Sustained rescue of prefrontal circuit dysfunction by antidepressant-induced spine formation.

The neurobiological mechanisms underlying the induction and remission of depressive episodes over time are not well understood. Through repeated longitudinal imaging of medial prefrontal microcircuits in the living brain, we found that prefrontal spinogenesis plays a critical role in sustaining specific antidepressant behavioral effects and maintaining long-term behavioral remission. Depression-related behavior was associated with targeted, branch-specific elimination of postsynaptic dendritic spines on prefrontal projection neurons. Antidepressant-dose ketamine reversed these effects by selectively rescuing eliminated spines and restoring coordinated activity in multicellular ensembles that predict motivated escape behavior. Prefrontal spinogenesis was required for the long-term maintenance of antidepressant effects on motivated escape behavior but not for their initial induction.

Mode of ascertainment is critical in assessing safety of percutaneous umbilical blood sampling.

Percutaneous umbilical blood sampling (PUBS) is increasingly utilized for cytogenetic assessment of the fetus. In the present study, outcome of 109 PUBS-derived fetal blood samples were analyzed according to mode of ascertainment: ultrasound-detected anatomic anomalies or intrauterine growth retardation (IUGR). Abnormal chromosome complements were found in 6 of 47 (12.8%) fetuses with anomalies but in only 1 of 62 (1.6%) fetuses with IUGR alone. Perinatal loss in fetuses with anatomic anomalies was 64.4%, compared with only 1.6% in fetuses with IUGR alone. Mode of patient ascertainment is an important factor that must be considered in determining procedure-related risks for PUBS.

Early and late intraventricular hemorrhage: the role of obstetric factors.

OBJECTIVE: To evaluate the influence of active phase labor and other obstetric factors on the development of periventricular-intraventricular hemorrhage in the neonate. METHODS: A total of 230 infants were studied. Antenatal enrollment was carried out when estimated fetal weight was 1750 g or less. Serial head ultrasound scans were performed to screen for periventricular-intraventricular hemorrhage, with the initial scan performed within minutes of birth. Scan findings and obstetric and neonatal variables collected prospectively at scheduled intervals were analyzed to determine the significant factors that predispose to intraventricular hemorrhage. RESULTS: In 47 infants (20%), intraventricular hemorrhage was detected within 1 hour of birth (early) and in another 49 (21%) at a later age (late). The overall incidence of hemorrhage was similar between vaginal and cesarean deliveries (41 and 44%, respectively). Early hemorrhage was more frequent in vaginal (28%) than cesarean deliveries (11%), whereas late hemorrhage was more frequent in cesarean deliveries. When the role of delivery mode and labor was analyzed by stepwise logistic regression, the odds ratios for development of early intraventricular hemorrhage increased in the following order: cesarean delivery with no labor, cesarean delivery with latent phase labor, vaginal delivery with forceps use, cesarean delivery with active phase labor, and vaginal delivery without forceps use. For late hemorrhage, the odds ratios increased in the following order: vaginal delivery with forceps, vaginal delivery without forceps, cesarean delivery with no labor, cesarean delivery with latent phase labor, and cesarean delivery with active phase labor. CONCLUSIONS: Active phase labor may predispose to early periventricular-intraventricular hemorrhage, but its influence may be attenuated by use of forceps or by abdominal delivery. The protective effect of forceps remains for late periventricular-intraventricular hemorrhage, but abdominal delivery does not seem to protect against late hemorrhage.

Nonimmune hydrops fetalis associated with maternal infection with syphilis.

Intrauterine infection with syphilis was diagnosed by reactive maternal serologic studies, ultrasonographic findings, and exclusion of other causes in three hydropic fetuses at 31, 34, and 35 weeks' gestation. With penicillin therapy and preterm delivery all infants survived through the perinatal period. Intrauterine infection that follows syphilis is a potentially treatable cause of nonimmune hydrops.

The effect of cesarean section on intraventricular hemorrhage in the preterm infant.

