Doppler echocardiography of fetal ductus arteriosus constriction versus increased right ventricular output.

A prospective longitudinal study from 121 examinations of 41 normal pregnant women showed that fetal ductal flow velocities increased with gestational age. These normal data were compared with data in three groups of fetuses with altered ductal flow velocities: 22 fetuses (mean gestational age 31.3 weeks) had ductal constriction due to maternal indomethacin treatment; 10 fetuses (mean gestational age 27.9 weeks) had been exposed to terbutaline, a positive inotropic agent and 14 fetuses (mean gestational age 33.3 weeks) had hypoplastic left heart syndrome. In normal fetuses maximal systolic, mean and end-diastolic ductal flow velocities increased linearly (p less than 0.0001). The pulsatility index did not change (mean +/- 2 SD: 2.46 +/- 0.52). Fetuses with ductal constriction had higher maximal, mean and end-diastolic flow velocities and a significantly lower pulsatility index than did normal fetuses (1.25 +/- 0.76; p less than 0.0005). Six of 10 fetuses of the terbutaline group and 8 of 14 fetuses with hypoplastic left heart syndrome had increased maximal flow velocity, but normal or only mildly elevated mean flow velocity. The pulsatility index in fetuses during terbutaline therapy and with hypoplastic left heart syndrome was significantly higher than in normal fetuses (3.11 +/- 0.46 and 3.09 +/- 0.7, respectively, vs. 2.46 +/- 0.52; p less than 0.0005). Fetal ductal waveform analysis was necessary to distinguish fetal ductal constriction from increased right ventricular output. These measurements may be helpful in the diagnosis of left-sided outflow obstruction and assessment of fetal hemodynamic data.

Nephrotic syndrome due to preeclamptic nephropathy in a hydatidiform mole and coexistent fetus.

A case study and review of the literature of 2 uncommon obstetric events associated with each other is presented. The diagnosis, treatment, and evaluation of a case of nephrotic syndrome due to preeclamptic nephropathy in a hydatidiform mole and coexistent fetus is presented. Cytogenic studies and appropriate follow-up therapy are discussed. The complete remission of renal and hypertensive complications with evacuation of the pregnancy and lack of malignant transformation is stressed and is found to be characteristic of "partial" mole.

Parvovirus B19 infection in a twin pregnancy.

BACKGROUND: Parvovirus infection has been associated with the development of nonimmune hydrops fetalis in pregnancy. This report describes a twin pregnancy in which one fetus was affected by parvovirus B19 and the other was not. CASE: A 35-year-old woman was found to have a twin gestation at genetic amniocentesis. Subsequent ultrasound at 18 weeks showed that twin B had evidence of hydrops fetalis. Serum from the mother tested positive for parvovirus B19 immunoglobulin (Ig) G and IgM. Cultured amniotic fluid from twin B was subsequently found to be positive for parvovirus B19. At 20 weeks' gestation, the hydropic fetus died. The unaffected fetus grew normally. At 40 weeks, the unaffected fetus was delivered vaginally with no difficulties. Cord blood from the unaffected fetus was negative for parvovirus B19 IgM. CONCLUSION: This case demonstrates differential infection of parvovirus B19 in a diamniotic, dichorionic twin pregnancy. One twin developed signs of hydrops fetalis consistent with parvovirus B19. The diagnosis was confirmed immunologically and by amniotic fluid culture. The second twin had no evidence of parvovirus B19 and no immunologic suggestion of infection at birth. This is the only known report of such differential transmission of parvovirus B19 in a twin pregnancy.

Measurement of systolic-diastolic ratio in the umbilical artery by continuous-wave and pulsed-wave Doppler ultrasound: comparison at different sites.

Analysis of umbilical artery flow velocity waveforms, especially systolic-diastolic (S-D) ratio, can predict some pregnancy abnormalities. Most of the earlier studies did not specify the exact segment of umbilical artery sampled. We studied 53 normal singleton pregnancies between 18-41 weeks' gestation to compare S-D ratio measurements of the umbilical artery at different sites: 1) abdominal insertion site, 2) placental insertion site, 3) mid-cord, and 4) an undetermined site. The mean S-D ratio was significantly different (P less than .01) at various segments of the umbilical artery--higher near the abdominal insertion site when compared with the mid-cord, near-placental, and undetermined sites. The S-D ratio at mid-cord was higher than at the undetermined site and the placental insertion site. The near-placental-site S-D ratio was not different from the undetermined site. A lower S-D ratio at the undetermined site may not adequately reflect the true physiologic status of the fetus. Specifying the site of measurement should be an integral part of any report, in order to describe accurately the pathophysiology of fetoplacental circulatory diseases.

