Central hemodynamic observations in untreated preeclamptic patients.

Reported central hemodynamics obtained with a Swan-Ganz pulmonary artery thermodilution catheter in preeclamptic patients show marked disparity, which has been interpreted to indicate a variable hemodynamic expression of the disease. However, the variability also may be due, at least in part, to the pharmacological treatment that most of the women studied received during Swan-Ganz measurements. To evaluate the effects of treatment on hemodynamics, we compared the results of Swan-Ganz measurements in 87 preeclamptic women who had received no treatment at all with those obtained in 47 preeclamptic women who had received various drugs and intravenous fluids. Control values were obtained in 10 normotensive pregnant volunteers. Measurements were performed between 25 and 34 weeks of gestation. The median (range) cardiac index in the untreated patients of 3.3 (2.0-5.3) l.min-1.m-2 was significantly lower than that in the treated patients of 4.3 (2.4-7.6) l.min-1.m-2 and in the normotensive pregnant women of 4.2 (3.5-4.6) l.min-1.m-2. The systemic vascular resistance index in the untreated group of 3,003 (1,771-5,225) dyne.sec.cm-5.m2 was significantly higher than that of 2,212 (1,057-3,688) in the treated and of 1,560 (1,430-2,019) dyne.sec.cm-5.m2 in the normotensive control group. The median (range) pulmonary capillary wedge pressure in the untreated group was 7 (-1-20) mm Hg and did not differ from that of 7 (0-25) mm Hg in the treated group. Variability of all hemodynamic variables was much lower in untreated than in treated patients.(ABSTRACT TRUNCATED AT 250 WORDS)

A comparison between the haemodynamic effects of oral nifedipine and intravenous dihydralazine in patients with severe pre-eclampsia.

OBJECTIVE: To compare the effects of a single oral dose of nifedipine with those of intravenous dihydralazine on central haemodynamics in pregnant women with severe pre-eclampsia. DESIGN: A prospective comparative study. SETTING: The High Risk Obstetric Unit, University Hospital Rotterdam Dijkzigt, Rotterdam. SUBJECTS: Twenty patients with severe pre-eclampsia between 27 and 35 weeks gestation with normal cardiac filling pressures and without fetal distress. INTERVENTIONS: A pulmonary artery thermodilution catheter and a radial artery line were placed. Ten patients chewed a 10-mg capsule of nifedipine and 10 patients received dihydralazine by intravenous infusion at a rate of 1-3 mg/h. Arterial pressures, heart rate, cardiac output and pulmonary capillary wedge pressure were determined before and after drug administration. Fetal condition was continuously monitored by cardiotocography. RESULTS: The reduction in arterial blood pressure obtained with both drugs was similar, and was associated with a similar rise in heart rate and cardiac output and a similar reduction in systemic vascular resistance. Pulmonary capillary wedge pressures decreased significantly less with nifedipine than with dihydralazine. Signs of fetal distress occurred in none of the nifedipine-treated patients, but in five of the patients treated with dihydralazine. CONCLUSION: From the haemodynamic viewpoint nifedipine seems to be a useful agent in the treatment of hypertensive emergencies in pregnancy.

Recurrence of vulvovaginal candidosis during pregnancy. Comparison of miconazole vs nystatin treatment.

The efficacy of miconazole and nystatin in the treatment of vulvovaginal candidosis was compared in a multicenter trial involving 94 pregnant patients. All patients had subjective complaints and were mycologically positive. Miconazole 2% vaginal cream was applied once daily for at least 10 days by 45 patients, whereas the 49 others received nystatin tablets for intravaginal application during 7 to 9 days. At the first examination following treatment, the cure rate with miconazole was 83% and with nystatin 68%. Follow-up examinations revealed a significantly lower recurrence rate in the miconazole-treated group. No important adverse experiences were noted.

Ultrasonic diagnosis of the large-for-dates infant.