OBJECTIVE: The null hypothesis is that active labor is a more important factor with regard to both timing and progression of periventricular-intraventricular hemorrhage than is route of delivery. Infants delivered by cesarean section after entering the active phase of labor will behave in a manner similar to that of previously studied infants delivered vaginally as to when periventricular-intraventricular hemorrhage occurs and frequency of progression. STUDY DESIGN: The 106 infants of 85 women delivered by cesarean section were the subjects of this study. Forty-six infants were in the no-labor group, 33 in the latent-phase labor group, and 27 in the active-phase labor group. Head ultrasonographic examinations were performed at delivery, at 1, 6, 12, and 24 hours, and then daily for the first 7 days of life. Continuous variables were compared by one-way analysis of variance among those infants with no hemorrhage or with periventricular-intraventricular hemorrhage. Categoric variables were compared by chi 2 analysis and Fisher's exact test when appropriate. A p value of less than 0.05 was considered significant. RESULTS: There was no difference in the frequency of early hemorrhage (less than or equal to 1 hour of age), late hemorrhage (greater than 1 hour of age), or overall periventricular-intraventricular hemorrhage in the infants not in labor, in latent-phase labor, or in active-phase labor at the time of cesarean section. However, the frequency of grade 3 or 4 hemorrhage and the progression of hemorrhage were significantly higher in the infants whose mothers had an active phase of labor compared with infants whose mothers had no labor or did not progress beyond the latent phase. Infants who had early periventricular-intraventricular hemorrhage (less than or equal to 1 hour of age) also had a higher frequency of progression of hemorrhage. CONCLUSIONS: Cesarean section before the active phase of labor does not change the overall frequency of hemorrhage but results in a lower frequency of progression to grade 3 or 4 hemorrhage. We do not feel that these data support performing more cesarean sections for preterm delivery as a method of preventing progression of periventricular-intraventricular hemorrhage in the preterm infant.

Unexplained elevated maternal serum alpha-fetoprotein is not predictive of adverse perinatal outcome in an indigent urban population.

OBJECTIVE: The null hypothesis of this study is that in an urban, indigent obstetric population at high risk for adverse perinatal outcome, unexplained elevations of maternal serum alpha-fetoprotein are not an additional predictor of adverse perinatal outcome. STUDY DESIGN: Perinatal outcomes of 72 patients from a clinic for indigent patients with unexplained elevated maternal serum alpha-fetoprotein levels were compared with those of matched controls from the same population with normal maternal serum alpha-fetoprotein levels. Subjects and controls were matched for age, race, parity, and presence or absence of Hollister risk factors. The frequency of adverse perinatal outcome in the two groups was subjected to matched-pair chi 2 analysis. RESULTS: Adverse perinatal outcome occurred in 38.9% (28 of 72) of subjects with unexplained elevated maternal serum alpha-fetoprotein levels greater than or equal to 2.5 multiples of the median, compared with 31.9% (23 of 72) of controls with normal maternal serum alpha-fetoprotein levels (p = 0.5). No statistically significant difference in adverse perinatal outcomes was found. CONCLUSIONS: Elevated maternal serum alpha-fetoprotein levels offer little if any additional predictive value for adverse perinatal outcome in populations already at high risk for such outcomes on the basis of obstetric or socioeconomic criteria.

Successive pregnancies complicated by idiopathic sideroblastic anemia.

Sideroblastic anemias are a diverse group of hypoproliferative anemias characterized by defective iron use within erythropoietic cells and a defect in heme biosynthesis. This report describes the first case of successive pregnancies in a patient with idiopathic sideroblastic anemia. Periodic transfusions with washed erythrocytes and oral pyridoxine resulted in normal maternal and perinatal outcome.

Fetal blood sampling in patients undergoing elective cesarean section: a correlation with cord blood gas values obtained at delivery.

The purpose of this study was to compare blood gas parameters obtained after delivery and cord clamping with those obtained in the intact fetal circulation. Eighteen patients undergoing elective cesarean section at term were studied. Before the induction of epidural anesthesia, cordocentesis was performed under ultrasonographic guidance. Subsequently, a second sample was obtained for cord blood gas analysis after delivery. Umbilical venous blood was analyzed for pH, PO2, PCO2, and base excess. When comparing samples obtained from the intact fetal circulation with those obtained after delivery, there was a significant difference in pH (7.36 +/- 0.03 vs 7.31 +/- 0.04; p less than 0.0001), PCO2 (41.15 +/- 3.66 vs 46.29 +/- 5.71; p less than 0.018), PO2 (32.92 +/- 8.54 vs 26.97 +/- 4.43, p less than 0.02), and base excess (-0.79 +/- 1.19 vs -2.36 +/- 1.48; p less than 0.0003). These results should be considered when cord blood gas values obtained at delivery are correlated with those from the prenatal fetal state. Blood gas values obtained at delivery may not reflect the true prenatal fetal acid-base status.

