Intravenous glucose infusion in labor does not affect maternal and fetal acid-base balance.

OBJECTIVE: This prospective randomized trial compares the effects of a 5% glucose solution or no infusion during labor on glucose levels, pH, pO2, pCO2, and base excess (BE) of normal pregnant women in early labor and at delivery, and on fetal cord blood. METHODS: Forty-three women were randomized to glucose infusion and 38 were controls. RESULTS: Starting glucose levels were independent from the fasting state. When no glucose supplementation was given, the labor itself was associated with a reduction of mean pH (from 7.42 to 7.36, P = 0.00001), mean pCO2 (from 25.7 to 24.4 mm Hg, P = 0.04), and mean BE (from -6.3 to -9.8 mEq/L, P = 0.00001), and an increase of capillary glucose (from a mean of 83 to 105 mg/dL, P = 0.00001). Infusions of glucose did not significantly alter maternal acid-base balance at delivery. pH, PO2, pCO2, and BE were similar in arterial and venous cord blood of both groups. No variables correlated with cord blood glucose levels or with glucose vein-artery difference. CONCLUSIONS: We conclude that a 5% glucose infusion does not significantly reduce maternal acidemia associated with vaginal delivery and therefore its use cannot be recommended, since maternal glucose is largely available during labor. Intrapartum glucose infusions do not alter the acid-base balance, when the fetus is well oxygenated.

'Dual positivity' for neural tube defects and down syndrome at maternal serum screening: gestational outcome.

OBJECTIVE: To evaluate the gestational outcome of pregnancies screen-positive for both neural tube defects (NTD) and Down syndrome (DS) ('dual positivity'). METHODS: Among 10,667 mid-trimester women screened for DS and NTD with alpha-fetoprotein (AFP), unconjugated estriol (uE3), and human chorionic gonadotropin (hCG), delivered up to July 1996, we have selected cases with both an unexplained AFP value > or = 2.5 multiples of median (MoM) and a DS risk > or = 1:250. All these pregnant women were managed with amniocentesis and/or CVS, ultrasound scans, and Doppler velocimetry. We have collected all data about the gestations with 'dual positivity' and no obvious explanation for these findings (cases with fetal malformations related to raised AFP). RESULTS: Twelve women (1.1:1,000) showed unexplained 'dual positivity'. Abnormal karyotypes were found in 3 fetuses, and pregnancies were terminated: there were 2 triploidies with partial hydatiform mola, and 1 DS. In 9 cases the fetal karyotype was normal, but a confined placental trisomy 16 was found in 4. Of the 9 continuing gestations, 8 displayed fetal growth retardation (FGR). One gestation ended with fetal death at 27 weeks. All 9 fetuses were morphologically normal, and 8 were small for gestational age. CONCLUSIONS: 'Dual positivity' at NTD/DS screening may anticipate pregnancy complications. The finding of trisomy 16 confined to the placenta and FGR in 4 cases suggests that at least some fetuses with growth restriction may suffer from a distinct placental disease. Maternal serum screening may have implications different from DS and NTD, as demonstrated by the 2 cases with triploidy and incomplete hydatiform mola, the 4 cases with placental trisomy 16, and the 4 cases of FGR of the 5 fetuses without chromosome abnormalities. As the pathologic outcome of these pregnancies is more important than the mere serum screening results, we feel that these cases need a strict work-up, including CVS, amniocentesis and ultrasound studies to better address the obstetrical management.

Anti-beta 2 glycoprotein I antibodies in a general obstetric population: preliminary results on the prevalence and correlation with pregnancy outcome. Anti-beta2 glycoprotein I antibodies are associated with some obstetrical complications, mainly preeclampsia-eclampsia.