Data on consecutive measurement of fetal biparietal diameter (BPD) and fetal chest area in 42 normal weight infants (birthweight 10--90th percentile) and 30 large-for-dates (birthweight above the 90th percentile) are presented. Pregnancy duration varied from 32 to 40 weeks. In the normal weight group fetal BPD and chest area were above the 95th percentile fo the normal curve in 7% and 5% of the cases; in the large-for-dates group the figures were 7% and 47%. Head to chest ratio fell below the fifth percentile of the normal curve in 53% of the large-for-dates against only 2% of the normal weight infants. In the detection of the large-for-dates infant ultrasonic measurement of fetal chest area appears to be superior to ultrasonic measurement of fetal BPD.

Errors in predicting maximal oxygen consumption in pregnant women.

This study was designed to determine the accuracy of estimated values of maximal heart rate (HRmax) and oxygen consumption (VO2) during pregnancy. We measured HR and maximal VO2 (VO2max) at rest and during cycle (CE) and treadmill exercise (TE) tests with rapidly increasing exercise intensities during gestation and after delivery. Pregnancy was found to affect the linear relationship of HR and %VO2max so that the intercept increases with advancing gestation and the slope decreases. Estimated maximal HR (HRmax, est), 220 - age (yr) x beats/min, overestimated measured HRmax by 8% (CE) and 5% (TE). For VO2max estimated by Astrand's nomogram (VO2max, est1) and by linear extrapolation of submaximal values of HR and VO2 to HRmax, est (VO2max, est2), individual errors were large (SD 17-28%). Mean VO2max, est1 overestimated measured VO2max by 20% during CE but not during TE (-2%) and elicited the erroneous impression that VO2max decreases during CE in pregnancy. Mean VO2max, est2 values were not significantly different from measured VO2max values. This apparent accuracy resulted from two opposing errors: 1) HRmax, est overestimated HRmax, and 2) above 70% VO2max the slope of the HR-%VO2max relationship was significantly reduced. Therefore neither method to estimate VO2max can replace the measurement of VO2max.

Maximal aerobic exercise in pregnant women: heart rate, O2 consumption, CO2 production, and ventilation.

This study was to determine whether pregnancy affects maximal aerobic power. We measured heart rate, O2 uptake (VO2), CO2 production (VCO2), and ventilation at rest and during bicycle (BE) and treadmill exercise (TE) tests with rapidly increasing exercise intensities at 16, 25, and 35 wk gestation and 7 wk after delivery. Maximal heart rate was slightly lower throughout pregnancy compared with the nonpregnant state during both BE [174 +/- 2 vs. 178 +/- 2 (SE) beats/min] and TE (178 +/- 2 vs. 183 +/- 2 beats/min). Maximal VO2 was unaffected by pregnancy during BE and TE (2.20 +/- 0.08, 2.16 +/- 0.08, 2.15 +/- 0.08, and 2.19 +/- 0.08 l/min for BE and 2.45 +/- 0.08, 2.38 +/- 0.09, 2.33 +/- 0.09, and 2.39 +/- 0.08 l/min for TE at 16, 25, and 35 wk gestation and 7 wk postpartum, respectively). As a result of increased VO2 at rest, the amount of O2 available for exercise (exercise minus rest) tended to decrease with advancing gestation, reaching statistical significance only during TE at 35 wk gestation (1.99 +/- 0.08 l/min vs. 2.10 +/- 0.08 l/min postpartum). Power showed a positive linear correlation with O2 availability during BE as well as TE, and the relationship was unaffected by pregnancy.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of experimental head compression on transcutaneous scalp PO2 in fetal lambs.

Equatorial compression of the fetal head is known to occur during labor; its effect on trancutaneous scalp PO2 (PtCO2) was investigated in acute experiments in four fetal lambs. Fetal PtCO2, and oxygen tension (PaO2) and flow in a carotid artery were continuously measured. Equatorial head compression was obtained by inflating a cuff around the fetal head. A strong relationship was shown to exist between PtCO2 and PaO2 values in the normoxemic and hypoxemic fetus. Stepwise compression of the fetal head resulted in a PtCO2 of zero at cuff pressures of 40 to 50 mmHg. Laborlike fetal head compression with an intensity of 50 to 70 mmHg and a duration of one minute resulted in a 30 to 60% fall in PtCO2. Fetal PaO2 remained stable in all experiments. The present findings indicate that values of PtCO2 during fetal head compression do not reflect fetal arterial oxygen tension. This questions the reliability of transcutaneous PO2 monitoring as a method of intrapartum surveillance.

