Asthma in pregnancy.

Contemporary management of the pregnant asthmatic is directed at controlling symptoms and treating the underlying cause of asthma, namely, inflammation. This article discusses the pathophysiology of asthma and the effects of asthma on pregnancy and vice versa and reviews the National Asthma Education Program guidelines for the treatment of asthma in pregnancy.

Human papillomavirus is more prevalent in first trimester spontaneously aborted products of conception compared to elective specimens.

In this study the possible role of human papillomaviruses (HPV) in spontaneous abortions is addressed by assaying for HPV DNA in first trimester spontaneous and electively aborted products of conception materials enriched for chorionic villi. The presence of HPVs was measured by polymerase chain reaction (PCR) amplification and DNA dot blot hybridization using an internal probe. The "broad spectrum" HPV primers were directed to amplify E6/E7 junction sequences, while the probe was of an HPV-16 sequence with significant homology to HPV-6/11. The quantity and quality of isolated DNA was also analyzed and compared by observing the PCR amplification of a cellular sequence from the human beta-globin gene. Fifteen of the 25 spontaneous samples (60%) were found to be positive for HPV E6/E7 sequences. In comparison, only 3 of the 15 elective samples (20%) were positive. This is the first study of HPV in fetal materials to incorporate material from elective abortions as a control group. Although confounding contamination from the cervix and vagina can't be ruled out, these data are significant and strongly suggest that HPVs are elevated in spontaneously aborted products of conception. Furthermore, these results suggest the possibility that HPVs may be etiologic agents of at least some spontaneous abortions.

Asthma treatment in pregnancy: a randomized controlled study.

OBJECTIVE: Our purpose was to study the effect of inhaled corticosteroids on asthma exacerbations in pregnancy. STUDY DESIGN: We prospectively studied 84 pregnant women with 105 asthma exacerbations. Women were hospitalized if the forced expiratory volume in 1 second was < 70% after sequential bronchodilator therapy. They were randomly assigned to receive either intravenous aminophylline and inhaled beta 2-adrenergic receptor agonist or intravenous methylprednisolone and a beta 2-adrenergic receptor agonist. At discharge women were randomly assigned to receive either inhaled beclomethasone, beta 2-adrenergic receptor agonist, and an oral corticosteroid taper or a beta 2-adrenergic receptor agonist and a corticosteroid taper. RESULTS: Sixty-five (62%) of 105 women with exacerbation required hospitalization. Aminophylline did not shorten response time or decrease hospital stay. Readmission rate was decreased by 55% in women given inhaled beclomethasone (33% vs 12%, p < 0.05, odds ratio 3.63, 95% confidence interval 1.01 to 13.08). Pregnancy-induced hypertension and cesarean delivery were increased over those of the general population. CONCLUSIONS: Intravenous aminophylline offers no therapeutic advantages. Continuous inhaled corticosteroids reduced the need for subsequent admissions.

Emergent obstetric management of uterine inversion.

Puerperal inversion of the uterus is an unusual and potentially life-threatening event occurring in the third stage of labor, but when managed promptly and aggressively inversion can result in minimal maternal morbidity and mortality. Once the diagnosis of inversion is made, measures should be undertaken to manage and correct acute blood loss and potential shock. In conjunction with anesthesia personnel, immediate uterine replacement should be considered. Uterine relaxants (MgSO4, terbutaline, or halothane) can be used if initial attempts fail; however, in the majority of patients successful immediate replacement without use of uterine relaxants is possible. The choice of anesthetic agent and uterine relaxants should be individualized based on the clinical scenario. Following manual replacement, massage and ecbolic agent(s) should be instituted immediately to prevent reinversion. Surgical repositioning via an abdominal or vaginal approach may be necessary in subacute or chronic inversions.

Chorioamnionitis: association of nonreassuring fetal heart-rate patterns and interval from diagnosis to delivery on neonatal outcome.

OBJECTIVE: The purpose of this study was to determine whether selected fetal heart-rate (FHR) patterns and the interval from diagnosis to delivery in pregnancies complicated by chorioamnionitis could predict neonatal outcome. METHODS: During a 6-month period, 217 consecutive patients with acute chorioamnionitis were prospectively identified in labor. Following delivery, the fetal monitor strips and hospital courses were reviewed for both the mother and neonate. Multiple logistic regression was used to analyze the presence of a nonreassuring FHR pattern and the effect on neonatal outcome. Fisher exact tests were used to analyze the time intervals from the diagnosis of chorioamnionitis to delivery and their significance on neonatal outcome parameters. RESULTS: The overall incidence of chorioamnionitis in our population was 2.3%. None of the independent variables analyzed following the diagnosis of chorioamnionitis until delivery were significantly associated with an umbilical artery (Ua) pH < 7.20. There were no differences in cord pH, Apgar scores, sepsis, admission to special-care nursery, and oxygen requirements in neonates based on the duration of time from the diagnosis of chorioamnionitis to delivery in our study. None of the newborns had pathologic fetal acidemia (Ua pH < 7.00). None of the FHR patterns we identified after the diagnosis of acute chorioamnionitis were significantly associated with neonates with a Ua pH < 7.20. CONCLUSIONS: An interval from diagnosis to delivery of up to 12 h plays little if any role in neonatal outcome.

Postpartum perineal morbidity after fourth-degree perineal repair.

OBJECTIVE: We attempted to determine the frequency of postpartum perineal morbidity (dehiscence, infection, and rectovaginal fistula) in women after fourth-degree perineal repair. STUDY DESIGN: The medical records of 390 women at Parkland Memorial Hospital with fourth-degree perineal repair during 1989 and 1990 were retrospectively reviewed in a case-cohort study. Statistical analysis included chi 2 contingency tables, Fisher exact test, Mann-Whitney test, and analysis of variance. RESULTS: Twenty-one of 390 women (5.4%) had postpartum perineal morbidity. Seven (1.8%) had dehiscence alone, 11 (2.8%) had infection and dehiscence, and 3 (0.8%) had infection alone. Overall there were 18 dehiscences (4.6%) and 14 infections (3.6%) in the total group with perineal morbidity. Two high rectovaginal fistulas were concomitantly detected in women with perineal dehiscence. Only shoulder dystocia, metritis, and postpartum fever occurred significantly more frequently in patients with postpartum perineal morbidity than in women without perineal morbidity. Smoking and human papillomavirus infection were not associated with perineal repair morbidity. CONCLUSIONS: Postpartum perineal morbidity after fourth-degree perineal repair is an uncommon event. It is not predicted by readily preventable antepartum or intrapartum factors.