Detection of smoking-related covalent DNA adducts in human placenta.

The presence of covalent DNA chemical addition products (adducts) in human term placentas was investigated by recently developed immunologic and 32P-postlabeling assays. DNA from placental specimens of smokers showed a small but not statistically significant increase in adduct levels when tested by antibodies to DNA modified with a benzo[a]pyrene dihydrodiol epoxide (BPDE-I), the ultimate carcinogenic derivative of benzo[a]pyrene. The postlabeling assay detected several modified nucleotides, one of which (adduct 1) strongly related to maternal smoking during pregnancy. This adduct was present in placental tissue from 16 of 17 smokers, but only 3 of 14 nonsmokers. Among smokers, levels of adduct 1 in general were only weakly related to questionnaire and biochemical measures of the intensity of smoking exposures, which suggests modulation by individual susceptibility factors. The adduct seemed to be derived from an aromatic carcinogen, but it may not result from several of the most intensely studied polycyclic aromatic hydrocarbons or aromatic amines in tobacco smoke. The data show the association of cigarette smoking with covalent damage to human DNA in vivo.

Characteristics of neonatal intensive care unit patients in North Carolina: a cross-sectional survey.

A shortage of neonatal intensive care facilities has been encountered in some areas of the country including North Carolina. To examine possible solutions to this health care delivery problem, a cross-sectional survey of all the neonatal intensive care units in North Carolina was performed to examine characteristics of patients occupying the beds in these facilities. It was found that a substantial amount of chronic care is now occurring in neonatal intensive care beds, with 38% of occupants of neonatal intensive care beds being 31 days of age or older and 3% being mechanically ventilated at 91 days of age or older. In addition, according to criteria established for this study, a substantial number of "convalescent" patients (32%) were occupying beds in neonatal intensive care units. It is concluded that an increase in both intermediate/convalescent care beds and establishment of chronic care facilities in North Carolina, rather than an increase in intensive care beds in these units, would alleviate the shortage of neonatal intensive care facilities. Further, the characteristics of the population occupying neonatal intensive care unit beds should be considered by health planners in addition to occupancy rate, when new facilities are being established.

Technique of early sonographic diagnosis of bilateral cleft lip and palate.

High-resolution real-time ultrasound equipment will lead to the evolution of techniques for the prenatal diagnosis of subtle fetal anomalies not seen before. A technique for the diagnosis of bilateral cleft lip and palate before 20 weeks' gestation with real-time ultrasound equipment is described and illustrated. Examination of the fetal face in the frontal and coronal planes should allow the diagnosis of severe clefting at an early gestational age.

Terms of confinement.

Through habit we have chosen words to describe antepartum, intrapartum, and postpartum events that are domineering and restricting and that are consistent with imprisonment. We must be cognizant of the potential impact of our language.

Relationship of fetal limb lengths to both biparietal diameter and gestational age.

Ultrasonic long bone imaging is a potentially valuable index of fetal growth. Reported here are fetal limb measurements in normal pregnancies, produced with readily available ultrasound equipment and described using simple statistical techniques. Lengths of femur, humerus, tibia/fibula, and radius/ulna are related to gestational age. Femur and humerus measurements are also related to biparietal diameter. Linear correlation is high and with few exceptions these results confirm those of other investigators. Comparability between these data and previously published work is examined and the utility of these standards of growth discussed. Long bone imaging is confirmed as being reliable, reproducible, and a viable alternative to the measurement of biparietal diameter in the biophysical assessment of fetal development.

Thrombotic thrombocytopenic purpura in early pregnancy.

Thrombotic thrombocytopenic purpura during pregnancy in which both mother and fetus have survived has been an exceedingly rare occurrence, due at least in part to the difficulty in distinguishing this uncommon disease from hematologic complications of preeclampsia. In the nonpregnant patient, the use of plasma infusion or exchange plasmapheresis as therapy of choice has resulted in a dramatic increase in survival. By using more specific criteria than the classical clinical pentad, the diagnosis of thrombotic thrombocytopenic purpura during pregnancy can be made with greater accuracy. The first known instance of the successful use of exchange plasmapheresis leading to the survival of both mother and fetus in thrombotic thrombocytopenic purpura clearly not secondary to preeclampsia is reported.