A randomized comparison of vacuum extraction delivery with a rigid and a pliable cup.

OBJECTIVE: To compare the effectiveness and complications of obstetric vacuum extraction with a rigid and a pliable cup, with a focus on neonatal retinal hemorrhage. METHODS: One hundred women requiring assisted delivery who met predefined criteria for vacuum extraction were randomly assigned to be delivered by the classic rigid Malmström cup or the pliable Silastic cup. RESULTS: Because of the faster induction of vacuum, delivery occurred more rapidly with the pliable cup, but the pliable cup detached significantly more often than the rigid cup. The overall failure rate was not significantly different between the cups. There were no significant differences between the groups with regard to Apgar scores, umbilical artery pH, birth canal trauma, or maternal blood loss, but scalp injury occurred less frequently with the soft than with the rigid cup. Retinal hemorrhage in the newborns showed a similar incidence of about 50%, and neonatal neurologic examination showed no significant differences between the groups. CONCLUSION: In comparison with the rigid cup, the advantage of the pliable cup is limited to a smaller incidence of neonatal scalp injury.

Anaerobic threshold and respiratory compensation in pregnant women.

In an effort to explore why CO2 output (VCO2) at peak exercise is lower during pregnancy than postpartum despite little change in the peak O2 uptake (VO2), we determined the VCO2/VO2 relationship during rapidly incremental exercise and estimated the anaerobic threshold (AT) and the respiratory compensation (RC) point. We measured heart rate, VO2, VCO2, and minute ventilation (VE) at rest and during cycle exercise tests with rapidly increasing exercise intensities until maximal effort in 33 volunteers at 16-, 25-, and 35-wk gestation and postpartum. Through modification of the V-slope method, we estimated the AT and RC point for each test by nonlinear regression analysis in a three-dimensional space (defined by VE, VO2, and VCO2) for a line assumed to have two breakpoints; we found a good fit for all tests. The AT and RC points were found at exercise intensities of approximately 50 and 80% peak VO2, respectively, with no significant differences between test periods. VE was significantly higher during pregnancy than during postpartum at rest and throughout incremental exercise. A lower peak VCO2 relative to peak VO2 during pregnancy compared with postpartum was reflected by a more shallow slope of VCO2 vs. VO2 above the AT point. This suggests that during pregnancy the buffering of lactic acid is reduced.

Peak ventilatory responses during cycling and swimming in pregnant and nonpregnant women.

This study was designed to determine whether pregnancy affects peak O2 uptake (VO2peak) during swimming compared with cycling. We studied 11 women at 30-34 wk gestation and 8-12 wk postpartum. We measured heart rate (HR), O2 uptake (VO2), CO2 output (VCO2), minute ventilation (VE), and lactic acid concentration. Peak HR was not significantly affected by the type of exercise or by pregnancy. VO2peak was 9% lower during swimming than during cycling but was not affected by pregnancy, with values for pregnancy cycling, pregnancy swimming, postpartum cycling, and postpartum swimming of 2.36 +/- 0.12, 2.11 +/- 0.11, 2.29 +/- 0.10, and 2.12 +/- 0.07 l/min, respectively. Peak VCO2 (VCO2peak) and peak VE were significantly lower during swimming than during cycling by 18-25%, but only VCO2peak during swimming was affected by pregnancy (-10%). Lactic acid concentrations were 12-17% lower after swimming than after cycling and 17-31% lower during pregnancy than postpartum. We conclude that perceived maximal exertion is reached at a lower percent maximal VO2 in swimming than in cycling and that the reduced energy expenditure is reflected by lower VO2peak, VCO2peak, and peak VE. Pregnancy, however, does not affect VO2peak in cycling or swimming.