Herpes simplex virus hepatitis in pregnancy. Two patients successfully treated with acyclovir.

Two cases of herpes simplex virus hepatitis in pregnancy are presented. Each case was characterized by extremely high serum aminotransferase levels with minimal bilirubin elevation. In both cases, liver biopsy was instrumental in arriving at the diagnosis. In addition, computed tomography showed a radiographic appearance of the liver not characteristically seen in other hepatic disorders of pregnancy. A high index of suspicion in the second case led to early recognition and treatment. Despite the presence of fulminant liver failure and evidence of herpes encephalitis in the other case, institution of therapy with acyclovir was associated with complete recovery in both patients. The present cases are compared and contrasted with the literature. The incidence of two cases within a 6-month period suggests that herpes simplex virus hepatitis in pregnancy may occur more frequently than previously reported.

Trial of labor in previous cesarean section patients, excluding classical cesarean sections.

The American College of Obstetricians and Gynecologists has supported the concept of a trial of labor in patients with a previous lower uterine transverse cesarean section, and its safety is generally accepted. The purpose of this report was to present the results of a year-long, prospective study in which the indications for trial of labor were liberalized. Only patients with a previous classical incision or "T" incision on the uterus were excluded. Two hundred seventy-two patients elected to undergo a trial of labor. Vaginal delivery occurred in 216 patients (76.5%). Oxytocin was used as needed, and epidural anesthesia was used in all patients who requested it. One uterine rupture occurred in a patient with a single lower transverse scar. The results of this study suggest that a trial of labor is a safe alternative for patients with a previous single or multiple lower uterine transverse incision or a lower uterine vertical incision. In addition, the use of epidural anesthesia and oxytocin appears safe in patients undergoing a trial of labor.

Preterm premature rupture of the membranes with fetal pulmonary maturity present: a prospective study.

Ninety-nine patients with premature rupture of the membranes (PROM) before 36 weeks' gestation and documented fetal pulmonary maturity were studied prospectively. Fifty-two patients in labor were allowed to deliver. The remaining 47 were randomly assigned to either prompt delivery (N = 26) or conservative management (N = 21). The overall corrected perinatal survival was excellent (96%). Only one death in the entire series clearly was due to prematurity. Expectant management prolonged gestation greater than one week in only four of 21 patients (19%), and was associated with a significantly increased risk of maternal infections. There were no failed inductions of labor, and 22 of 24 induced patients (92%) delivered vaginally. Neonatal morbidity was similar in each group. These findings in an indigent, largely black population suggest that when pulmonary maturity is present, the maternal risks of conservative management may exceed the potential benefit to the fetus and newborn. The findings of this study may be specific to the population studied, and extrapolation to dissimilar populations may not be warranted.

Comparison of phospholipids in vaginal and amniocentesis specimens of patients with premature rupture of membranes.

Amniotic fluid was obtained from the vaginal pool and by transabdominal amniocentesis in 28 patients who were admitted to the hospital between 26 and 35 weeks' gestation with premature rupture of the membranes. Phospholipid profiles were obtained on all specimens with the use of high-performance liquid chromatography. The lecithin/sphingomyelin ratio, phosphatidylglycerol, phosphatidylinositol, phosphatidylethanolamine, phosphatidylserine, and lysolecithin were all analyzed to determine the effect of vaginal contamination. With the use of a paired t test, only lysolecithin was shown to be significantly affected by vaginal contamination (p less than 0.05). As determined by high-performance liquid chromatography, evaluation of phospholipids in vaginal fluid of patients with premature rupture of the membranes appears to be an accurate and reliable method for predicting fetal lung maturity.

Hexoprenaline tocolysis for intrapartum fetal distress and acidosis.

Hexoprenaline, a selective beta 2-sympathomimetic drug, was administered to 12 patients with severe distress in labor. The fetal distress was documented by fetal heart rate abnormalities in association with a fetal scalp blood pH of less than 7.20. The mean fetal scalp pH was 7.17 +/- 0.17 before treatment. A 7.5- to 10-micrograms intravenous bolus of hexoprenaline was followed by an intravenous infusion titrated to inhibit uterine contractions. According to protocol, all patients delivered by cesarean section approximately 40 minutes after the bolus injection. The mean cord blood pH was 7.31 +/- 0.06. No infant had a five-minute Apgar score of less than 8, and there were no significant maternal or fetal side effects.

