Intravenous and inhaled epoprostenol for primary pulmonary hypertension during pregnancy and delivery.

BACKGROUND: Primary pulmonary hypertension carries a significant mortality risk during pregnancy and delivery. CASE: A 36-year-old pregnant woman with primary pulmonary hypertension was transferred to us with severe dyspnea. Intravenous epoprostenol was started, titrated, and maintained until labor augmentation. Because systemic epoprostenol treatment can interfere with platelet aggregation, we switched to inhaled epoprostenol, administered under a U.S. Food and Drug Administration-approved investigational new drug license, before epidural catheter placement. The inhaled drug was continued because it achieved better control of pulmonary hypertension. An uneventful forceps-assisted vaginal delivery was performed, and intravenous epoprostenol was restarted after the delivery. Mother and baby were well 6 months postpartum. CONCLUSION: Intravenous epoprostenol treatment is effective in management of pregnant and postpartum women with primary pulmonary hypertension. Inhaled epoprostenol was effective during the intrapartum and immediate postpartum period.

Does preeclampsia influence fetal lung maturity?

OBJECTIVE: This retrospective study compared the fetal lung maturity biochemical profile of patients having preeclampsia with that of patients having preterm labor. STUDY DESIGN: Amniotic fluid was obtained by transabdominal amniocentesis in 90 patients, 59 patients with preterm labor (PTL) and 31 patients with preeclampsia (PRE). Pregnancies with fetal growth restriction were excluded. Fetal lung maturity was assessed by lecithin/sphingomyelin ratio (L/S) and by a fluorescence polarimetry assay (FLM). Mean values of L/S ratios and FLM were compared between the PTL and the PRE groups, each within two gestational age subgroups (27-32.9 weeks gestation and 33-36 weeks gestation). Student t-test, Chi-square test Fisher's exact test were used for statistical analysis. A p value < 0.05 was considered significant. RESULTS: During the gestational age interval of 33-36 weeks, the mean L/S ratios were significantly lower in pregnancies complicated by PRE than in those complicated by PTL (1.99 +/- 0.26 and 2.4 +/- 0.57, respectively; p = 0.01). Similarly, during this gestational age interval, the FLM values were also lower in PRE than in PTL, although the difference did not reach statistical significance. CONCLUSION: During the gestational age between 33 and 36 weeks of gestation, the biochemical profile of preeclamptic patients without IUGR has a significant lower L/S ratio compared to that of preterm patients.

Haplogroup-associated differences in neonatal death and incidence of low birth weight at elevation: a preliminary assessment.

OBJECTIVE: We sought to assess reproductive fitness differences between mitochondrial deoxyribonucleic acid haplogroups at high altitude. STUDY DESIGN: This study considers differences in outcomes of conception, birth weight, and neonatal mortality rates for 62 women classified according to haplogroups (B or non-B). RESULTS: The number of low-weight births (<2500 g) for the non-B group was significant (P =.019). Mothers in the non-B group reported more spontaneous abortions (P =.171) and stillbirths (P =.301). The difference in conceptions per woman between groups was significant (P =.036). However, no difference in infants alive at 1 month of age was evident. Neonatal death was significant (P =.017). The odds of an unsuccessful outcome among mothers in the B group was compared with mothers in the non-B group and was significant (P =.029). The chance of an adverse outcome, that is, fetal or infant death before 1 month, for mothers in the B group was between 11.1% and 88.7% lower than for mothers in the non-B group. CONCLUSIONS: The neonatal mortality rate for the non-B group was significantly elevated relative to the B group. The molecular basis for these observations is not clear.

Neonatal pulmonary hypoplasia and perinatal mortality in patients with midtrimester rupture of amniotic membranes--a critical analysis.