OBJECTIVE: To evaluate the prevalence in normal pregnancies of anti-32 glycoprotein I (anti-beta2GPI) antibodies, and their association with obstetrical complications. STUDY DESIGN: Prospective study of anti-beta2GPI and anticardiolipin (CL) antibodies in 510 healthy pregnant women at 15-18 weeks. According to the results, women were categorized into three groups: group I, negative for both antibodies; group II, positive for anti-beta2GPI antibodies; group III, positive for aCL only. The rates of fetal loss, abruptio placentae, preeclampsia-eclampsia, and fetal growth retardation were compared in the three groups. RESULTS: Anti-beta2GPI antibodies were found in 20 women (3.9%) and aCL in 8 patients (1.6%). Obstetrical complications were more frequent, even if not significantly different, in group II, 15%, than in group I, 4.1% (difference 10.9%; 95% confidence interval (CI): 1.6-20.2%; p=0.0575), while no complications were seen in group III. Preeclampsia-eclampsia were significantly more frequent in group II (10%) than in group I (0.8%; difference 9.2%; 95% CI: 4.4-14%; p=0.021). The prevalence of fetal growth retardation was not significantly different in the two groups (5% vs. 2%, respectively). COMMENT: Our findings indicate that anti-beta2GPI antibodies are associated with some obstetrical complications, mainly preeclampsia-eclampsia, even if more conventional antiphospholipid antibodies are not present. This observation suggests that these antibodies should be investigated in such cases, in order to improve the outcome of subsequent pregnancies, as well as in women with a history of early and/or recurrent severe preeclampsia in order to start a prophylactic treatment (i.e. low-dose aspirin or heparin).

Laparoscopic colorectal resection. A multicenter Italian study.

BACKGROUND: The aim of the present study was to evaluate retrospectively the experience of six surgical units currently performing laparoscopic colorectal surgery. METHODS: From November 1991 to January 1994, 200 patients (103 male, 97 female; mean age 62.5 years) were candidates for, and received, laparoscopic colorectal resection for benign (54) or malignant (196) lesions. All the units excluded patients with locally advanced organ tumors and all cases with suspected perforation and ascites. One center submitted to laparoscopic resection only stage I and IV adenocarcinoma. All surgeons considered obesity a relative contraindication. The following data were analyzed: indications, conversion rate to open surgery, operative time, morbidity and mortality, resumption of gastrointestinal function, number of lymph nodes harvested, hospital stay. RESULTS: Twenty-one out of 200 patients were converted to open surgery (10.5%); 37 patients had a complete laparoscopic procedure (17.1%); 137 had an assisted resection (68.5%); and the remaining 5 patients had a facilitated resection. The mean operative time was 208 min (90-480) for assisted resection and 275 min (54-550) for complete laparoscopic resection. The mortality rate was 1.7%; the overall morbidity was 19.6% (major complications 11.2%). All patients quickly became ambulatory and showed a prompt resumption of gastrointestinal functions, and less postoperative pain if compared with converted cases. The average number of lymph nodes was 12.1 (range 1-32). The mean hospital stay was 8.6 days (range 5-14.5). The mean follow-up was 16 months (range 6-24). The recurrence rate 11.7%. CONCLUSIONS: Laparoscopy seems to offer the possibility of minimally invasive treatment, but long-term follow-up is needed to evaluate the efficacy of laparoscopic surgery in the treatment of colorectal cancer.

Maternal serum screening and trisomy 16 confined to the placenta.

Five cases of trisomy 16 confined to the placenta have been detected by invasive procedures (amniocentesis and chorionic villus sampling) after high-risk results for Down syndrome and neural tube defects in a maternal serum screening programme of 6614 consecutive cases. All five pregnancies displayed unusually elevated levels of human chorionic gonadotropin and four out of five also had raised alpha-fetoprotein values. No structural malformation was present but all five pregnancies were complicated by fetal growth retardation, and one by intrauterine death. From our results, we suggest that both amniocentesis and chorionic villus sampling should be considered in the management of cases with high mid-trimester levels of these analytes.

Antiphospholipid antibodies and risk of intrauterine late fetal death.