Placental transfer of Org 10172, a low-molecular weight heparinoid, in the awake late-pregnant guinea pig.

The placental transfer of Org 10172, a low-molecular weight heparinoid, was determined in 12 awake late-pregnant guinea pigs. Nine animals receiving placebo served as controls. After 5 days i.v. treatment with Org 10172 (2 x 300 anti-Xa U/kg/day), anti-Xa activity in fetal plasma amounted to 2.4% of the maternal concentration. The Org 10172 transfer across the placenta was also evaluated with 3H-labelled Org 10172. One hour after the administration of the latter compound, fetal Org 10172-bound 3H-activity had reached 1.5% of the maternal value. The associated extremely low placental Org 10172 transfer indicates that the Org 10172 transport across the placenta of the guinea pig is membrane-limited and that the placental permeability is negligibly low. Since the hemochorial placenta of the guinea pig closely resembles that of the human, it is likely that similar transplacental transfer properties of Org 10172 apply to man.

Serum ferritin and iron stores during pregnancy.

The iron status of two groups of pregnant women was investigated. One group did not receive iron (group B), the other erceived 100 mg iron/day (group A). 1. In all individuals concentrations of hemoglobin, serum iron, transferrin and serum ferritin were determined at regular intervals from the third month until delivery and at 3 months after delivery. The same determinations were performed in cord blood. 2. Changes in iron status appeared to be less in individuals with iron supplement than in those without iron supplement. A fall in Hb, serum iron and serum ferritin is observed in all individuals. 3. Three months after delivery the Hb concentration has generally returned to the normal female value, but the serum ferritin concentration is still very low. 4. The fetus does not discriminate as to the iron status of the mother. In both groups (A and B) cord blood values appeard to be not significantly different.

Characteristics and motives of women choosing elective induction of labour.

Personal characteristics of healthy term pregnant women who chose elective induction or spontaneous onset of labour and the motives for their choice were assessed. Almost 50% of 237 women with uncomplicated pregnancies opted for elective induction when offered the opportunity. These women appeared to have had more complaints during their pregnancy and menstrual periods, more complications in their obstetrical history and to be more anxious about their labour than women who chose a spontaneous onset of labour. Predominant motives were a feeling of safety and the desire to shorten the duration of pregnancy. These characteristics and motives seem to reflect a lack of trust in physical reproductive functions. It is concluded that in evaluating effects of elective induction of labour, pre-existing differences between women who choose elective induction and women who opt for a spontaneous onset must be taken into account.

Prevention of pre-eclampsia: status and perspectives 2000.

Because pre-eclampsia is a relatively common complication of pregnancy and forms a major cause of maternal, fetal, and neonatal morbidity and mortality, attempts at prevention are justified, but hampered by the fact that as yet no reliable and acceptable screening tests for women at risk are available. Analysis of the many interventions advocated to prevent or delay the onset of pre-eclampsia reveals that dietary calcium supplementation and prophylactic low-dose aspirin treatment have shown promise of efficacy in small randomized, placebo-controlled trials, but the results of large, multicenter trials are generally disappointing. The disappointing results obtained in large, multicenter trials may in part be explained by the lack of strict criteria for inclusion, late initiation of treatment, use of ill-defined end points, different timing of aspirin ingestion, and low patient compliance. Recent evidence that supplementation with vitamins C and E could prevent pre-eclampsia awaits confirmation. Future clinical trials on prevention of pre-eclampsia should be based on results of basic research.

Invasive hemodynamic monitoring in pregnancy.

Invasive hemodynamic monitoring is indicated in the critically ill pregnant or postpartum patient, whose hemodynamic state cannot be reliably determined by clinical observation and noninvasive methods. In addition, precise hemodynamic information must be indispensable to determine and monitor treatment. Complications of central hemodynamic monitoring using the Swan-Ganz catheter appear to be rare in experienced hands. To maintain and expand the necessary skills and experience, invasive hemodynamic monitoring should be centralized in obstetric intensive care units.

