage during pregnancy is life threatening to both the mother and her fetus. Physiologic preparation for blood loss at parturition does take place but the wise clinician also prepares for this eventuality. The usual causes of hemorrhage are discussed in this article, as well as a useful clinical approach to priorities in the management steps for obstetric hemorrhage shock are also presented.

Obstetric management of the very low birth weight fetus.

Obstetric management of the very low birth weight fetus (less than 1500 gm) is reviewed based on current literature. Issues of the pharmacologic therapy of preterm labor, enhancement of lung maturity, and management of labor and delivery are discussed.

In vitro studies on the control of human myometrial gap junctions.

In this study human myometrial tissues were examined for the presence of gap junctions by quantitative electron microscopy before and after incubation in tissue culture media with and without indomethacin. The area of gap junctions was very low in tissues from pregnant women at term but not labor, before incubation. After 24 and 48 h incubation without any treatment, segments of some of the same tissues developed many gap junctions and other tissues contained few junctions. Prostaglandin E (PGE), prostaglandin F (PGF) and prostaglandin F metabolite (PGF metabolite) levels in the media at various times were measured by radioimmunoassay. The prostaglandins increased progressively during the incubation period. Treatment of tissues with indomethacin decreased prostaglandin levels in the media and increased the numbers of gap junctions in those control tissues that developed few junctions over the same incubation interval. We conclude that the capacity of human myometrial tissues to develop gap junctions in vitro may depend upon a maturational stage in preparation for labor. Furthermore, our results suggest that products of the cyclo-oxygenase or lipoxygenase pathways may control the presence of gap junctions in the human myometrium and that changes in synthesis in these patterns may occur as part of the maturational process.

Spontaneous and induced cervical ripening. Natural dilation and effacement process and current cervical ripening techniques.

During gestation, the cervix forms a tight sphincter to ensure the integrity of the pregnancy. Toward the end of the pregnancy, hormone-mediated biochemical changes cause the cervix to ripen and become softer and more pliable to allow passage of the fetus. Failure of the cervix to ripen may result in delayed onset of labor and a prolonged and complicated course, especially if labor is artificially induced. Attempts to induce cervical ripening have involved the use of mechanical methods, estrogen and estrogen precursors, relaxin and prostaglandins. The ideal ripening agent is simple and noninvasive, effective within 24 hours, does not compromise mother or fetus and does not stimulate labor (during the ripening process).

Amniotic fluid composition in normal baboon pregnancies.

In order to compare the chemical composition of baboon and human amniotic fluid, 70 amniotic fluid samples were obtained from 58 normal baboon pregnancies at times ranging from 88 to 178 days (term, 180 days). Protein content averaged (+/- S.E.) 0.67 +/- 0.26 gm/dl, osmolality averaged 263 +/- 1.1 mOsm/kg, and pH averaged 7.74 +/- 0.034 units. These variables were not affected by length of gestation. Creatinine content increased parabolically with duration of gestation (r = 0.74; p less than 0.001). Forty percent of the samples had delta OD450 values of 0; the others had delta OD450 values ranging from 0.002 to 0.145. No decline in delta OD450 with gestational maturity was evident. These data suggest that the chemical environment of the baboon fetus is similar but not identical to that of the human fetus.

Double-blind comparison of maternal analgesia and neonatal neurobehaviour following intravenous butorphanol and meperidine.

Butorphanol (1 mg and 2 mg) and meperidine (40 mg and 80 mg), given intravenously, were evaluated for analgesic efficacy and safety in a double-blind randomized study employing 200 consenting pre-partum patients in moderate to severe pain during the late first stage of labour. Both drugs provided adequate relief of pain to the mothers. There was no significant difference in the rate of cervical dilation, the foetal heart rate, the Apgar score, pain relief or neonatal neurobehavioural scores betweeen those receiving butorphanol and those receiving meperidine. Twenty-two mothers who received butorphanol and eleven who received meperidine nursed their infants with no adverse effects observed. Side-effects were generally infrequent in this study; however, more side-effects were reported by the patients and observed by the investigator in the meperidine-treated cases (13%) than in the cases treated with butorphanol (2%).

Tympanic versus rectal thermometry in pregnant women.

OBJECTIVE: To assess the accuracy of the tympanic membrane thermometer for use with pregnant women. DESIGN: Cross-sectional descriptive study. SETTING: A major medical center in the midwestern United States. PARTICIPANTS: Thirty-three hospitalized, afebrile pregnant women. MAIN OUTCOME MEASURES: Tympanic membrane thermometers and glass mercury thermometers were used to measure body temperature at the ear and rectum, respectively. The results were compared using two statistical methods: the Pearson correlation coefficient and a new technique suggested by Bland and Altman (1986). RESULTS: Auditory canal temperature measured by a tympanic membrane thermometer correlated with rectal temperature as measured by a glass mercury thermometer (r = 0.38, p = 0.01). Thus, the tympanic membrane thermometer is acceptable for monitoring the body temperature of pregnant women. However, the device's estimation of rectal temperature is not clinically reliable. CONCLUSIONS: Tympanic membrane thermometers, when applied with direct measures, are acceptable for use with pregnant women. It is not recommended that the rectal estimate mode be used with pregnant women.