Cardiac tamponade in pregnancy during central hyperalimentation.

Cardiac tamponade from central venous catheterization occurs in less than 1% of cases. This report describes the first case of cardiac tamponade associated with total parenteral nutrition during pregnancy. Cardiac tamponade with subsequent nutrition during pregnancy. Cardiac tamponade with subsequent cardiac arrest occurred on the seventh day of central hyperalimentation for hyperemesis gravidarum. Maternal cardiopulmonary resuscitation was accomplished after pericardiocentesis, but maternal brain death and fetal death occurred. Diagnostic and therapeutic issues unique to cardiac tamponade during pregnancy are discussed.

Fetal death from sepsis following a reassuring intrapartum fetal acoustic stimulation test.

An intrapartum fetal death within 20 minutes of a reassuring acoustically stimulated fetal heart rate acceleration is reported. The cause of death in this instance was congenital pneumonia, gram-negative sepsis, and meconium aspiration. Umbilical cord pH values obtained at delivery did not demonstrate asphyxia (ie, low pO2, high pCO2, and low pH), but suggested a metabolic acidosis typical of sepsis.

Color flow mapping and Doppler velocimetry in the diagnosis and management of a placental chorioangioma associated with nonimmune fetal hydrops.

BACKGROUND: Placental chorioangiomas are the most common tumors of the placenta, occurring in 1% of all pregnancies. With the increasing use of ultrasound, prenatal recognition of these tumors is becoming more common. CASE: A 36-year-old woman presented at 28 weeks' gestation with an intrauterine mass suggested by color flow and Doppler studies to be a vascular tumor. Because of the association of these findings to nonimmune fetal hydrops, management included umbilical blood sampling and intravascular transfusion for fetal anemia. This intervention temporarily corrected the hydrops and significantly prolonged the pregnancy. CONCLUSION: Color flow mapping and Doppler flow studies of intrauterine tumors associated with fetal nonimmune hydrops can be helpful in both diagnosis and management.

Intrauterine manometry: reapplication of an old concept.

Electronic fetal heart rate and uterine activity monitoring during labor requires expensive equipment and a source of electricity. However, it is not available to most of the women in the world. Intrauterine manometry provides a method which can be employed in underdeveloped settings to assess uterine contractions and to time auscultation. The vertical column of fluid in a standard intrauterine pressure catheter (IUPC) correlated well (R = 0.93) with the intrauterine pressure measurements obtained by a standard IUPC/pressure transducer system. Intrauterine manometry provides an alternative measure of uterine tone which may be employed in underdeveloped areas.

Effect of arachidonic acid (ARA), prostaglandins E2 (PGE2), and F2alpha (PGF2alpha) on sensitized spleen cells in the hemolytic plaque assay.

Spleen cells from the BDF1 generation of DBA male X C57Bl/6 female matings sensitized with sheep erythrocytes (SRBC) were exposed to various concentrations of ARA, PGE2, and PGF2alpha for 90 minutes in vitro at 37 degrees C. Following exposure these sensitized spleen cells were then examined in the hemolytic plaque assay. No changes were demonstrated in the number of plaque forming cells (PFC) with 0.1 microgram/ml of ARA treatment. However, an increase in the number of PFC occurred with increasing concentrations of ARA. A significant increase (p less than 0.01) in PFC (59%) was shown with 10.0 microgram/ml of ARA. PGE2 treatment at 10.0 and 100.0 microgram/ml showed no evidence of increase, but a slight decrease (10%) was shown with 100.0 microgram/ml. On the other hand, exposure to PGF2alpha showed a significant increase (p less than 0.05) in PFC at the 10.0 microgram/ml (35%) and the 100.0 microgram/ml (29% levels, respectively. The data suggest that both ARA and PGF2alpha enhanced PFC formation.

Measurement of cardiac output in pregnancy by thoracic electrical bioimpedance and thermodilution. A preliminary report.

Thoracic electrical bioimpedance is a noninvasive, continuous method of obtaining cardiac output that requires no operator skill. However, the most recent thoracic electrical bioimpedance technology has not been validated in pregnancy. We therefore compared two methods of measuring cardiac output in pregnancy, thoracic electrical bioimpedance and thermodilution. We studied 11 patients who required pulmonary artery catheterization for peripartum management and measured cardiac output simultaneously by thoracic electrical bioimpedance and thermodilution. Among eight of nine patients, there was agreement (within +/- 20%) between the two methods. Bivariate linear regression with these nine cases showed excellent correlation (r = 0.91, p less than 0.001) with a slope of 1.04, which indicated a one-to-one relationship between thoracic electrical bioimpedance and thermodilution. The remaining two cases were removed from analysis because of septic shock in one case (which invalidates thoracic electrical bioimpedance) and 4+ tricuspid regurgitation in another case (which invalidates thermodilution). These data support that thoracic electrical bioimpedance measurement of cardiac output may be valid in most peripartum patients.

