Blood glucose control during pregnancy.

Pregnant diabetic women represent a unique category of patient in whom diabetic control is most desirable, since even minor degrees of hyperglycemia have adverse effects on the conceptus. In 18 insulin-dependent pregnant diabetic women (White Class B, N = 4; C, N = 5; D, N = 7; and R, N =2), we have utilized a therapeutic program consisting of intensive patient education, a multiple-component insulin regimen (two to four injections daily), careful dietary control, and meticulous balancing of food, activity, and insulin dosage, monitoring such balance with patient-determined blood glucose measurements four to seven times daily using the Dextrostix/Eyetone system. Our goals for blood glucose management have been to attain fasting levels of 60-90 mg/dl, preprandial levels less than 105 mg/dl, and postprandial levels less than 120 mg/dl, in the absence of significant hypoglycemia. We have been able to attain these goals for most of the period of monitoring in the majority of these patients, while in the others we have achieved marked improvement in diabetic control, although we did not consistently attain our goals. Despite this, there was not infrequent neonatal morbidity, including a 33% frequency of macrosomia, an 11% frequency of significant hypoglycemia, and a 22% frequency of congenital malformation. Nevertheless, all infants survived and are generally healthy, whereas only 38% of 21 previous pregnancies in these same women have eventuated in living offspring. Thus, although further refinement is clearly indicated, it appears that our approach has resulted in improved pregnancy outcome. Patient self-monitoring of blood glucose is a procedure that is relatively simple, practical, acceptable to patients, and facilitates the attainment of glycemic control.

A birth center affiliated with the tertiary care center: comparison of outcome.

A matched pair study compares 250 low risk women delivered in a tertiary care center with a similar group cared for and delivered in an affiliated birth center. The patients could be matched in every respect with the exception of educational background. Twenty-one percent of the birth center patients required transfer to the hospital during the intrapartum period. Differences were found in cervical dilatation upon admission and length of labor. Intermittent fetal heart auscultation was used exclusively in birth center mothers, oral fluids and light diet were allowed. The hospital group received intravenous fluids. Oxytocin augmentation was used twice as often, and the incidence of shoulder dystocia appeared significantly higher in the control group. The reasons for transfer are described. The one neonatal death was due to persistent fetal circulation.

Medroxyprogesterone acetate and carbohydrate metabolism: measurement of glucose, insulin, and growth hormone during 6 months' time.

PIP: To assess the effect of injectable 6 alpha-methyl-17-acetoxyprogesterone (MP) on carbohydrate metabolism, prospective investigations were performed on 49 women. Oral glucose tolerance tests were performed before the initial administration of the drug, and after 6 months of usage. Measurements were also made of blood glucose, plasma insulin, and plasma growth hormone levels at these times. Blood glucose levels rose in 85.7% of the subjects, plasma insulin levels rose in all 49 subjects, and a rise in weight was recorded for 77% of the subjects. Glucose tolerance curves prior to the administration of the drug showed 7 borderline abnormal and 2 diabetic. After 6 months, this finding rose to 9 borderline abnormal and 3 diabetic. Fasting ambulatory growth hormone levels were unchanged. No mechanism for the changes that did occur are known. It is suggested that before any women are given this preparation, a thorough test of their carbohydrate metabolism should be performed.^ieng

Vaginal delivery after cesarean section.

The incidence of cesarean scar rupture varies from 0.64 to .24 per cent, with some institutions reporting no ruptures. Associated maternal mortality is extremely low, especially in low segment transverse incisions, so as to be almost nonexistent. Maternal mortality from cesarean section is higher than from vaginal delivery. Fetal mortality as a result of low segment scar rupture is at most 12.5 per cent. With modern methods of monitoring this should be reduced to zero. Several authors already report no fetal mortalities. Patients who have had a previous cesarean section should be allowed an attempt to deliver vaginally based on carefully selected criteria. Their labors should be followed closely by a qualified individual and are expected to follow norm-progressive course. The intrauterine cavity should be explored postpartum for defects. The cost of hospital care to the family is considerably reduced, and hospital bed utilization improved by allowing vaginal deliveries of women who have had previous cesarean sections, because of decreased operative risks, postpartum morbidity, and shorter hospital stays. The recovery period for the patient who delivered vaginally will generally be considerably reduced. Each subsequent pregnancy in which vaginal delivery is contemplated must be screened and managed as though it were her first after a section. Physicians should not charge different fees for elective repeat cesarean section versus vaginal delivery of the previous cesarean. Allowing a trial of labor in carefully selected patients is one step toward decreasing the cesarean section rate.

