A false negative oxytocin challenge test.

A negative oxytocin challenge test has been considered a very reassuring finding in managing pregnancies in which the fetus is at risk from uteroplacental insufficency. In the case described here a fetal death in utero occurred 4 days after a negative oxytocin challenge test in a Class D diabetic patient, but in that period of time the patient's metabolic status deteriorated. A negative oxytocin challenge test does not protect the fetus from a subsequent acute event such as abruptio placentae, a cord accident, or diabetic ketoacidosis.

The effect of magnesium sulfate on fetal heart rate baseline variability.

Variability of the baseline fetal heart rate is correlated with good fetal outcome, and loss of baseline variability has been observed as a sign of fetal distress. Central nervous system depressing drugs may also decrease fetal heart rate variability, and thus recognition of the effect of medication on the baseline fetal heart rate is important for accurate interpretation of fetal monitor tracings. In the cases reported, marked decrease in fetal heart rate variability was observed within 4 minutes of intravenous administration of magnesium sulfate, and fetal outcome was good in all cases.

Penile nerve block for newborn circumcision.

Circumcision in neonates is performed, almost universally, without anesthesia or analgesia. It is associated with pain, crying, agitation, and physiologic stress. Twenty infants receiving penile nerve block for circumcision were compared with ten infants having circumcision without anesthesia. Heart rate and blood pressure rose 34 and 15%, respectively, in unblocked infants, and were unchanged in infants receiving local anesthesia. Oxygen saturation declined 16% in unanesthetized infants compared with 6% in blocked infants (P less than .03). Anesthetized infants were less agitated and cried less. Peak plasma concentrations of the local anesthetic lidocaine averaged 0.51 +/- 0.17 microgram/mL (range 0.1-1.6), well below accepted toxic levels. There were no local or systemic complications.

Doppler ultrasound and maternal erythrocyte fragility.

Maternal erythrocyte fragility was studied in eight controls and in 16 women exposed to Doppler ultrasound monitoring during labor. Blood samples were taken before and after Doppler monitoring and no significant change in erythrocyte fragility was seen, although there was a trend toward increased fragility in patients exposed continuously for more than seven hours.

Unilateral ovarian abscess associated with the intrauterine device.

Four cases of primary ovarian abscess associated with intrauterine contraceptive devices are presented. It is proposed that both their unilaterality and the fact that they were primary in the ovary rather than tuboovarian are due to the fact that bacteria from the intrauterine device are shed continuously through the fallopian tubes, resulting in the inoculation of the corpus luteum, a unilateral structure. Removal of the ovarian abscess without additional surgical therapy is sufficient for a patient with this type of pelvic infection.

Carbamazepine levels in pregnancy and lactation.

An epileptic patient whose seizures were controlled with carbamazepine and primidone was followed throughout pregnancy and lactation. Blood levels of primidone decreased during pregnancy and rose postpartum requiring dosage adjustments. Pharmacologically insignificant amounts of the drug were detected in breast milk. A review of the literature revealed 94 infants exposed to carbamazepine in utero and no evidence to date that this drug carries a teratogenic risk.

Cost-effective criteria for glucose screening.

To study cost-effective screening criteria for gestational diabetes, a prospective study of 1012 patients was completed. All patients underwent a glucose screen between 26 and 30 weeks of gestation, consisting of a 50-g oral glucose load followed by a one-hour plasma glucose determination. Patients with a glucose screen greater than or equal to 130 mg/dL were studied with a standard three-hour oral glucose tolerance test. The incidence of gestational diabetes was 2.4% (24 of 1012). Only one gestational diabetic was identified with a glucose screen below 150 mg/dL. Twenty-two of the 24 cases were at least 24 years old. Twenty-one of the 24 (88%) gestational diabetes had a glucose screen greater than or equal to 150 mg/dL and were 24 years old or greater. The cost of the diagnosis in these latter patients was 40% of the cost of diagnosis of universal screening with a threshold of 130 mg/dL. It is concluded that screening with a threshold of 150 mg/dL only patients who are at least 24 years old should be considered an alternative to universal screening.

Prostaglandin F metabolite concentration as a prognostic factor in preterm labor.

Concentration of the 13,14-dihydro,15 keto-metabolite of prostaglandin F2 alpha (PGFM) was measured in women being observed for preterm labor. The mean initial PGFM level was significantly higher in patients who delivered preterm (65.9 +/- 9.7 pg/mL; N = 14) than in patients not in preterm labor (32.1 +/- 4.3 pg/mL; N = 11; P less than .01). Plasma PGFM concentrations decreased significantly during ritodrine therapy only in successfully treated patients (P less than .05). All patients with initial PGFM concentrations greater than or equal to 55 pg/mL delivered preterm. Two of four patients not considered to be in preterm labor but who delivered prematurely (within five days of initial evaluation) had initial PGFM concentrations of greater than 55 pg/mL. Concentration determinations of PGFM might be a useful adjunct in identifying early preterm labor and in predicting success of tocolytic therapy.

Multiple pregnancy with late death of one fetus.