OBJECTIVE: We sought to critically assess the risk factors for neonatal pulmonary hypoplasia and perinatal death in patients with preterm rupture of the amniotic membranes from 15 to 28 weeks' gestation. STUDY DESIGN: This was a prospective cohort study. The study patients had preterm rupture of the amniotic membranes at 15 to 28 weeks' gestation and were without fetal anomalies, multiple gestation, and oligohydramnios before rupture of the membranes. The amniotic fluid volume index was determined at admission and weekly afterward until delivery. RESULTS: The incidence of pulmonary hypoplasia was 12.9% (21/163). The overall perinatal mortality rate was 54% (88/163). Logistic regression analysis revealed the following: (1) Gestational age at rupture of the membranes, the latency period, and either the initial or the average amniotic fluid index have significant influence on the development of pulmonary hypoplasia; (2) gestational age at rupture of the membranes and latency period are significant factors in predicting perinatal death. CONCLUSIONS: In this large population of patients with rupture of membranes at 15 to 28 weeks' gestation, gestational age at rupture of the membranes, latency period, and amniotic fluid index were important independent predictors of neonatal pulmonary hypoplasia. In addition, gestational age at rupture of the membranes and latency period were important independent determinants of perinatal death. Expectant management of patients with preterm rupture of the amniotic membranes during this gestational age interval was associated with improved perinatal survival, even though it may increase the risk of pulmonary hypoplasia.

Impact of oligohydramnios on maternal and perinatal outcomes of spontaneous premature rupture of the membranes at 18-28 weeks.

OBJECTIVE: We compare the maternal and perinatal outcomes between 69 patients with oligohydramnios and 49 patients with adequate fluid at the time of initial evaluation for PROM. METHODS: One hundred and eighteen patients with spontaneous premature rupture of the membranes (PROM) at 18-28 weeks are included in the study. Inclusion criteria are singleton gestation, normal fetal anatomical survey and normal amniotic fluid prior to PROM, and absence of labor or abruption at the time of PROM. Oligohydramnios is defined as an amniotic fluid index (AFI) <5 cm of measurable pockets of amniotic fluid which are free of umbilical cord. Expectant management was carried during the 3-year period. The overall perinatal survival is 66%. Pulmonary hypoplasia is present in 18%, and skeletal deformities in 3% of all neonates. RESULTS: There is no significant difference between the two groups in the mean gestational ages at PROM (172+/-17 d vs. 171+/-14 d), latency periods (9+/-14 d vs. 8+/-13 d), incidences of chorioamnionitis (48 vs. 39%), endometritis (19 vs. 14%), neonatal sepsis (11 vs. 13%), or skeletal deformities (6 vs. 0%). Patients with oligohydraminos have significantly higher incidences of fetal heart rate decelerations (59 vs. 38%) and C-section (38 vs. 16%) (P < 0.05) than patients with adequate amniotic fluid. CONCLUSIONS: After adjusting for confounding variables, neonates with oligohydramnios are twice as likely to develop pulmonary hypoplasia (20 vs. 10%) and more likely to experience neonatal death (30 vs. 20%) when compared to those with adequate fluid, even though the difference is not statistically significant.

Role of fetal echocardiography in the management of isolated fetal heart block with ventricular rate <55 bpm.

Persistent bradycardia is an uncommon cardiac problem in fetuses but carries a high mortality in those with a ventricular rate <55 bpm. Fetal heart block is one of the most common causes of persistent fetal bradycardia (PFB). An optimal method for assessing and monitoring cardiovascular compensation in the setting of PFB due to heart block has not been fully established. We report the application of two-dimensional and Doppler echocardiography in close monitoring of cardiac function and hemodynamics in a third-trimester fetus with a ventricular rate <55 bpm due to heart block, which assisted in successful management of the pregnancy to term. Hemodynamic and cardiac adaptive changes in compromised fetuses, particularly due to heart block, are discussed.

The neonatal bisacromial diameter: a prenatal sonographic evaluation.

This study was designed to determine which fetal ultrasonographic parameter best correlates with the neonatal bisacromial diameter (BAD). The latter is defined as the distance between the two acromions of the scapulae. The study population included fifty-four uncomplicated singleton pregnant patients whose infants with birth weights of more than 3000 grams were delivered within a week of ultrasound examinations. Six fetal biometric parameters: circumferences of the chest, abdomen, head, arm, and thigh, and estimated fetal weight were obtained by ultrasonography and were compared with the BAD. The best predictor of the neonatal bisacromial diameter was the fetal chest circumference (r = 0.67, p = 0.003) followed by the arm circumference, (r = 0.59, p = 0.03). The fetal chest circumference correlates well with the neonatal shoulder girth as reflected by the neonatal bisacromial diameter.

Complete hydatidiform mole and surviving coexistent twin.