Symptomatic liver hemangioma with intra-tumor hemorrhage treated by angiography and embolization during pregnancy.

BACKGROUND: Cavernous hemangiomas are the most common benign tumors of the liver and are found in about 2% of autopsy patients. The vast majority are small (less than 4 cm) and asymptomatic, but there have been a few reported cases of these lesions leading to severe pain and even spontaneous fatal hemorrhage. Estrogen may cause the growth of liver hemangiomas, but there is a paucity of information concerning the effect of pregnancy upon these lesions. CASE: A patient presented at 18 weeks' gestation with the acute onset of vomiting and epigastric pain. A right upper-quadrant ultrasound scan found a 9-cm hypodense lesion within the liver, and magnetic resonance imaging (MRI) suggested a hemangioma. The lesion was believed to be inoperable, and selective catheterization of the common hepatic artery was performed. An angiogram demonstrated a round vascular mass 12 cm in diameter occupying much of the left side of the liver, with the vascular supply from the middle hepatic artery and to a lesser extent from the left hepatic artery. Embolization was performed, and a post-embolization image demonstrated satisfactory occlusion of the vessels treated. The patient's epigastric pain resolved after the procedure. The lesion was observed with monthly ultrasound and regressed to about 50% of its original size. The patient was scheduled for an elective primary cesarean delivery at 39 weeks to avoid possible rupture of the hepatic hemangioma during the second stage of labor. Her cesarean and postpartum course were uncomplicated. CONCLUSION: A symptomatic liver hemangioma with intratumor hemorrhage can be successfully treated with embolization during pregnancy. Because of the paucity of reported cases, it is uncertain whether vaginal birth is contraindicated in these patients.

Patient attitude toward home uterine activity monitoring.

Forty private patients using a home uterine activity monitoring system and daily contact with nursing staff (Term Guard monitor and Tokos Perinatal Nursing Service; Tokos Medical Corp., Santa Ana, CA) were surveyed after delivery. Twenty-seven responses (67.5%) were obtained. The majority of the responding patients (81%) felt that the monitor helped their pregnancy and 92% would recommend it to family and friends. Eighty-five percent thought that the monitor and related nursing services would be something that they would use in future pregnancies. No subject concluded that the monitor depersonalized their obstetric care. Forty-one percent of the patients felt that the device was an intrusion into their life-style. Seventy-eight percent thought that the device was beneficial in their understanding of preterm labor and in learning to perceive their own baseline uterine activity. Almost 60% of the subjects noted that the monitor was useful in determining uterine activity because they did not perceive any contractions. Approximately 65% felt that unnecessary trips to the hospital for prolonged monitoring were prevented by the availability of 24-hour-a-day, 7-day-a-week emergency transmission and nurse contact. Nearly three-fourths of the patients felt that unnecessary calls to the physician were prevented by their ability to monitor. In summary, the services were well accepted by the patients and, despite the intrusion into their life-style, most felt that home uterine activity monitoring improved the outcome of their pregnancy.

Preeclampsia, trisomy 13, and the placental bed.

Genetic predisposition and abnormal trophoblastic function are thought to contribute to the development of preeclampsia. A multipara developed severe preeclampsia and subsequently delivered a live growth-retarded infant with trisomy 13. Biopsy of the placental bed taken immediately after delivery demonstrated inadequate trophoblastic remodeling of the maternal uterine vasculature, with an absence of normal physiologic changes in the spiral arteries. This case suggests that fetal trisomy 13 can be associated with preeclampsia in multiparous women and that abnormal trophoblastic invasion may contribute to the pathophysiology.

Management of the pregnant patient with a cerebral venous angioma: a report of two cases.

Though there is a large body of knowledge regarding the management of pregnant women with arterial lesions in the central nervous system, little information is available on venous malformations. We report our experience with two pregnant patients with cerebral venous angiomas. These lesions are usually asymptomatic and only rarely cause seizures or subarachnoid hemorrhage. Based on our experience and literature review, we suggest that patients with venous angiomas without a history of hemorrhage can safely undergo labor and vaginal delivery.