Pseudotumor cerebri in pregnancy.

Pseudotumor cerebri is an enigmatic neurologic disorder markedly more common in women of childbearing age. Diagnosis, management, and pregnancy outcome of nine women with active disease are described. Pregnancy is not contraindicated in women with pseudotumor cerebri, and termination of pregnancy is seldom required.

Fetal and uterine responses to immersion and exercise.

We evaluated the responses of the fetal-maternal unit to immersion and exercise in the water at 15, 25, and 35 weeks' gestation. As seen by underwater ultrasound, fetuses demonstrated body, limb, and breathing movements. Fetal heart rates (FHRs) were normal, and unchanged from those at rest, during maternal exercise in the water at 60% VO2 maximum. In 21 of 23 cases, post-exercise nonstress tests were reactive within ten minutes. There was no uterine activity seen at either 25 or 35 weeks' gestation. Maternal serum alpha-fetoprotein was unaffected at all gestational ages. Neither maternal temperature nor calculated plasma volume changed during exercise. This general lack of effect contrasts with results from other studies involving similar levels of exercise on land. We speculate that the plasma volume expansion with immersion contributes to the normal FHR responses seen in this study.

Selected use of midline episiotomy: effect on perineal trauma.

A prospective, nonrandomized controlled study was performed to determine the effect of using midline episiotomy only for mothers who experienced fetal distress and/or operative vaginal delivery. Such a policy resulted in a significant decline in third- and fourth-degree lacerations in nulliparous women. This reduction was most pronounced in nulliparous women delivering infants larger than 3400 g. No third- or fourth-degree laceration occurred without antecedent episiotomy in any woman. A policy of using episiotomy selectively appears to lower the incidence of perineal trauma.

Single-probe spectrophotometry in the assessment of fetal oxygenation.

Six sheep fetuses were monitored with a single-probe tissue spectrophotometer. This spectrophotometer provides continuous digital output of the index of hemoglobin that is saturated with oxygen. To vary the fetal pO2, each maternal ewe was given room air, 100% oxygen, 12% oxygen, and 100% nitrogen via rebreathing bag. Fetal venous (N = 4) or arterial (N = 2) blood was analyzed for pO2. There was excellent correlation between the index of hemoglobin saturated with oxygen and the fetal pO2. The single-probe spectrophotometer overcomes two of the technical problems encountered when a double-probe spectrophotometer is used.

Toward the ethical evaluation and use of maternal-fetal surgery.

BACKGROUND: Important clinical, social, and ethical questions are associated with the evaluation and use of surgical approaches aimed at correcting fetal anatomic abnormalities. In particular, the expansion of maternal-fetal surgery to ameliorate nonlethal fetal conditions has intensified the need to address issues about the adequacy of technology assessment and the safety of those who undergo these novel procedures. APPROACH: After discussions at a multidisciplinary conference, we reviewed the development and current practices of maternal-fetal surgery and analyzed the relevant ethical issues concerning the use of maternal-fetal surgery for nonlethal conditions, focusing on the correction of myelomeningocele. FINDINGS: Characterizing nonvalidated maternal-fetal surgery procedures as "innovative therapy" blurs the boundaries between research and therapy and creates uncertainty about the obligations of clinicians and researchers. Further, maternal-fetal surgery raises ethical issues related to maternal risks and benefits, informed consent, distinguishing lethal from nonlethal conditions, withholding unproven treatments, entrepreneurship, and prioritization. RECOMMENDATIONS: To help ensure that maternal-fetal surgery will be studied and eventually applied in a scientifically and ethically sound manner, we offer several recommendations. First, innovation in maternal-fetal surgery should be conducted and evaluated as research. Second, women must be considered research subjects in these trials. Third, the informed consent process must ensure adequate comprehension and genuine voluntariness in those considering participation. Fourth, discriminatory and fearful attitudes toward individuals with disabilities should be addressed explicitly prior to making a decision to proceed with maternal-fetal surgery in an attempt to correct such disabilities. Fifth, maternal-fetal surgery should not be performed for cosmetic indications unless and until there is reliable evidence that maternal-fetal surgery can be performed safely and that long-term side effects on women and their offspring are minimal. Sixth, centers of excellence should be established for conducting research and providing maternal-fetal surgery. Seventh, funding for research on maternal-fetal surgery should be considered in the context of societal needs.