Uterine rupture: are intrauterine pressure catheters useful in the diagnosis?

The usefulness of the intrauterine pressure catheter in the diagnosis of uterine rupture was assessed by review of 76 cases of uterine rupture, 39 of which were monitored with an intrauterine pressure catheter. The classic description of a loss of intrauterine pressure or cessation of labor was not observed in any of the patients. However, an increase in baseline intrauterine pressure was observed in four patients with an intrauterine pressure catheter. The increase in pressure was associated with severe variable decelerations such that by itself the intrauterine pressure catheter added little to the diagnosis of uterine rupture.

Systemic vascular resistance index determined by thoracic electrical bioimpedance predicts the risk for maternal hypotension during regional anesthesia for cesarean delivery.

OBJECTIVE: Our purpose was to evaluate the predictive value of the baseline systemic vascular resistance index for the development of maternal hypotension during regional anesthesia for cesarean delivery. STUDY DESIGN: Patients receiving a standardized spinal or epidural anesthetic for nonemergency cesarean delivery were studied prospectively. Hemodynamic data were obtained noninvasively with an NCCOM-3 cardiac output monitor (Bomed Medical Manufacturing, Irvine, Calif.), which uses thoracic electrical bioimpedance to estimate stroke volume and cardiac output. Measurements obtained were indexed to body surface area. The systemic vascular resistance index was calculated from mean arterial pressure and thoracic electrical bioimpedance-derived cardiac index. Hemodynamic data obtained were analyzed to identify statistically significant predictors of maternal hypotension. RESULTS: Maternal hypotension occurred in 24 of 42 (57%) patients studied. The incidence of hypotension did not differ between the types of anesthesia: spinal 17 of 274 (62%) versus epidural 7 of 15 (47%, p=0.48). The mean interval to the onset of hypotension was 12.2 minutes (SD 2.2 minutes, range 2 to 24 minutes). Mean (SD) baseline maternal systolic blood pressure was higher in patients who had hypotension (145 torr [4]) than those who did not (129 torr [4], p=0.01). The mean (SD) baseline systemic vascular resistance index was higher in patients who had hypotension (633 [SD 36] dyne . cm . sec-5/m2) than those who did not (454 [SD 29] dyne . cm . sec-5/m2; p =0.001). With receiver-operator characteristic curves, a baseline systemic vascular resistance index of 500 had a sensitivity of 83%, a specificity of 78%, a positive predictive value of 83%, and a negative predictive value of 78% for maternal hypotension (odds ratio 17.5, 95% confidence interval 3.1 to 109.4). A baseline systolic blood pressure of 140 torr had a sensitivity and specificity of 42% and 72%, respectively (odds ratio 1.9, 95% confidence interval 0.4 to 8.8). CONCLUSIONS: Baseline systemic vascular resistance index obtained by noninvasive cardiac output monitoring with thoracic electrical bioimpedance and systolic blood pressure are useful to predict the risk for maternal hypotension with regional anesthesia. Patients with increased baseline systemic vascular resistance index or systolic blood pressure are at increased risk for hypotension.

Calcium/creatinine ratio and microalbuminuria in the prediction of preeclampsia.

Eighty-eight normotensive gravid women between 24 and 34 weeks of gestation underwent urine evaluation for the presence of microalbuminuria and urinary calcium excretion (calcium/creatinine ratio). Preeclampsia subsequently developed in 83% of patients with a high level of microalbuminuria (greater than or equal to 11 micrograms/ml) and a low calcium/creatinine ratio (less than or equal to 0.04). Conversely, 94% of women who did not demonstrate high microalbuminuria and a low calcium/creatinine ratio remained normotensive at the time of delivery. These results suggest that changes in renal function are present in gravid women who are otherwise free of symptoms in whom preeclampsia will eventually develop. Testing for microalbuminuria and a calcium/creatinine ratio may be a useful screening tool in predicting the subsequent development of preeclampsia.

Exercise prescription in pregnancy: weight-bearing versus non-weight-bearing exercise.

Bicycle ergometry (non-weight-bearing exercise) and treadmill (weight-bearing exercise) were compared to assess physiologic responses to similar work loads. A total of 22 subjects at 29.3 +/- 1.6 (+/- SEM) weeks' gestation who performed non-weight-bearing exercise were compared with 15 similarly fit subjects at 26.1 +/- 2.3 weeks' gestation who performed weight-bearing exercise at three submaximal levels. Measurements by indirect calorimetry indicate preferential carbohydrate use during non-weight-bearing exercise at submaximal levels.