Transplacental passage of isradipine in the treatment of pregnancy-induced hypertension.

The aim of this study was to assess the concentration of isradipine in maternal and fetal plasma, and in amniotic fluid under steady-state conditions. Eight women were treated with 5-mg isradipine tablets twice daily and eight women were given slow-release isradipine capsules (SRO) twice daily for hypertension in pregnancy. Blood and amniotic fluid sampling for analysis of drug concentration was performed at delivery. In the isradipine tablet group, maternal and fetal plasma levels were 788 +/- 701 pg/mL (mean +/- SD) and 270 +/- 90 pg/mL, respectively. The corresponding levels in the SRO-treated group were 463 +/- 217 pg/mL and 185 +/- 95 pg/mL, respectively. In the amniotic fluid, the concentration was 74 +/- 42 pg/mL in the tablet group and 45 +/- 14 pg/mL in the SRO group. Therefore, isradipine passes the placental barrier, but its concentration is considerably lower in the fetal compartments.

Cervical score and onset of spontaneous labor in prolonged pregnancy dated by second-trimester ultrasonic scan.

The interval from expected day of delivery to spontaneous onset of labor was correlated with parity and cervical score in 103 women with uncomplicated prolonged pregnancy (greater than 294 days). All women had a routine ultrasonic scan in weeks 16-18 for the purpose of dating. The mean (+/- SD) modified Bishop score on entry to the study was 4.15 +/- 2.0 for nulliparas and 4.90 +/- 2.1 for multiparas. The duration beyond 294 days to spontaneous onset of labor varied little (mean 3.5-4.5 days) for nulliparas with scores greater than 2 and for multiparas regardless of score. Nulliparous women with a poor score (less than 3) had spontaneous onset of labor and delivery within a mean of 9.8 days. Half of the multiparas (50.0%) and 43.9% of the nulliparas gave birth within 3 days. About 90% of all women gave birth within 7 days. All but three had a vaginal delivery; the instrumental vaginal delivery rate was 16.3%. The results suggest that in postterm women dated with a second-trimester ultrasonic scan, the cervical scores are in general more favorable than previously reported in series not dated with early scans. The postterm group is also much smaller, and the time interval from entry into the postterm period to spontaneous onset of labor is shorter.

A five-year experience with terbutaline for preterm labor: low rate of severe side effects.

The medical records of 330 patients treated with terbutaline infusion for the inhibition of preterm labor were reviewed over a five-year period. In patients with intact membranes the results were uniformly good, particularly when treatment was instituted before the 30th week. Half these patients had a prolonged labor of six weeks or more; in most cases of treatment failure complications already existed on admission. In only nine patients (2.7%) terbutaline treatment was stopped due to side effects: predominantly maternal tachycardia or vomiting. Two patients had chest symptoms, but in no case was pulmonary edema diagnosed. The results suggested that a low incidence of severe side effects can be obtained if the following precautions are taken: glucose is used as the infusion medium, instead of sodium chloride; concentrated solutions are given to avoid fluid overload; the patients are carefully controlled; and the infusion is immediately reduced or stopped if signs of severe side effects appear.

Combined decelerations--clinical significance and relation to uterine activity.

A combined fetal heart rate deceleration consists of a first (either early or variable) component and a second (late) component. All patients with combined decelerations during a 2-year period of routine fetal monitoring were studied. The incidence was 1.1% (70 patients). Most patient were at low risk, and the combined decelerations appeared predominantly late in the first stage of labor. In all but 5, labor was stimulated by oxytocin infusion. In two thirds of patients, intrauterine pressure was recorded; uterine hyperactivity was found in 78.7%. Combined decelerations with a total loss of at least 90 beats and lasting for at least 60 seconds were associated with low fetal scalp pH. Ten percent of infants were born in the occiput posterior position. The results indicate a relation between abnormal uterine activity and combined fetal heart decelerations. This type of deceleration could serve as a warning signal of excessive oxytocin administration.

Intrapartum fetal acidosis in preterm infants: fetal monitoring and long-term morbidity.

Fetal heart rate (FHR) and fetal acid-base status were studied prospectively in 61 patients in preterm labor of unknown etiology. Neonatal data were analyzed, and all surviving infants participated in a follow-up study for at least two years. Ominous FHR patterns correlated well with fetal acidosis. Infants with fetal acidosis (pH less than 7.25 in scalp blood) had more neurologic abnormalities in the neonatal period and a higher rate of neurodevelopmental disabilities at the follow-up than nonacidotic infants of the same gestational weeks. In the surveillance of patients in preterm labor electronic fetal monitoring is mandatory. At late or pronounced variable decelerations, pH analysis of fetal scalp blood should be performed immediately. If not available, prompt abdominal delivery is recommended.