Pregnancy in a patient with eosinophilic granulomatosis of the lung: a case report.

BACKGROUND: There are three syndromes of histiocytosis X: eosinophilic granulomatosis of the lungs, Hand-Schüller-Christian disease, and Letterer-Siwe disease. Although there have been five case reports of Hand-Schüller-Christian disease in pregnancy, we found none describing pregnancy in patients with eosinophilic granulomatosis. CASE: We present a report of eosinophilic granulomatosis of the lungs in pregnancy. The patient's pregnancy was complicated by fetal growth retardation (FGR) and oligohydramnios, but resulted in the delivery of a healthy infant. Her pulmonary disease remained stable. CONCLUSION: Pregnancy does not appear to exacerbate pulmonary eosinophilic granulomatosis. In this patient, pregnancy was complicated by FGR and oligohydramnios. This case report may be valuable in counseling patients with eosinophilic granulomatosis who are currently pregnant or contemplating pregnancy.

Histiocytosis X and pregnancy.

Histiocytosis X is associated with a pathologic proliferation of mononuclear histiocytes in the reticular endothelial system. Different clinical manifestations of this group of disorders may occur. Pregnancy and histiocytosis X infrequently occur simultaneously. Four cases previously reported along with 1 new case of histiocytosis X and pregnancy are reviewed in this report. Only chronic histiocytosis X, Hand-Schüller-Christian disease (HSCD), has been reported to occur during pregnancy. The most frequent complication during pregnancy was the onset or exacerbation of diabetes insipidus, as frequently seen with this disorder. The possibility that HSCD may alter pituitary function may contribute to the infrequent occurrence of pregnancy in patients with this disorder.

In-hospital maternal mortality in the United States: time trends and relation to method of delivery.

To study time trends in maternal mortality in the United States and to attempt to compare the risk of cesarean with vaginal delivery, information from the Professional Activities Study of the Commission on Professional and Hospital Activities for 3 years-1970, 1974, and 1978-was reviewed. For all deliveries, mortality per 100,000 deliveries declined from 25.7 in 1970 to 14.3 in 1978. For vaginal deliveries, mortality per 100,000 deliveries declined from 20.4 to 9.8. For cesarean deliveries, mortality per 100,000 births decreased more than for vaginal deliveries, from 113.8 to 40.9. Mortality for deliveries with no mention of complications, lacerations, or uterine rupture declined significantly from 1970 to 1978. Mortality for deliveries complicated by dystocia or malpresentation declined significantly from 1970 to 1974, but failed to decline thereafter. Mortality for deliveries complicated by a previous cesarean or by antepartum hemorrhage did not decline significantly from 1970 to 1978. For all complications with a sufficient number of vaginal and cesarean deliveries, except deliveries complicated by malpresentation or antepartum hemorrhage, mortality was at least twice as high in cesarean as in vaginal deliveries. Based on a comparison of mortality after a previous cesarean with mortality for all vaginal deliveries with no complication, the authors conclude that cesarean delivery is probably neither less than 2 nor more than 4 times more hazardous than vaginal delivery.

Elevated second trimester maternal serum alpha-fetoprotein and cytomegalovirus infection.

