Glyceryl trinitrate and ritodrine in tocolysis: an international multicenter randomized study. GTN Preterm Labour Investigation Group.

OBJECTIVE: To compare the efficacy of transdermal glyceryl trinitrate and intravenous (IV) ritodrine as tocolytics. METHODS: Two hundred forty-five women with preterm labor and intact membranes between 24 and 36 weeks' gestation were randomized to transdermal glyceryl trinitrate or intravenous ritodrine. Treatment was continued until contractions stopped or a maximum of 7 days. Glyceryl trinitrate was administered as a 10- or 20-mg transdermal patch. Intravenous ritodrine was administered according to nationally available guidelines. The primary outcome was prolongation of gestation expressed as a percentage of the time from entry to 37 weeks. Secondary outcomes were proportion of women who delivered the same day, next day, or within 7 and 14 days of entry, and by 32, 34, and 37 weeks. Analysis was by intention to treat. RESULTS: Twelve women (5%) were lost to follow-up. Glyceryl trinitrate and ritodrine prolonged gestation by 74% of time to 37 weeks (difference glyceryl trinitrate-ritodrine 0%; 95% confidence interval (CI) -10%, +10%). There was no significant difference in the proportion of women receiving glyceryl trinitrate or ritodrine who delivered within the specified days from study entry or weeks of gestation; however, 42 women who received glyceryl trinitrate and 58 women who received ritodrine delivered by 37 weeks (difference -11%; 95% CI -24%, +2%). No serious maternal side effects were reported for ritodrine or glyceryl trinitrate. CONCLUSION: We found no overall difference between glyceryl trinitrate and ritodrine in the acute tocolysis of preterm labor but a suggested advantage of glyceryl trinitrate over ritodrine in reducing preterm delivery rate. The maternal side effect profile and treatment discontinuation rates were fewer for glyceryl trinitrate, suggesting it was a safer alternative to ritodrine.

[Ultrasonography of the uterine cervix in pregnancy. Curve of normality in a longitudinal and cross-sectional study]. / Studio ecografico del collo dell'utero in gravidanza. Curva di normalità in uno studio longitudinale e trasversale.

BACKGROUND: The aim of the study was to establish a normality curve of cervical length variations during pregnancy in our pregnant women population, to be compared with pathological cases (risk of preterm labor and cervical incompetence). DESIGN: A prospective longitudinal and cross-sectional study in women with single pregnancy and without risk factors for preterm labor was carried on. SETTING: Obstetric and Gynecology Department, University of Brescia, Italy. POPULATION OR SAMPLE: One hundred and thirty-four pregnant women with single pregnancy, 112 cross-sectionally and 22 longitudinally followed, with labor at term, were selected. Sixty-eight were nulliparous, 66 pluriparous. Multiple pregnancy, previous placental and vaginal bleeding were excluded. METHODS: A transvaginal probe was used to assess uterine cervix and the patients were studied from the 12th to 41st gestational week. Statistical analysis was carried out by Student's "t"-test and Z-test. MEASURES: Cervical longitudinal diameter, internal uterine os and funneling were assessed. RESULTS: No statistically significant differences emerged in the curves with regard to nulliparous and pluriparous patients. The cut-off between normality and pathology, from the 24th to the 32nd gestational week (2ndSD), seems to correspond to a cervical length lower than 25 mm; a significant progressive decrement of the cervical longitudinal diameter begins from the 28th gestational week. CONCLUSIONS: These results allows the gathering of reference data about normality to compare with pathology (cervical incompetence and preterm delivery), which could be useful both for prevention and follow-up of these cases.

Anti-beta 2 glycoprotein I antibodies in a general obstetric population: preliminary results on the prevalence and correlation with pregnancy outcome. Anti-beta2 glycoprotein I antibodies are associated with some obstetrical complications, mainly preeclampsia-eclampsia.