Low-dose aspirin in pregnancy: changes in patterns of prescription in The Netherlands.

OBJECTIVE: To describe patterns of prescription in the Netherlands of low-dose aspirin in pregnancy. DESIGN: Anonymous written inquiry in 1989 and 1991. SUBJECTS: Gynecologists in the Netherlands (619 in 1989 and 618 in 1991), practicing in training and non-training hospitals. MAIN OUTCOME MEASURES: Prescription rates for prevention of pregnancy-induced hypertension and fetal growth retardation, or for intention to treat. RESULTS: The response rates were 52% in 1989 and 58% in 1991, covering approximately 61% and 62%, respectively, of the practicing gynecologists in the Netherlands. The use for prevention increased from 53% to 79% and for therapeutic intentions from 25% to 48%. CONCLUSION: The prescription rate for low-dose aspirin increased markedly from 1989 to 1991, without evidence for its benefit from the literature published in the same time period.

The Marfan syndrome and pregnancy: a retrospective study in a Dutch population.

OBJECTIVE: To assess the course and outcome of pregnancies in women with the Marfan syndrome with the aim of developing guidelines for counseling. STUDY DESIGN: A retrospective study based on data collected from members of the Dutch Association of Marfan patients. Pregnancies and neonatal outcomes of affected mothers were compared with those of non-affected mothers who delivered a Marfan infant. RESULTS: In a group of 44 affected women 78 pregnancies beyond 24 weeks of gestation were evaluated, compared with 51 in non-affected women. Obstetric course and neonatal outcome of pregnancy were similar in both groups. Aortic dissection was observed in five affected women, three of which were known to have an aorta diameter of 40 mm or more; two neurovascular events were recorded; all mothers survived. CONCLUSIONS: A preconceptional aortic diameter of 40 mm or more, progression of dilatation and decreased cardiac function are risk factors in pregnancy for women with the Marfan syndrome. A multidisciplinary approach is recommended for the care of these patients and their infants.

Brain tumors and pregnancy. Presentation of a case and a review of the literature.

A case of brain tumor complicating a full-term pregnancy is reported. The literature is reviewed to show the effect of pregnancy on these tumors, the method of diagnosis, and management. Pregnancy often unmasks the existence of an intracranial neoplasm. The diagnosis can easily be missed, as the symptoms such as headache, vomiting, visual disturbance etc. are often encountered in pregnancy with or without pre-eclampsia. A high index of suspicion on the part of the obstetrician is a key to timely diagnosis. Computerized axial tomography is extremely useful in confirming or refuting the diagnosis of brain tumor. Generally speaking, neurosurgical intervention is best deferred until after delivery. In most cases, pregnancy may be allowed to continue under close supervision until the baby is reasonably mature. Labor may be induced in suitable cases, and the baby should be delivered by elective forceps as soon as the second stage of labor is reached to cut down maternal bearing-down efforts.

Torsion of the fallopian tube; a case report of a bilateral non-simultaneous torsion and a review of the literature.

The history is described of a patient with bilateral non-simultaneous torsion of the fallopian tubes occurring 10 yr after sterilization and with an interval of 1 yr. A review of the literature is presented which highlights the incidence, the clinical picture, the etiology, the prevention and the treatment of tubal torsion.

Transabdominal cerclage for closure of the incompetent cervix.

In addition to the limited published experience with transabdominal cervical cerclage (TCC) we report the use of this procedure in 14 women with a diagnosis of cervical incompetence, and a cervical deformity or defect precluding the usual transvaginal approach. In 13 pregnant patients and in one nonpregnant woman a band was placed transabdominally around the cervix at the level of the isthmus. No significant perioperative complications occurred. Two women had two consecutive pregnancies following TCC, so we report the outcome of 16 pregnancies. Fetal salvage increased from 16% before to 94% after TCC. Our experience and an analysis of the available literature support the view that TCC may be a beneficial procedure in women with cervical incompetence due to a severely traumatized cervix.