Chorioamnionitis and the isolation of microorganisms from the placenta.

Specimens for the isolation of microorganisms were obtained from the cervical canal in 83 and from the placenta in 86 of 90 women delivered by cesarean section. In addition, the placentas from 87 of these women were examined histopathologically. No correlation was found between the isolation of a given microorganism from the cervical canal and infectious disease in mothers and/or neonates. Isolation of microorganisms from the placenta was correlated with rupture of the membranes occurring six or more hours before surgery and, in women with intact fetal membranes, was correlated with uterine activity. Chorioamnionitis histopathologically was associated with maternal and/or neonatal infections and prematurity. Microorganisms were not isolated significantly more often from the placenta in cases with chorioamnionitis than without. The value of cervical and placental cultures in predicting intrauterine infection is questionable.

Intrapartum electronic fetal monitoring in low-risk pregnancies.

The value of fetal monitoring in low-risk pregnancies was evaluated in 4278 deliveries, 85% of all low-risk patients delivered in 1977 and 1978 at the University Hospital of Lund. An irreproachable tracing was recorded in less than half the cases. Fetal heart rate changes demanding scalp pH measurements or operative intervention for fetal distress occurred in about 10% of all deliveries. In only 30 patients (0.7%) was cesarean section performed for fetal distress. No intrapartal deaths occurred. The perinatal mortality (antenatal deaths excluded) was 0.14%. Only 3 of 1000 newborns had an Apgar score less than 7 at 5 minutes. The reported negative implications of routine fetal monitoring, such as overdiagnosis of fetal distress, cannot be verified in this study when electronic fetal monitoring and pH measurements are combined. The excellent fetal outcome suggests benefits from routine electronic fetal monitoring even in low-risk pregnancies.

Influence of occiput posterior position on the fetal heart rate pattern.

Fetal heart rate (FHR) recordings of 138 deliveries with the fetus in the occiput posterior position (OPP) are compared with recordings of 138 control fetuses in the occiput anterior position (OAP). The 2 groups are comparable in maternal age, parity, duration of first stage of labor, frequency of nerve blocks for analgesia, and incidence of cord complications. Variable decelerations were significantly more frequent and more pronounced in the OPP group than in the controls. The number of newborns with low Apgar scores was similar in both groups, despite a large number of pronounced decelerations in the OPP group. Possible mechanisms for the origin of variable decelerations in the occiput posterior position are discussed.

Risk factors for fever in labor.

OBJECTIVE: To identify risk factors for fever in labor. METHODS: A retrospective case-control study was conducted. Maternal sublingual temperature was measured every 2-4 hours during labor in 3109 of 3860 consecutive term parturients presenting from September 1992 through December 1993. Women who had fever (at least one recorded temperature of 38C or more, n = 72) during labor were compared with those who remained afebrile (n = 3037). Furthermore, a matched-pair case-control study was conducted, involving 250 women at term who developed fever in labor and 250 controls matched for parity and duration of labor; all delivered between January 1989 and December 1993. A conditional multiple logistic regression analysis was used to identify independent risk factors for fever during labor. RESULTS: In the case-control study, fever was associated with epidural analgesia, nulliparity, and a long duration of labor. These three variables were also related among themselves. However, multiple regression analysis showed that all three variables were independently associated with maternal temperature. In the matched-pair study, epidural analgesia, rupture of membranes longer than 24 hours, latency phase exceeding 8 hours, and a temperature in the upper normal range (37.5-37.9C) at admission were independent risk factors for developing fever in labor. CONCLUSION: Epidural analgesia, duration of labor, and a long interval from rupture of membranes to delivery were independent risk factors for maternal fever in labor.

Risk factors for acidemia at birth.

OBJECTIVE: To identify risk factors for acidemia at birth. METHODS: From September 1988 to December 1996, cord arterial blood pH was measured in 23,016 of 27,064 live-born infants (85.0%). Values below 7.05 were observed in 264 newborns (1.1%), of whom 14 born by cesarean delivery before labor and one triplet infant were excluded from the study. The remaining 249 newborns with acidemia and their mothers were compared with 249 unmatched controls with normal pH (the first infant with umbilical arterial pH above 7.10 born after each case). Multivariate logistic regression was used to adjust for potentially confounding variables. RESULTS: Variables significantly and independently associated with acidemia at birth were labor with breech presentation (adjusted odds ratio [OR]2.9), oxytocin administration (OR 2.1), meperidine administration (OR 2.0), cord entanglement (OR 1.7), and male gender of the infant (OR 1.4). Clinical evidence of chorioamnionitis also was associated with acidemia, although after adjustment for prematurity, the association was not statistically significant (OR 3.9, 95% confidence interval 0.8, 19). CONCLUSION: Labor with breech presentation, administration of oxytocin and meperidine, cord entanglement, and male gender are associated with an increased risk for insufficient fetomaternal gas exchange.