OBJECTIVE: To evaluate the prevalence in normal pregnancies of anti-32 glycoprotein I (anti-beta2GPI) antibodies, and their association with obstetrical complications. STUDY DESIGN: Prospective study of anti-beta2GPI and anticardiolipin (CL) antibodies in 510 healthy pregnant women at 15-18 weeks. According to the results, women were categorized into three groups: group I, negative for both antibodies; group II, positive for anti-beta2GPI antibodies; group III, positive for aCL only. The rates of fetal loss, abruptio placentae, preeclampsia-eclampsia, and fetal growth retardation were compared in the three groups. RESULTS: Anti-beta2GPI antibodies were found in 20 women (3.9%) and aCL in 8 patients (1.6%). Obstetrical complications were more frequent, even if not significantly different, in group II, 15%, than in group I, 4.1% (difference 10.9%; 95% confidence interval (CI): 1.6-20.2%; p=0.0575), while no complications were seen in group III. Preeclampsia-eclampsia were significantly more frequent in group II (10%) than in group I (0.8%; difference 9.2%; 95% CI: 4.4-14%; p=0.021). The prevalence of fetal growth retardation was not significantly different in the two groups (5% vs. 2%, respectively). COMMENT: Our findings indicate that anti-beta2GPI antibodies are associated with some obstetrical complications, mainly preeclampsia-eclampsia, even if more conventional antiphospholipid antibodies are not present. This observation suggests that these antibodies should be investigated in such cases, in order to improve the outcome of subsequent pregnancies, as well as in women with a history of early and/or recurrent severe preeclampsia in order to start a prophylactic treatment (i.e. low-dose aspirin or heparin).

[Streptococcus group B and pregnancy: the therapeutic role of topical intravaginal clindamycin]. / Streptococco di gruppo B e gravidanza: ruolo terapeutico della clindamicina topica intravaginale.

OBJECTIVE: To evaluate the clinical and therapeutic efficacy of 2% clindamycin vaginal cream in pregnant women heavily colonized with group B streptococci (GBS). STUDY DESIGN: A prospective, clinical trial in which carriers of group B streptococci were randomized to receive topical intravaginal clindamycin or oral amoxicillin. PATIENTS: We randomized 105 pregnant women: 55 received 2% clindamycin vaginal cream (100 mg/day for 7 days) and 50 oral amoxicillin (2 g/day for 7 days). INTERVENTIONS: Patients were treated during pregnancy, none of them received intrapartum chemoprophylaxis. On the other hand, all the neonates, within 24 hours from delivery, were studied from the microbiological point of view, carrying out auricolar, nasal, oropharyngeal and umbilical cultures. RELIEFS: The eradication of the microorganism was evaluated by performing a vaginal culture after 6 weeks from the beginning of antibiotic therapy. RESULTS: The eradication rate of the microorganism was significantly higher in women treated with topical clindamycin compared with the group receiving oral amoxicillin (71% versus 36%; p < 0.05). The neonatal outcome was similar in the two groups in terms of gestational age at delivery and mean birthweight. None of the neonates was admitted to the neonatal intensive care unit and no cases of neonatal sepsis were recorded. CONCLUSIONS: From our experience we can conclude that, during pregnancy, a treatment with topical intravaginal clindamycin may be useful in the eradication of GBS.

[Hypertension in pregnancy: management protocols and pregnancy outcome followed at our ambulatory service]. / Patologia ipertensiva in gravidanza: protocolli assistenziali ed esiti delle gravidanze seguite presso il nostro ambulatorio.