Principles of alternating pressure surfaces.

Alternating pressure air mattresses (APAMs) have been in clinical use for nearly 50 years, yet little has been published on their design rationale. Although early systems were recognized as an effective tool in preventing pressure ulcers, serious quality and reliability problems hampered their use. Today, several types of APAMs, including overlays and mattress replacements, are routinely used in the prevention and treatment of pressure ulcers in many clinical settings. Caution must be exercised, however, when comparing interface pressure measurements on APAMs and static surfaces. This paper discusses some of the characteristics of alternating surfaces that may have an effect on the body.

Carcinoma of the cervix among women in their twenties. A 14% prevalence deserves our respect!

The purpose of this study was to estimate the value of routine vaginal cytology in women under 30 years of age. Over a five-year period, 18,160 vaginal cytological examinations were made on women aged 20 through 29 years, and 424 women (2.3%) were found to have Papanicolaou smears class III, IV, or V. Of these 424 patients, 122 (28.8%) were found to have carcinoma of the cervix. A tissue diagnosis of intraepithelial carcinoma was obtained in 103 women. The remaining 19 patients proved to have invasive carcinoma of the cervix. Approximately one third of this group of women with positive cytology failed to return for tissue diagnosis so the true prevalence of cancer was probably in the region of 40%. The findings suggest that women deserve routine vaginal cytological examinations irrespective of age.

Evidence for the presence of calsequestrin in both peripheral and interior regions of sheep Purkinje fibers.

Localization of calsequestrin in sheep Purkinje fibers was determined by indirect immunofluorescence labeling of cryostat sections of sheep myocardium from the intraventricular wall. The results presented show that calsequestrin is present in discrete foci at the peripheral, as well as the interior regions of the cytoplasm. Since Purkinje fibers lack transverse tubules, the presence of calsequestrin at specific foci in the interior regions of the cytoplasm in these cells suggests that calsequestrin is localized in the lumen of peripheral junctional sarcoplasmic reticulum, as well as in the lumen of corbular sarcoplasmic reticulum present in the I band region of the myofibrils. Assuming that the function of calsequestrin is to sequester calcium into the lumen of the sarcoplasmic reticulum, these results imply that two structurally different regions of the sarcoplasmic reticulum function as calcium storage sites in mammalian Purkinje fibers and raises the possibility that calcium storage and/or release from these two sites might be regulated differently.

Frog cardiac calsequestrin. Identification, characterization, and subcellular distribution in two structurally distinct regions of peripheral sarcoplasmic reticulum in frog ventricular myocardium.

Calsequestrin is a calcium-binding protein known to sequester calcium accumulated in the sarcoplasmic reticulum (SR) of muscle cells during relaxation. In the present study, we used affinity-purified antibodies to chicken cardiac calsequestrin to identify a 60,000-Da calsequestrin in frog myocardium. Like previously identified cardiac calsequestrins, it is enriched in cardiac microsomes, it is enriched by biochemical procedures previously used to purify cardiac and skeletal calsequestrins, and it exhibits a pH-dependent shift in its apparent Mr on a two-dimensional gel system. Finally, the NH2-terminal amino acid sequence of this 60,000-Da immunoreactive protein purified by fast protein liquid chromatography was identical to that of rabbit skeletal and canine cardiac calsequestrin. Thus, we conclude that this protein corresponds to the calsequestrin isoform in frog ventricular muscle. Frog calsequestrin was localized in discrete foci present at the periphery but absent from the central regions of frog ventricular myocytes as determined by immunofluorescence labeling. Immunoelectron microscopic labeling demonstrated that calsequestrin was confined to the lumen of two structurally distinct regions of the SR, where it was localized in the subsarcolemmal region of the myofibers. One of these appeared to correspond to the terminal SR previously reported to be closely apposed to the sarcolemma of frog myofibers. The other region, although close to the sarcolemma, was not physically joined to it and appeared to correspond to corbular SR. It generally is believed that frog cardiac SR does not provide activator Ca2+ required for excitation-contraction coupling. However, the identification of a calsequestrin isoform very similar to mammalian cardiac calsequestrin that is confined to specialized regions of frog cardiac SR lends support to the idea that frog cardiac SR has the ability to store Ca2+ and thus function in some capacity in frog cardiac muscle contraction.