Intrapartum fetal monitoring in preterm deliveries: prospective study.

Fetal heart rate (FHR) and fetal acid-base status were prospectively studied in 61 patients in preterm labor of unknown etiology. Tachycardia (43%), decreased variability (39%), and variable decelerations (61%) were often recorded. Fetal acidosis (pH less than 7.25 in scalp blood) occurred in 52% of patients delivered in weeks 28 to 33 and in 8% of patients delivered in weeks 34 to 36 of gestation. Ominous FHR changes considered classic for fetal distress were very frequently associated with fetal acidosis, but among the most immature infants with fetal acidosis several had tachycardia and decreased variability combined with variable decelerations of innocent appearance. Patients treated with a beta-receptor agonist (terbutaline) for inhibition of preterm labor had fetal tachycardia and decreased variability more often than nontreated patients. No positive correlation with fetal acidosis for these FHR changes could be demonstrated in the terbutaline-treated patients. The results indicate that fetal acidosis can appear rapidly and frequently among the most immature infants during labor, and emphasize the value of considering the gestational age and the administration of beta-receptor stimulators in the assessment of the FHR pattern in preterm labor.

Effect of ritodrine on labor after premature rupture of the membranes.

The effect on labor of administering ritodrine after a premature rupture of the membranes (PROM) was studied in a double-blind trial in 30 patients. The patients were selected according to the following criteria: 28 to 36 weeks' gestation, only 1 fetus, cervix dilated 4 cm or less, and absence of pyrexia or other signs of uterine infection. Fourteen patients received ritodrine and 16 received a placebo. The 2 groups were statistically comparable. None of the patients receiving ritodrine delivered within 24 hours. The difference between the 2 groups was statistically significant with respect to the number of patients delivered within 24 hours (P less than 0.05). However, after 24 hours, there was no difference between the groups as regards the length of pregnancy. The infections registered in the mothers of infants were few and easily controlled. The incidence of idiopathic respiratory distress syndrome (IRDS) was low in the study and allows no conclusions concerning the benefit of prolonging the pregnancy for more than 24 hours after PROM.

Conization as treatment of carcinoma in situ of the uterine cervix.

A series of 343 consecutive cases with the preoperative diagnosis of carcinoma in situ of the uterine cervix treated by cervical conization is presented. In 93% of these patients cervical cytology returned to normal. The follow-up period ranged from 1 to 5 years. There was significantly greater chance for an apparent cure in cases in which histologic evaluation indicated free margins of resection (98%) than in those where the margins were involved by the neoplastic process (70%). Colposcopic evaluation to determine the site for punch biopsies and adequate resection margins could greatly enhance the success of therapeutic conization. The urgent need for conservative management of cervical intraepithelial neoplasia because of its predominance among young women is discussed.

Admission test: a screening test for fetal distress in labor.

The usefulness of a short electronic fetal heart rate recording at admission of patients in labor (admission test) was investigated in low-risk patients in two prospective studies. The admission test was done in a concealed manner, and the result of the test was evaluated after delivery so as not to influence the clinical management. In part I of the investigation, the test was performed in 130 patients monitored during labor with pH determinations in scalp blood and in cord blood at birth. Patients with reactive admission tests had a low rate of intrauterine asphyxia in labor (0.9%), whereas half of the patients with ominous traces had intrauterine fetal asphyxia with a low scalp blood pH and neonatal depression. Similar results were obtained in part II, when the admission test was used as a screening procedure involving 1041 patients. The test was reactive in 94.3%, and in this group fetal distress (cesarean section, or forceps on that indication, or an Apgar score less than 7 at five minutes) occurred in 1.3%. Ten patients (1.0%) had ominous tests; four of these had fetal distress, and one of these fetuses died in utero three hours after admission, during which time stethoscopic auscultation failed to detect the fetal compromise. It is concluded that the admission test can detect fetal distress already present at admission and unnecessary delay in intervention can be avoided in such a case. The test seems also to have some predictive value for the fetal well-being for the next few hours of labor. The test is simple and convenient for screening purposes.

A study of complications in preterm deliveries after prolonged premature rupture of the membranes.