OBJECTIVE: To verify the usefulness of an outpatient Clinic for Hypertension in Pregnancy after 10 years of activity. STUDY DESIGN: A retrospective analysis of the outcomes of pregnancies followed at our outpatient Clinic from 1980 through 1990 was performed. PATIENTS: 607 pregnant women were followed-up: 179 patients developed gestational hypertension during one or more of their previous pregnancies, 275 were affected by chronic hypertension and 213 developed hypertension during the present pregnancy. INTERVENTIONS: Detailed protocols of treatment and management of patients were observed. RELIEFS: Pregnancy outcomes regarding the incidence of preeclampsia and small for gestational age (SGA) newborns was evaluated. The outcome was considered good when gestational age at delivery was more than 36 weeks and neonatal birthweight was adequate for gestational age. RESULTS: The patients with preeclampsia in previous pregnancies developed this complication in 5%; patients with gestational hypertension in the actual pregnancy or with chronic hypertension had a significant proteinuria in 12% and 6.2% of cases respectively. Higher incidence of SGA was found in patients who developed preeclampsia (58%) and in chronic hypertensive pregnancies (34%), while only 13% of SGA was in patients with hypertension in previous pregnancies. CONCLUSION: From our experience we can conclude that an outpatient Clinic for hypertension in pregnancy is extremely useful to give the opportunity for application of same criteria of management and therapy. This allow to admit to the hospital only patients with any signs of development of preeclampsia.

Idiopathic eosinophilic pneumonia and pregnancy: report of a case.

A case of chronic eosinophilic pneumonia and pregnancy is reported. In 1989, a 24-year-old woman with chronic eosinophilic pneumonia became pregnant. We decided not to stop steroid therapy. Except for premature preterm rupture of the membrane she had a uneventful pregnancy and a male infant with no distress syndrome.

Herpes gestationis.

Herpes gestationis is a rare autoimmune disease of pregnancy characterized by itching and skin lesions. The disease causes prominently maternal discomfort, but fetal and neonatal complications have been reported; however the frequency and severity of fetal illness are still debated. We describe three cases of herpes gestationis diagnosed and managed at our institution in the last 3 years.

Systemic lupus erythematosus and pregnancy: a prospective study.

We have prospectively followed 25 pregnancies in 21 patients: 20 were affected by systemic lupus erythematosus (SLE) and 1 by subacute cutaneous lupus erythematosus (SCLE). A flexible treatment schedule was applied to the follow-up of all the pregnancies, and included low dose aspirin, steroids at medium-low dosage and, if needed, azathioprine (AZA) after 20 weeks of gestation. There were 4 spontaneous first trimester abortions and 21 live-born neonates without major problems related to the treatment or to the maternal disease. The relapse rate of the disease recorded during the observation period was 0.07 patient/month, not different from that already reported in SLE patients (pregnant or nonpregnant). Obstetrical complications were relatively frequent, but careful monitoring allowed us to avoid late fetal wastage. We conclude that in SLE patients a successful pregnancy outcome, without worsening of the disease, can be obtained with a careful multidisciplinary follow-up.

Nonenzymic glycation of isolated human glomerular basement membrane changes its physicochemical characteristics and binding properties.

The chronic hyperglycemia in diabetes mellitus enhances the nonenzymic glycation of structural proteins possibly increasing the formation of highly reactive advanced glycation end products (AGE). These protein changes might be involved in tissue-damaging mechanisms leading to diabetic complications, including diabetic nephropathy. To simulate these events, an in vitro model, based on isolated human glomerular basement membrane (hGBM), has been developed. In this study we have investigated the extent of AGE formation and the binding changes induced by the nonenzymic glycation of hGBM. An enriched fraction of hGBM was isolated from normal human kidneys and glycated in vitro by incubation with glucose (500 mmol/l) at 37 degrees C for 10 days. The presence of AGE was investigated by two methods - spectrofluorescence and the diazonium salt reaction - both specific for this type of chemical entity. The binding capacity of glycated hGBM was tested by a 10-day incubation with human insulin, albumin, immunoglobulin G and fibrinogen. Higher relative spectrofluorescence values at 440 nm emission (20.0 +/- 2.0 vs. 12.5 +/- 5.0) and higher absorbance values at 492 nm (0.798 +/- 0.063 vs. 0.429 +/- 0.228) indicated the presence of increased levels of AGE in glycated vs. native hGBM. Insulin and the three proteins were bound to hGBM in increased amounts after its glycation (p less than 0.05). The results obtained in this in vitro model confirm that enhanced nonenzymic glycation of hGBM induces the formation of AGE and possibly, through these compounds, alters its physicochemical and binding properties. This reaction might contribute to the mechanisms eventually leading to diabetic nephropathy.