Twenty cases of fetal death complicating a multiple pregnancy after 20 weeks' gestation are reviewed. We evaluated gestational age at diagnosis and delivery (29.3 +/- 0.7 and 31.8 +/- 0.9 weeks, respectively), interval from diagnosis to delivery (2.6 +/- 0.6 weeks), and cause of fetal death as a group and by type of placentation (76.5% monochorionic). Eighty-five percent of the surviving fetuses were delivered preterm, and the four neonatal deaths were all due to extreme prematurity, with a mean (+/- SEM) birth weight of 794 +/- 237 g. Perinatal mortality was 585 per 1000, 450 for twin A and 750 for twin B. The causes of fetal death varied. Maternal disseminated intravascular coagulation was not diagnosed in any pregnancy in the present series. The high risk of complications related to preterm birth, compared with the low risk of problems related to continuation of a multiple pregnancy after diagnosis of a fetal death, argues in favor of conservative management in this setting.

Vulvar carcinoma with hypercalcemia.

Hypercalcemia associated with nonmetastatic malignancy has been reported most frequently with lung or kidney tumors, while among gynecologic malignancies, the ovary has been the most common primary site. The pertinent clinicopathologic features of 2 cases of nonmetastatic vulvar carcinoma producing hypercalcemia are described in the present report. Including 3 previously reported cases, the vulva is seen to be the second most common site in the female genital tract for production of this paraendocrine syndrome. The clinician should be aware of the association of hypercalcemia and mental confusion with bulky vulvar tumors, so that surgery will not needlessly be delayed in a futile attempt to correct the hypercalcemia medically,

Acute bacterial endocarditis with postpartum aortic valve replacement.

A case of acute bacterial endocarditis with aortic valve abscess, aortic insufficiency, and congestive heart failure at 32 weeks' gestation is described. Prompt valve replacement is indicated due to the risks of embolism to the coronary arteries and brain, and to the high mortality of such patients with medical management only. The infant was delivered prematurely to avoid the intraoperative risks to the fetus of cardiac surgery. General rather than regional anesthesia was chosen because venous pooling from a regional block would necessitate preoperative fluid loading and vasopressor therapy, which would be stressful for an already failing heart. In the presence of severe congestive heart failure, the patient underwent cesarean section and delivered a health 2020-g male infant; 36 hours later the aortic valve was successfully replaced with a no. 21 Byork-Shiley prosthesis. The infecting organism was Streptococcus viridans.

Fetal distress during a maternal systemic allergic reaction.

Systemic allergic reactions to food ingestion rarely result in life-threatening situations. When these reactions occur during pregnancy, however, the accompanying physiologic changes may result in fetal distress. A case of repetitive late decelerations in the fetal heart rate during a maternal allergic reaction is presented. Prompt and aggressive medical management brought about total resolution of maternal and fetal compromise.

Plasmapheresis for the treatment of repeated early pregnancy wastage associated with anti-P.

It has been proposed that the blood group antibody, anti-P, produced by p or Pk individuals may cause abortion early in pregnancy. The authors have studied and successfully treated a Pk woman with anti-P who had 13 consecutive first-trimester miscarriages. Anti-P was implicated as the cause of repeated pregnancy loss after extensive clinical, endocrinologic, immunologic, and chromosomal evaluations. To remove P blood group antibodies, plasmapheresis was begun at five weeks' gestation during the 14th pregnancy with one plasma volume exchange two to three times per week. This therapy resulted in a reduction in the titer of anti-P, and the patient was delivered of a viable female infant after 33 weeks' gestation. The management and outcome indicate that habitual abortion presumably due to anti-P can be successfully treated with plasmapheresis. This case provides additional evidence that anti-P is responsible for abortions in p or Pk women, and that these abortions are immunologically mediated.

Experience with an adolescent pregnancy program. A preliminary report.

A program has been designed to give comprehensive health care services to pregnant adolescents. The program components include community liason, patient education, counseling and social services, a nurse "on call" program for labor and delivery, and pediatric nurse-practitioner followup. In addition, a drug use identification component screens the patients by interview and urinalysis. Hypertensive disorders of pregnancy occurred in 10% of the first 202 patients. Forty-three percent had anemia (hematocrit less than 35%), and screening cervical cultures for gonorrhea were positive in 3.5%. Cigarettes, alcohol, and marijuana constituted the most common nonmedical drugs used, and aspirin the most common medical drug. Eighty-one percent of the patients attended 7 or more antenatal visits, one-half did not miss a single clinic appointment, and 95% completed a post-partum visit, indicating that the program was well accepted by the adolescents.

Premature rupture of the membranes and prolonged latency.

The aim of this retrospective study in 8320 patients with premature rupture of the membranes (PROM) was to determine the consequences of prolongation of the latent period. Among patients with pregnancies of more than 37 weeks' duration, those with PROM and latent periods of more than 1 day demonstrated an increased incidence of intrapartum fever (IPF), whereas those with latent periods of more than 3 days demonstrated a marked increase in fetal (but not neonatal) deaths. Although IPF and perinatal mortality were more common in preterm pregnancies, neither was found to increase or decrease with prolonged latency, provided differences in gestational ages and race were taken into account. In the absence of chorioamnionitis, there appears to be no benefit to delivery before 37 weeks' gestation.