First trimester chorionic villi sampling and direct chromosome preparations.

Chorionic villi sampling was performed on 52 patients prior to elective termination of their pregnancies. Villi were obtained in 42, and direct chromosome preparations were successful in 41 of them. The use of a mixture of 0.075 M potassium chloride and 1% sodium citrate in the ratio of 2:1 for hypotonic treatment and 40% acetic acid for cell dispersal yielded chromosomes with good morphology and G-bands.

Fetal supraventricular tachycardia: in utero therapy with digoxin and quinidine.

Digoxin has been successfully used to treat fetal supraventricular tachycardia. When therapy with digoxin fails, alternative therapies have met with equivocal success. In this report, successful fetal therapy with maternally administered digoxin and quinidine is presented in three consecutive patients with fetal supraventricular tachycardia. The arrhythmia was eliminated in each instance. Fetal ascites, present in two fetuses, was completely reversed. Intrapartum fetal distress was not observed. The rationale of this therapy and a review of pertinent literature are also presented.

Inaccuracy of Dubowitz gestational age in low birth weight infants.

The Dubowitz gestational age was compared to the obstetric clinical age of 119 predominantly black mother-infant pairs for whom certain clinical criteria were met. Forty-five hypertensive and 74 nonhypertensive gestations with infant birth weight less than 2500 g were evaluated. Overall the clinical age was 33.6 +/- 4.5 weeks versus 34.7 +/- 4.3 weeks by Dubowitz age (P = NS). The Dubowitz age differed from clinical age by more than 2 weeks in 33.6% (40/119). Of gestations under 33 weeks (clinical age) (N = 45) the clinical age was 30.1 +/- 2.4 weeks as compared to the Dubowitz age of 32.2 +/- 2.7 weeks (P less than .01). Fifty-one percent (23/45) of Dubowitz ages were more than two weeks discordant with the clinical age. The Dubowitz assessment of gestational age may be unacceptably inaccurate in the determination of gestational age in low birth weight infants, particularly in those whose gestational age is less than 33 weeks. The findings suggest that studies in which conclusions were based on the Dubowitz age assessment may need reevaluation.

Late postpartum eclampsia: an update.

Eclampsia occurring more than 48 hours postpartum has been observed in an unusual number of patients. From August 1977 to November 1982 at E. H. Crump Women's Hospital and Perinatal Center (Memphis), there were 132 documented cases of eclampsia, of which 36 (27%) occurred postpartum. Seventeen (47%) of these occurred more than 48 hours postpartum. Preeclampsia was diagnosed before the onset of convulsions in 12 patients, all of whom received intravenous magnesium sulfate postpartum. The mean duration of postdelivery magnesium sulfate therapy was 32 hours (range 24 to 72 hours). Headaches and visual disturbances were reported by all 17 patients before onset of convulsions. Physical and laboratory findings immediately after the convulsions were consistent with eclampsia. Treatment consisted primarily of intravenous magnesium sulfate. Neurologic consultation was obtained to rule out a neurologic disorder, and metabolic studies were also done. Electroencephalograms were done on 15 patients; eight of them showed patterns consistent with encephalopathy.

Plasma volume findings in patients with mild pregnancy-induced hypertension.

With the Evans blue dye-dilution technique, plasma volume was serially measured at 29 to 33 weeks' and 34 to 40 weeks' gestation in 74 pregnant women with documented mild pregnancy-induced hypertension (PIH) and 25 well-matched normotensive primigravid women. The relationship of plasma volume to clinical course, perinatal outcome, and other laboratory findings was subsequently analyzed. The patients with mild PIH were categorized into two groups based on infant outcome: appropriate for gestational age (AGA) and small for gestational age (SGA). The mean age, height, and hematocrit of the study and control patients were similar. The group of patients with mild PIH had significantly higher mean arterial blood pressures and uric acid levels (p less than 0.001). There was no difference in mean plasma volume findings between the normotensive group and the mild PIH group delivered of AGA infants. Plasma volume was reduced only in pregnancies with mild PIH with delivery of SGA infants. It is concluded that plasma volume is not reduced in most patients with mild PIH. However, plasma volume might be useful in identifying a subgroup of patients with mild PIH at risk for delivering an SGA infant.