Beta-thromboglobulin in patients with acute and chronic coronary artery disease.

Beta-thromboglobulin (beta TG) plasma levels were measured by radioimmunoassay in 14 patients with acute myocardial infarction (MI), in 13 with myocardial ischemia and recurrent episodes of angina and in 14 subjects with a past history of MI. Increased beta TG plasma values were observed in patients with acute MI and with myocardial ischemia whereas subjects with a past history of MI showed results not significantly different from normal subjects. Daily measurements in acute MI showed in five cases a second peak of beta TG values which suggests the occurrence of a deep vein thrombosis. The increased platelet consumption in MI was not related with the extent of the necrosis. We suggest, therefore, that platelet activation is associated with myocardial ischemia rather than necrosis.

[A case of neonatal convulsions caused by transitory normocalcemic primary hypomagnesemia. Clinical considerations]. / Su un caso di convulsioni neonatali da ipomagnesiemia primitiva normocalcemica transitoria. Considerazioni cliniche.

The Authors present a case of a primitive normocalcemic hypomagnesimy in a four days newborn. She was hospitalized for convulsive disorders at the Maternity Hospital Foggia - Neonatal Pathology Section. Although her birth had been normal and she was in good condition, the four days infant had clonic crises which in a short time became tonic-clonic generalized convulsive crises. We all know that in a four days newborn the appearance of this kind of convulsive crises is rare and dangerous, so we added, at the normal therapies, a therapy based on somministration of magnesium, first by parentheral intravenous injections, then by mouth. Our check up at one, three and five months of life on the newborn showed how she was growing normally without any bodily or neurological abnormality.

[Echocardiographic evaluation of myocardial infarct patients undergoing rehabilitation]. / Valutazione ecocardiografica del paziente infartuato sottoposto a riabilitazione.

29 patients with a recent myocardial infarction underwent a M-mode echocardiographic study before and after an ergometric training in order to study the training effects on the left ventricular function and on the cardiac chambers dimensions. 25 patients in the same clinical conditions and no trained acted as a control group and were evaluated with the same procedure. Our results show, in the trained group, a significant reduction of the diastolic (-5.6%) and systolic (-6.5%) diameters of the left ventricle and of the diameter of the left atrium (-7.5%). Moreover we observed an improvement of the left ventricular kinesis, as showed by the increased systolic movement of left posterior wall and of the interventricular septum and by the increased ventricular performance, as it results from increased systolic movement of the aortic root. In the control group no significant variation of the examined data was observed. The reduction of the diameters and the improvement of the kinesis and of ventricular performance could be explained by the reduced after-load and it shows the presence of direct beneficial effects of the exercise training on the heart, consisting both of improved cardiac mechanics and of a reduced MVO2.

[The stress systolic time intervals in the diagnosis of ischaemic heart disease. Study of the recovery in patients with persistent ischemia (author's transl)]. / I tempi sistolici da sforzo nella diagnostica della cardiopatia ischemica.

The changes in systolic time intervals (STI) LVET, PEP/LVET) between rest conditions, maximal exercise and after seven minutes after upright bicycle stress test were measured in 31 consecutive subjects: 14 "control" normal subjects, and 17 subjects with ischemic heart disease. The purpose of this investigation was to evaluate the specificity and sensitivity of the stress - STI in the identification of patients with positive exercise ECG and of patients with markedly positive exercise ECG that shown a late recovery persistent ischemia. The changes of STI are different in the control group and in ischemic heart disease group pts with negative exercise stress test and pts with positive or markedly positive exercise ecg. In the literature the usefulness of stress STI in the diagnosis of coronary disease is not univocally accepted. Our results indicate that STI are not a parameters that have an available correlation ith the stress myocardial ischemia even at distance of haemodynamic variations of maximal exercise and recovery and in presence of late recovery persistent ischemia.