A case is presented of intrauterine cytomegalovirus infection. Initially, the infection was most probably manifested by elevated second trimester maternal serum alpha-fetoprotein levels. Placental involvement by the infectious agent may have produced the elevations in maternal serum. Alpha-fetoprotein elevation unrelated to fetal anatomic abnormalities, twins, or incorrect dates may represent a potential marker of placental pathology.

Prenatal detection of intraamniotic bands: implications and management.

The prenatal diagnosis of intraamniotic bands with confirmation at delivery is presented, and the pertinent literature is reviewed. The significance of intrauterine membranes or bands detected during pregnancy is not known. Direct fetal involvement by these structures has been reported in only one instance, but malformations apparently unrelated to amniotic bands have been common among reported cases. Serial ultrasound examinations are recommended both to exclude pseudosac, extrachorionic hemorrhage, blighted twin, and other possible causes of membranous structures and to search for fetal abnormalities.

Obstetric care of the affected carrier of hemophilia B.

Hemophilia B (factor IX deficiency) is an X-linked recessive clotting disorder similar to hemophilia A. In both diseases, phenotypic expression of the disorder may occur in significant numbers of heterozygous carriers. This is presumably due to random inactivation of one of the two X chromosomes of the female carrier as described by the Lyon hypothesis. Described herein is the obstetric care of a severely affected heterozygous carrier of hemophilia B. Predelivery automated plasma exchange was used to raise factor IX levels successfully. Commercial factor concentrates were avoided. The Lyon hypothesis is discussed in detail, and recommendations are made for the care of the clotting factor-deficient gravid woman.

Determinants of fetal heart rate response to vibroacoustic stimulation in labor.

To determine whether the fetal heart accelerates in response to a sound stimulus in labor, 40 women at various stages of labor were chosen at random to receive either a vibroacoustic stimulus or sham stimulus over the fetal head. Subsequent fetal heart rate (FHR) accelerations occurred to a significantly greater extent in study patients. One hundred thirty-two high- and low-risk patients were studied to determine correlations between the acceleration response and other maternal and fetal variables. There was a statistically significant negative correlation between the heart rate response to stimulation and three maternal variables: the degree of cervical dilation, the presence of ruptured membranes, and use of epidural anesthesia. The degree of fetal response did not correlate significantly with fetal distress at delivery or abnormal FHR tracings at the time of stimulation. Fewer than one-fifth of the fetuses manifested variable heart rate decelerations after the stimulation. In light of possible risks, the clinical use of the fetal acoustic stimulation test in labor should wait until its diagnostic value is better defined.

Hydramnios and maternal renal failure: relief with fetal therapy.

Hydramnios and maternal renal compromise are described in a singleton pregnancy with a large fetal abdominal cystic mass. Both the hydramnios and the renal failure resolved after percutaneous drainage of the fetal cyst. Rapid reaccumulation of the mass resulted in redrainage and placement of an indwelling cyst/amniotic cavity diversion shunt. Successful continuous decompression and uneventful continuation of the pregnancy were observed for four weeks. The relationship between fetal abdominal masses and hydramnios is discussed.

Recurrent idiopathic fetal hydrops: results of prenatal therapy.

A case of nonimmune hydrops recurring within a sibship is reported. Progressive severe fetal ascites and hydramnios at 31 weeks' gestation led to fetal paracentesis for both therapeutic and diagnostic purposes. A successfully placed indwelling peritoneal-amniotic diversion shunt functioned well but became dislodged, and rapid recurrence of ascites and hydramnios required two subsequent drainage procedures. Neonatal death occurred from pulmonary failure after delivery at 34 weeks' gestation, as had happened in the similarly affected sibling. Amniotic and fetal peritoneal pressures, biochemical analysis, and bacteriologic studies of fluid samples are reviewed. Although this experience adds to the knowledge of fluid dynamics in fetal ascites and hydramnios, it does not clearly support or refute such therapy in the care of fetal hydrops from nonimmunologic causes. Management issues are discussed.