STUDY OBJECTIVE: Goal of the study was to analyze the relationship between anticardiolipin antibodies, lupus anticoagulant and the risk of intrauterine late fetal death. DESIGN: A case-control study was conducted in a network of general and teaching hospitals in northern Italy. Cases studied were 99 women (median age 27 years), without clinical evidence of systemic lupus erythematosus or other immunological disorders who had an 'unexplained' intrauterine fetal death at or after the 20 weeks of gestation. The control subjects were 85 women (median age 28 years) who gave birth at term (> 37 weeks gestation) to healthy infants on randomly selected days at the same hospitals where cases had been identified. RESULTS: The presence of lupus anticoagulant was detected in four of the 99 cases (4%, 95% confidence interval 2%-15%) and none of the 85 controls. A total of 10 out of the 89 cases (11%, 95 confidence interval 6%-23%), but none of the 79 controls for whom anticardiolipin antibodies value was available had elevated anticardiolipin antibodies; this difference was statistically significant (chi 2(1) = 9.38, p < 0.01).

Herpes gestationis.

Herpes gestationis is a rare autoimmune disease of pregnancy characterized by itching and skin lesions. The disease causes prominently maternal discomfort, but fetal and neonatal complications have been reported; however the frequency and severity of fetal illness are still debated. We describe three cases of herpes gestationis diagnosed and managed at our institution in the last 3 years.

Low dose aspirin in pregnancy: a clinical and biochemical study of effects on the newborn.

Low dose Aspirin in pregnancy reduces the incidence of intra uterine growth retardation (IUGR) and pregnancy induced hypertension (PIH) in women at risk for these complications. To investigate if this drug, even in a low dose, could expose the newborn to hemorrhagic complications, we studied ten neonates whose mothers had been taking 50 mg/day of Aspirin from the 12th week of pregnancy until delivery and compared them with eight newborns whose mothers didn't take the drug. No hemorrhagic complications (emathemesis, ecchymoses or petechiae, subconjunctival hemorrhage, cephaloematomas etc.) were observed in the fetuses exposed to Aspirin or in the control group. No hemorrhagic lesions were found by ultrasound brain scan on the fourth day of life. Newborns exposed to Aspirin showed a significantly lower thromboxane concentration on the first day of life (median 73 ng/ml versus 217 ng/ml); however on the fourth day the level of serum thromboxane in the cases exposed reached the values of the unexposed ones (median 146 ng/ml versus 143 ng/ml). In conclusion low dose Aspirin in pregnancy can be considered a safe drug without and adverse effect on the newborn.

Systemic lupus erythematosus and pregnancy: a prospective study.

We have prospectively followed 25 pregnancies in 21 patients: 20 were affected by systemic lupus erythematosus (SLE) and 1 by subacute cutaneous lupus erythematosus (SCLE). A flexible treatment schedule was applied to the follow-up of all the pregnancies, and included low dose aspirin, steroids at medium-low dosage and, if needed, azathioprine (AZA) after 20 weeks of gestation. There were 4 spontaneous first trimester abortions and 21 live-born neonates without major problems related to the treatment or to the maternal disease. The relapse rate of the disease recorded during the observation period was 0.07 patient/month, not different from that already reported in SLE patients (pregnant or nonpregnant). Obstetrical complications were relatively frequent, but careful monitoring allowed us to avoid late fetal wastage. We conclude that in SLE patients a successful pregnancy outcome, without worsening of the disease, can be obtained with a careful multidisciplinary follow-up.

Ceftazidime in antibiotic prophylaxis for emergency cesarean section: a randomized prospective study.

The efficacy of two randomized antibiotic prophylactic schedules with ceftazidime (group A: single preoperative 2 g intramuscular dose; group B: 3 perioperative 1 g intramuscular doses every 6 h) was evaluated in 200 pregnant women undergoing cesarean section. Postoperative complications were observed in 9 cases (4 in group A and 5 in group B; p = NS). Analysis of possible risk factors revealed 1) a relationship between postoperative morbidity and overweight (body mass index above 30) in group A only; 2) a possible contributory effect of duration of labor (more than 6 h) in group A; and 3) a possible effect of duration of rupture of the membranes (more than 6 h) in group B only. The results obtained lead to the conclusion that single-dose prophylaxis with ceftazidime is as effective as short-term 3-dose ceftazidime prophylaxis in preventing post-cesarean complications.

[Myelin]. / La mielina.

The lipid and protein composition and the metabolic turnover of myelin in the C.N.S., are briefly reported. For a better understanding, it seemed useful to introduce some historical data on the discovery of myelin and to give a morphological description at structural and ultrastructural level.