The risk of infection for mother and baby after spontaneous rupture of the membranes was evaluated in a prospective study of 24 patients with ruptured membranes before the 36th week of pregnancy. The mean length of pregnancy after rupture was 10 days and 2 hours. Only patients harboring Group B streptococci or E. coli in the urogenital tract were treated with antibiotics (during delivery). With the exception of 1 woman, all patients harbored one or more pathogens in the urogenital tract. Four mothers were infected but all recovered. One of 26 infants died from infection. The study did not confirm any association between prolonged rupture of the membranes and the frequency of idiopathic respiratory distress syndrome, nor did it contradict attempts to actively prolong pregnancy after rupture of the membranes.

Transient fetal cerebral dysfunction after road traffic accident. A case report.

We present a case at 30 weeks gestation with transient abnormal fetal cerebral function after a road traffic accident, with loss of fetal movements and abnormal FHR tracings for almost 1 week. The pregnancy had after this incident a normal course and a healthy baby boy was born at term. We suggest the mechanism to be related to fetal hypoxia after excessive maternal psychological stress.

Transient fetal cerebral dysfunction after road traffic accident. A case report.

We present a case at 30 weeks gestation with transient abnormal fetal cerebral function after a road traffic accident, with loss of fetal movements and abnormal FHR tracings for almost 1 week. The pregnancy had after this incident a normal course and a healthy baby boy was born at term. We suggest the mechanism to be related to fetal hypoxia after excessive maternal psychological stress.

Prevalence of stress incontinence among women delivered by elective cesarian section.

A retrospective investigation into the prevalence of stress incontinence in women delivered by elective cesarian section (without experience of labor) in Lund from 1974 to 1979, was carried out in 1980. Of 264 women whose replies were solicited, 204 responded. The others had moved about and could not be reached. Permanent stress incontinence was reported by a significant number of patients without experience of labor. This supports our earlier findings which indicated that pregnancy and hereditary factors are more decisive in bringing about stress incontinence than the delivery itself.

Prognosis and long-term follow-up of a twin after antenatal death of the co-twin.

It is generally believed that among twin pregnancies with one fetal loss prior to delivery, the surviving twin has an increased rate of perinatal mortality and childhood morbidity (cerebral palsy and mental retardation). By using data from the National Medical Birth Registry of Sweden between 1973 and 1983, we identified 206 gestations with the death of at least one twin (in 36 pregnancies both twins died) prior to delivery. The original medical records were retrieved for study. The presence of childhood morbidity for 65 of 129 surviving (8 years of age or older) twins born between 1973 and 1980 was evaluated by a questionnaire sent to rehabilitation centers for disabled children, as well as to offices for the Provision of Care for the Mentally Retarded. Perinatal mortality for a twin after the antenatal death of the co-twin was considerable. Fifty percent of survivors died before 34 weeks' gestation, and 18.7% thereafter. At follow-up, 8 years or more after birth, three twins (4.6%) were handicapped. Our results indicate the need for careful monitoring of the surviving twin fetus after one twin has succumbed prenatally.

Randomised controlled trial of atenolol and pindolol in human pregnancy: effects on fetal haemodynamics.

OBJECTIVE: To compare the effects of uteroplacental circulation of two beta adrenoceptor blockers, atenolol (cardioselective) and pindolol (non-selective with intrinsic sympathomimetic activity). DESIGN: Controlled double blind double dummy study. SETTING: Departments of obstetrics and gynaecology in two Swedish university hospitals. SUBJECTS: 29 women with pregnancy induced hypertension in the third trimester, 13 randomised to atenolol and 16 to pindolol. MAIN OUTCOME MEASURES: Pulsatility index in fetal aorta, umbilical artery, and maternal arcuate artery. Volumetric blood flow in fetal aorta and umbilical vein. RESULTS: Mean arterial blood pressure decreased by 9.0 (95% confidence interval -13.0 to -5.0) mm Hg in the atenolol group and by 7.8 (-11.4 to -4.2) mm Hg in the pindolol group. During atenolol treatment the pulsatility index increased significantly from 1.82 (SD 0.20) to 2.07 (0.32) in the fetal thoracic descending aorta, from 1.44 (0.28) to 1.79 (0.27) in the abdominal aorta, and from 0.93 (0.17) to 1.05 (0.19) in the umbilical artery; the volumetric blood flow in the umbilical vein decreased from 106 (28.8) to 84 (22.6) ml/min/kg. No such changes were seen after treatment with pindolol. Birth weight was similar in the two groups but placental weight was significantly different (529 (122) g in atenolol group v 653 (136) g in pindolol group; p = 0.03). CONCLUSION: The hypotensive effect was similar with both drugs, but only the beta 1 blocker atenolol had significant effects on fetal haemodynamics, although within normal ranges. The implications of these findings can be only speculative, but negative fetal consequences of beta 1 adrenoceptor blockade cannot be excluded.