Twin gestations consisting of a complete hydatidiform mole and coexisting fetus are rare and associated with an increased risk of persistent gestational trophoblastic tumor. Data were abstracted from 25 well-documented cases from the literature to which we added an additional case. Cases were then separated according to whether the pregnancy was evacuated before fetal viability (19 cases) or resulted in a surviving infant (7 cases). The previable and viable groups did not differ with respect to mean age, gravidity, parity, presenting symptoms, accuracy of sonographic diagnosis in identifying the molar component, uterine size at evacuation, or the presence of preeclampsia and theca lutein cysts. Statistically significant differences (P < .05) were detected between the previable and viable groups in estimated gestational age at evacuation (18.6 weeks vs. 33.0 weeks), the discrepancy between uterine size and estimated gestational age at evacuation (8.1 weeks vs. 1.0 weeks), and preevacuation serum hCG level (1,078,416 vs. 167,883 mIU/liter). Persistent GTT developed in 68.4 percent of the previable group patients and 28.6 percent of those in the viable group (P = .09). In patients with complete hydatidiform mole and coexistent fetus, fetal survival is associated with clinical characteristics suggestive of less exuberant molar growth. The advanced gestational age required to produce a viable, surviving fetus is not an independent risk factor for the development of persistent GTT.

Amniotic fluid alpha fetoprotein (AFAFP) and maternal serum alpha fetoprotein (MSAFP) in abdominal pregnancies: correlation with extent and site of placental implantation and clinical implications.

The hypotheses are evaluated that in abdominal pregnancies 1) elevated MSAFP is due to an altered maternal-placental interface, and 2) differences in MSAFP levels may reflect placental location within the peritoneal cavity. A review of 1,193 ectopic pregnancies from 1983-1993 identified three cases of advanced abdominal pregnancy. All three had undergone second trimester genetic amniocentesis for amniotic fluid alpha fetoprotein (AFAFP) and karyotype. The clinical course was reviewed (including presentation and surgical findings). MSAFP was elevated in two of the three cases (3.63 and 4.88 MoM). AFAFP and fetal karyotype were normal in all three cases. Elevated MSAFP values were associated with more extensive visceral implantation, longer surgical operative time, greater blood loss and transfusion requirements. Abdominal pregnancies with elevated MSAFP appear to have more extensive placental involvement of the abdominal viscera; this would, in fact, account for the elevated MSAFP values given the normal AFAFP.

Devastating sequelae of alloimmune thrombocytopenia: an entity that deserves more attention.

UNLABELLED: In alloimmune thrombocytopenia, maternal sensitization to a fetal platelet alloantigen results in fetal thrombocytopenia. Even in primipara, 20% of offspring can suffer intracranial hemorrhage, half of which occur in utero. Ninety percent of subsequent pregnancies will be equally or more severely affected. We describe two patients whose previous pregnancies were complicated by neonatal alloimmune thrombocytopenia (NAIT). As expected, NAIT recurred, with devastating sequelae in both cases. One case presented with hydrops fetalis, a previously unreported association; the other fetus developed extensive intracranial hemorrhages in utero. Because both previous obstetrical histories had gone unrecognized, no preventative strategies had been undertaken. CONCLUSION: Better recognition of this disease through a positive obstetrical history is needed in order to properly counsel patients and institute appropriate prenatal treatment regimens.

Molecular genotyping of fetal platelet antigens with uncultured amniocytes.

OBJECTIVE: Amino acid substitutions in platelet membrane glycoproteins result in alloantigens implicated in neonatal alloimmune thrombocytopenia. We report the use of the reverse dot blot technique to genotype the five major fetal platelet alloantigens from amniotic fluid cells. STUDY DESIGN: We evaluated a patient with Bakb platelet antibodies who had a previous pregnancy complicated by fetal intracranial hemorrhage. The father was heterozygous Baka/Bakb, giving the pregnancy a 50% risk for platelet incompatibility between mother and fetus. Amniotic fluid was obtained at 16 weeks. Deoxyribonuleic acid was extracted from uncultured amniocytes and amplified with polymerase chain reaction. These products were hybridized to filters containing oligonucleotides specific for each of the 10 different platelet antigen alleles. Reactivity was detected with a chromogenic substrate. RESULTS: The reverse dot blot genotyping of uncultured amniocytes revealed the fetus to be Baka/Baka, thus not at risk for neonatal alloimmune thrombocytopenia. CONCLUSION: Precise knowledge of fetal platelet type by amniocentesis could obviate the need for fetal blood sampling and significantly alter prenatal management of neonatal alloimmune thrombocytopenia.