Sickle-delta beta thalassemia: mild sickling disorder with serious morbidity in pregnancy.

Two patients with sickle-delta gamma thalassemia are reported who experienced the typical complications of sickling disorders in the last 2 months of 4 pregnancies. The diagnosis, genetics, and management of pregnancy in this rare hematologic disease, which causes minimal morbidity in the nonpregnant woman, are discussed.

Cefoxitin versus clindamycin and gentamicin in the treatment of postcesarean section infections.

Cefoxitin, a cefamycin derivative, has demonstrated activity against a broad spectrum of aerobic and anaerobic bacterial pathogens. The efficacy and safety of cefoxitin were compared with that of the combination of clindamycin and gentamicin in the treatment of postcesarean section infection. Ninety-eight patients were evaluated. Cefoxitin cured 36 of 48 patients (75%); clindamycin/gentamicin cured 38 of 50 (76%) (P greater than .05). Febrile degree hours and length of hospital stay did not differ between the two study groups. No patient experienced abscess formation or septic pelvic thrombophlebitis. Both therapies were well tolerated. In the authors' experience, cefoxitin as a single agent was as effective in the treatment of postoperative pelvic infection as the combination of clindamycin and gentamicin.

Fetal-maternal bleeding associated with genetic amniocentesis: real-time versus static ultrasound.

The incidence of fetal to maternal bleeding was studied in 773 consecutive patients having genetic amniocentesis by measuring maternal serum alpha-fetoprotein elevation following the procedure. The frequency of fetal to maternal bleeding was significantly lower in patients having amniocentesis immediately after real-time ultrasound (21 of 429 cases, 4.9%) when compared with patients having static B-mode ultrasound before the procedure (31 of 344 cases, 9.0%). A lower frequency of fetal to maternal bleeding was observed in the real-time group for anterior or partially anterior placentas (8.1%) and posterior or fundal posterior placentas (0%) when compared with the static B-mode group (12.9 and 5.2%, respectively). The rate of spontaneous abortion in patients with fetal to maternal bleeding (12.8%) was significantly higher than the rate in patients who did not demonstrate such bleeding (1.45%). The implications of these findings with regard to the safety of amniocentesis and the benefit of routine preliminary ultrasound evaluation are discussed.

The utility of the TDx test in the assessment of fetal lung maturity.

Accurate assessment of fetal lung maturity is essential in the management of high-risk obstetric patients. New rapid techniques have been developed to supplement time-consuming chromatographic methods. We compared one of these newer methods, the TDx-FLM, to the standard tests for fetal pulmonary maturity. There was an excellent correlation between the TDx and the lecithin-sphingomyelin ratio (r = 0.78). Although a TDx value of 70 or greater is considered mature, we found a value of 50 or greater predictive of fetal lung maturity in 100% of cases, and have chosen to redefine a mature value as 50 or greater in our institution. This value has greatly enhanced the clinical applicability of the test, allowing use of a large number of specimens from the previously poorly understood and often disregarded borderline category.

The EcoRV genetic polymorphism of human monoamine oxidase type A is not associated with Parkinson's disease and does not modify the effect of smoking on Parkinson's disease.

We previously observed an association with Parkinson's (PD), and modification of the effect of smoking on PD, by a polymorphism of the monoamine oxidase B (MAO-B) gene. The A form of monoamine oxidase (MAO-A) shares with MAO-B many characteristics that could be relevant to PD, especially proneuroxicant bioactivation and dopamine metabolism. MAO-A is also inhibited by tobacco smoke, which bears an apparent protective effect on PD. We investigated the possibility that MAO-A genetic variants may also be involved in predisposition to PD and in modification of the effect of smoking. Three-hundred and seventy-one subjects--145 idiopathic PD cases and 226 age/gender-matched controls--were genotyped for the EcoRV polymorphism of MAO-A gene which has been related to increased enzyme activity. MAO-A EcoRV polymorphism was neither significantly associated with PD nor did it modify the inverse relationship with smoking. These results suggest that the EcoRV polymorphism of MAO-A is not an important biomarker of PD risk.

Premature constriction of the ductus arteriosus.