Effect of proteolipid protein on central nervous system myelin membrane fluidity.

The effect which intrinsic (proteolipid) protein has on fluidity of central nervous system myelin membrane was measured through differences in temperature-dependent anisotropy of the lipid-soluble fluorescence probe, 1,6-diphenyl-1,3,5-hexatriene (DPH), in multilamellar vesicles (MLV) prepared from total myelin lipids in the presence and absence of proteolipid protein. Very little difference was observed in the anisotropies of DPH incorporated into intact myelin membrane vesicles compared with MLV reconstituted from total myelin lipid plus proteolipid protein but excluding myelin basic protein. In contrast, a significant decrease (P less than 0.01) in anisotropy was observed when MLV prepared from total myelin lipids depleted of proteolipid protein were compared with vesicles containing proteolipid protein. Given the different distributions of myelin basic protein and proteolipid protein suggested by freeze-fracture, neutron and X-ray diffraction studies, and the fact that the hydrophobic DPH probe is known to distribute in the non-polar regions of lipid bilayers, we interpret the marked decrease in anisotropy when proteolipid protein is excluded from MLV to suggest that at least part of the proteolipid is distributed in the hydrocarbon region of the MLV. These findings are consistent with the earlier physical studies and recent postulations that extensive hydrophobic segments exist in proteolipid protein and that these hydrophobic segments are buried in the myelin lipid bilayer and alternate with hydrophilic extra-membrane segments.

Human plasma prekallikrein and high molecular weight kininogen decrease during parturition.

Prekallikrein and high molecular weight kininogen were measured in plasma taken from nine women during parturition. Prekallikrein decreased significantly (p less than 0.01) from 1.49 +/- 0.15 S-2302 U/ml (mean +/- SEM) in early labor to 1.26 +/- 0.13 S-2302 U/ml in the immediate postpartum period. Immunoreactive high molecular weight kininogen also significantly decreased from 76 +/- 5 micrograms/ml to 68 +/- 5 micrograms/ml one day postpartum (p less than 0.01). Both proteins rose to normal levels within two days. The data suggest that the kallikrein-kinin system is utilized during parturition.

The safety and efficacy of tocolytic agents for the treatment of preterm labor.

Pharmacologic inhibition of uterine contractions remains the mainstay of treatment for preterm labor despite the ongoing controversy regarding its effectiveness. A diverse variety of tocolytic medications have been proposed for clinical use, with betamimetics and magnesium sulfate being the common therapeutic agents of choice in the United States today. The clinician using these agents should be aware of the significant maternal and fetal side-effects associated with these particular medications. New classes of pharmacologic agents, including prostaglandin synthetase inhibitors, calcium channel blockers and phosphodiesterase inhibitors, have been proposed as tocolytic agents and are currently undergoing critical clinical evaluation. The purpose of this review is to provide a compilation of the available clinical studies that document the safety and efficacy of these various tocolytic agents.

The pharmacologic inhibition of premature labor.

Oxytocin, elevated estrogen-progesterone ratio, fetal corticosteroids, prostaglandins, catecholamines, and changes in uterine blood flow have all been implicated as triggers of labor. In approximately one-third of cases of threatened premature labor contractions stop spontaneously. Thus placebo-controlled randomized trials of any new drug for inhibition of premature labor are necessary, as the spontaneous cessation of contractions always favors the claimed therapeutic efficacy. Alcohol inhibits the release of endogenous oxytocin and has an additional direct effect on the myometrium. In one study alcohol was more effective than placebo in the postponement of delivery. Isoxsuprine, ritodrine, and terbutaline have also been shown to be better than placebo in the inhibition of premature labor, and the beta adrenergic agents appear to be more effective than alcohol. Prostaglandin inhibitors such as indomethacin are currently under investigation. Success is correlated with early administration of the therapy, which requires treating some patients whose contractions might have stopped spontaneoulsy. As different factors may be involved in triggering premature labor, if one therapeutic approach fails another should be initiated promptly.

Situational and financial barriers to prenatal care in a sample of low-income, inner-city women.

The relationship between the use of prenatal care and factors that may impede access to care was examined in a sample of low-income, inner-city women. Situational and financial barriers to care were not important correlates of utilization. In unadjusted analyses, only insurance status and employment status were associated with utilization. Of the sociodemographic characteristics studied, only parity was strongly associated with the use of prenatal care. When the apparent associations between utilization and insurance status and utilization and employment were analyzed controlling for parity, the estimated strength and statistical significance of these relationships diminished considerably. Multiparous women who were more likely than primiparous women to be underutilizers were also more likely to be on medical assistance and to be unemployed. These findings suggest that situational and financial barriers are not important correlates of utilization for low-income, adult women living in urban areas where there are accessible clinic facilities and public transportation. Efforts to identify and surmount other kinds of barriers may prove to be a more effective approach to prenatal outreach for women in these circumstances.