[Comparison between holter dynamic ECG and exercise stress test in the evaluation of ventricular arrhythmias in patients with ischaemic heart disease (author's transl)]. / Confronto tra l'ECG dinamico e il test da sforzo nello studio delle aritmie nell'infarto miocardico recente.

The Authors have examined the possibility for diagnostic and prognostic value of exercise stress test and of dynamic ecg in the identification of ventricular ectopic activity which represent a factor risk of sudden death. 41 male patients with IHD and Myocardial Infarction were given exercise stress test and Holter monitoring according to the usual methods. Both methods were useful to identify Pts with arrhythmias. The total incidence of ventricular ectopic beats was 78% with Holter and 46% with exercise test. Holter monitoring showed a major possibility to detect high degree arrhythmias (39%) against 9% of exercise test. Two methods are not comparable, not it was possible to demonstrate statistically significant incidence of ventricular ectopics with respect to the localization of M.I. 90% of Pts with positive exercise test (angina and/or ecg alterations) showed ventricular ectopic beats against 45% of Pts with negative exercise test. The association of ventricular ectopic beats in Holter and positive response to exercise test is highly predictable of sudden death. The results of investigation suggest the opportunity to evaluate Pts with MI by both methods, dynamic ecg and exercise stress test.

[Exercise test in women with abnormal ecg (author's transl)]. / Il test ergometrico in donne con elettrocardiogramma a riposo alterato.

114 women with abnormal resting electrocardiograms underwent exercise test on bicycle ergometry; they were grouped as follows: --group I: 40 asymptomatic females; --group II: 67 cases with atypical chest pain; --group III: 7 cases with typical angina. The exercise test was always maximal or submaximal SL. The only criteria used for positive stress was a 1 mm or more ischemic ST segment depression below the resting level, for at least 0.08 sec. The test was positive in 11 subjects (10.7%): 5 women of group II (7.5%) and 6 of group III (85.7%). Our results suggest that repolarisation abnormalities, not caused by hypertrophy, conduction disturbances and drugs, do not modify the outcomes of stress test. Ischemic patterns during exercise test are more frequently seen when flat or diphasic T waves are present in control ECG. In the majority of patients in all groups the T wave either does not change or becomes more positive or less negative after exercise. A greater prevalence of resting hypertension and arrhythmias is present in patients with positive tests.

[The exercise stress test in patients with intraventricular conduction troubles (author's transl)]. / Il test ergometrico nelle anomalie della conduzione intraventricolare.

The results of exercise stress test in 86 patients with intraventricular conduction troubles (BBBand or Emiblock) are discussed in order to asses the meaning of exercise induced ECG alterations and possibly of an etiopathogenetic interpretation. The AA. examined the following parameters during stress test and recovery: max heart rate, percent of teoric max heart rate, max BP, max heart rate x BP product, AQRS at rest and during recovery immediately after exercise test, QRS duration, ST depression, T amplitude. The majority (91,67%) of isolated RBBB patients had negative test; 30,43% of RBBB + LAEmiblock patients had ECG signs and clinical symptoms of myocardial ischemia. In LBBB patients the test was considered positive only if present ST depression and precordial pain. The AQRS tends during exercise to the right; in the 60% of RBBB + LAEmiblock patients it can be seen a tendency to left axis deviation; the amplitude of T-wave is increasing in more than 50% in LBBB. The conclusions are that in patients with intraventricular conduction troubles the interpretation of results is always difficult; the presence of clinical symptoms like precordial pain may give an aide when associated to the ECG variations.