Prostaglandin synthetase inhibition in the fetus may induce constriction of the ductus arteriosus. Clinical experience is now accumulating that proves that this potential complication is reversible and that it is easily diagnosed by Doppler echocardiography.

Pregnancies complicated by liver disease and liver dysfunction.

Although liver dysfunction is infrequently seen in pregnancy, it can result in severe maternal and fetal compromise. An unrecognized case of acute fatty liver may result in both maternal and fetal death. Failure to screen for hepatitis B can result in a newborn who will be a hepatitis carrier for life. Because of such consequences, the obstetrician must remain vigilant for signs of liver dysfunction and must understand the pathophysiology of these disorders.

Cost-effective approach to office screening for gestational diabetes.

Gestational diabetes is a common problem during pregnancy. There are numerous screening programs, all of which are costly and time consuming. During a 6-month period, 50 patients were screened for gestational diabetes with a standard 50-g oral glucose load, and 1 hour later a capillary blood specimen was evaluated by means of a reflectance meter and a venous sample was evaluated in the hospital laboratory. We found that the capillary blood glucose determination was accurate, but we recommend that specific cutoff values for each meter be established for each facility. By using the glucose reflectance meter, 90% of patients will not require laboratory studies, which results in significant cost savings. Besides cost savings, the immediate results obtained by a reflectance meter allow for prompt identification of an abnormal screen and prompt scheduling for further evaluation of glucose intolerance during the pregnancy.

Obstetric clavicular fractures. A three-year analysis.

A three-year retrospective study of al deliveries in a military residency program revealed 24 cases of fractured clavicles. Fifteen of these 24 cases were thoroughly reviewed. The incidence of clavicular fractures was 7.2 per 1,000 term deliveries. Fractured clavicle seemed to be best correlated with birth weight, level of obstetric experience of the delivering physician and midforceps deliveries. It was not well correlated with type of anesthesia, length of labor, length of second stage, Apgar scores, parity and judged difficulty of delivery. Only 1 infant of 15 suffered neurologic injury. A review of the literature and suggestions for possible prevention are presented.

High-risk obstetrics. The three-year experience of four subspecialists.

The development of maternal-fetal medicine as a subspecialty in obstetrics and gynecology is fairly new. The specialists involved in this area are usually hospital based and involved in multiple activities, including teaching, administration and research. The role of this subspecialist as a provider of primary care to a high-risk obstetric population is important but has not been reported on previously. In this context high-risk obstetrics refers to intercurrent obstetric problems, previous obstetric problems, previous medical problems, infertility and the supposedly high-risk group of physicians and physicians' wives.

Safety of predeposit autologous blood donation in the third trimester of pregnancy.

The option of predeposit autologous blood donation (PABD) before elective surgery has been gaining popularity as a means of eliminating the transmission of the acquired immune deficiency syndrome and hepatitis. It also prevents potential antigen sensitization and transfusion reactions. The use of PABD in pregnant women has been described, but its safety for both mother and fetus, especially in the first and third trimester, has not been established. After studying 16 third-trimester pregnant women with antenatal surveillance techniques and continuous fetal monitoring, we concluded that PABD is a safe procedure for both mother and fetus.

Glycemic control in pregnant diabetic women using a continuous subcutaneous insulin infusion pump.

Five insulin-dependent diabetics in the third trimester of pregnancy were first stabilized on morning and evening injections of both short- and long-acting insulin. Blood sugars were determined hourly from 7 A.M. to 7 P.M. and then every two hours from 7 P.M. to 7 A.M. After glycemic control was established, the patients were treated with continuous subcutaneous insulin infusion via a pump that administers a basal dosage at predetermined intervals and bolus doses preprandially. Mean blood sugar, glycemic excursions and intervals of hypoglycemia and hyperglycemia were calculated after three to five days of infusion therapy. The continuous subcutaneous insulin infusion with the pump did not improve glycemic control in the group as a whole, but in two of five patients there was a significant decrease in mean blood sugar. A trend towards a decrease in glycemic excursions as well as hypoglycemia and hyperglycemia was also obtained. Three patients were managed with long-term home and in-hospital use of the continuous subcutaneous insulin infusion pump. It proved to be efficacious and safe in establishing euglycemia. This study of a portable insulin infusion pump affirms its ability to maintain glycemic control and its safety for long-term therapy during pregnancy.