Confirmation of paternal disomy in a twin molar pregnancy. A case report.

BACKGROUND: Paternal dispermy can be the pathogenesis of complete molar pregnancy. CASE: A 23-year-old, white woman, gravida 4, para 1, was pregnant with a twin gestation by ovulation induction with metrodin. Ultrasound evaluation confirmed an intrauterine pregnancy in conjunction with what appeared to be a hydatidiform mole. The karyotype in the molar pregnancy, obtained from chorionic villus sampling, showed a pair of paternally derived inverted chromosomes 9, confirming the diagnosis of a complete mole. Uncontrollable hemorrhage with a rapid rise in the beta-human chorionic gonadotropin titer necessitated evacuation of the uterus. The patient was followed with beta-human chorionic gonadotropin titers for a year, with no evidence of recurrence. CONCLUSION: This case illustrates paternal disomy in a complete molar pregnancy documented by a paternal chromosome 9 inversion.

Effects of physiologic load of pregnancy on left ventricular contractility and remodeling.

Left ventricular (LV) adaptation to the hemodynamic load of pregnancy has been studied with load-sensitive ejection-phase indexes, but the results of these studies are conflicting. The aim of this study was to examine the effects of the hemodynamic load of pregnancy on the contractile state of the left ventricle by using load-adjusted indexes of contractility. Thirty-four healthy women were prospectively studied by serial echo and Doppler examinations at six periods during pregnancy and after delivery. LV volume increased 10.5%, paralleling the change in stroke volume. End-systolic stress, an index of myocardial afterload, decreased 28.8% because of a decrease in end-systolic pressure and an increase in LV thickness/diameter ratio. Despite the increase in preload and the decrease in afterload, ejection phase indexes did not change during or after pregnancy. Although remaining within the normal range, the afterload-adjusted velocity of circumferential fiber shortening, an index of contractility that is relatively insensitive to preload, transiently decreased by 1.75 SDs during gestation, returning to non-pregnant values 2 to 4 weeks postpartum. Thus the increase in hemodynamic load that characterizes normal pregnancy is associated with preservation of global pump function. The transient decrease in contractile state may represent an adaptation phase of the contractile elements of the myocardium to the rapid changes in loading conditions observed during the first trimester of pregnancy.

Marker proteins in the particulate fraction of third-trimester amniotic fluid.

The present clinical evaluation of fetal lung maturity relies largely on the determination of the amniotic surfactant phospholipids phosphotidylglycerol, lecithin, and sphingomyelin, but there are many false negatives as well as false positives among diabetics. The use of other components of lung surfactant, namely, the hydrophobic surfactant proteins (SPs) has long been suggested as an alternative to the classical assay, but tests based on the detection of immunoreactive SP-A have not proved superior or supplanted phospholipid ratios as an index. This report investigates the proteins in a fraction of third-trimester human amniotic fluid (the particulate fraction) enriched in the SP complexes that form the surfactant monolayer. The proteins were analyzed by two-dimensional polyacrylamide gel electrophoresis and visualized by silver staining and immunoblotting. Eight proteins are of particular interest. Three novel proteins (termed AFPP-1, AFPP-4, and AFPP-8) and the alpha-fetoprotein/human serum albumin complex (AFPP-7) can be detected throughout the 28- to 38-week gestational window. The protein that is referred to as AFPP-2 could be identified as SP-A on the basis of immunologic cross-reactivity as well as size and charge characteristics. The time course of appearance of AFPP-2 was also followed in patients with Rh isoimmunization syndrome and was found to be the same as that seen for SP-A. The SP-A was detected as at least five major charged isoforms with multiple subisoforms of different molecular weight and can be distinguished from a related set of proteins (AFPP-5) that appear with a different time course but are possible precursors. Two other proteins (AFPP-3, AFPP-6), which are detectable inconsistently bear some similarity to others reported previously but not extensively characterized. These results define both constant and variable proteins of the particulate fraction of the amniotic fluid and indicate that certain protein isoforms are changing throughout the third trimester. These data enhance the possibility of the utilization of these proteins as markers of lung maturity in conditions such as maternal diabetes.

Treatment of polyhydramnios with indomethacin.

Polyhydramnios detected in a pregnancy should always be investigated thoroughly. We believe chromosomal abnormalities should be excluded, but that determination need not delay therapy. Indomethacin has been shown to reduce amniotic fluid volume in certain cases, but a strict monitoring schedule should be followed whenever it is administered. At our institution, we are investigating the effect on the fetus of newer, more selective prostaglandin synthetase inhibitors that should have beneficial effects similar to indomethacin, but be devoid of its unwanted side effects.

Nimodipine in the management of preeclampsia: maternal and fetal effects.

OBJECTIVE: Our purpose was to determine the effects of orally administered nimodipine on selected maternal and fetal parameters in patients with preeclampsia. STUDY DESIGN: Ten consecutive patients were given 30 mg of nimodipine orally every 4 hours from admission until 24 hours after delivery. Maternal and fetal cerebral blood velocity, umbilical artery blood velocity, fetal heart rate variability, maternal blood pressure and heart rate, and transplacental passage of the drug were studied. All 10 patients were delivered within 24 hours of the first dose of nimodipine. RESULTS: There was an acute and significant reduction in the pulsatility index in the smaller diameter maternal cerebral arteries (ophthalmic and central retinal) and in the fetal middle cerebral artery. The umbilical artery systolic/diastolic ratio was also significantly reduced. Maternal blood pressure was controlled without the need for other antihypertensive medication, and although there was an increase in heart rate after administration of the drug, it was well tolerated. Nimodipine reached significant maternal and fetal levels within 2 hours. CONCLUSIONS: Nimodipine is rapidly absorbed after oral administration and has significant maternal and fetal cerebral vasodilator activity. It is an effective, easily administered antihypertensive agent when used in patients with preeclampsia.

The effect of acute volume expansion and vasodilatation with verapamil on uterine and umbilical artery Doppler indices in severe preeclampsia.

UNLABELLED: Preeclampsia is associated with increased peripheral, uterine, and umbilical artery resistance. Acute blood pressure reduction may result in shunting of blood and sudden fetal distress. We therefore investigated the effects of volume expansion and verapamil therapy on uteroplacental and umbilical resistance during treatment of preeclampsia. MATERIALS AND METHODS: Five severe preeclamptics underwent volume expansion and subsequent vasodilatation with an infusion of verapamil. Invasive hemodynamic monitoring and Doppler ultrasonography were used to study changes in maternal, uterine, and umbilical hemodynamics. RESULTS: Volume expansion and subsequent verapamil therapy was associated with significant changes in maternal hemodynamics without significant change in uteroplacental or umbilical resistance. Uterine artery waveform changes were noted, with disappearance of notching in some cases. CONCLUSIONS: Volume expansion and verapamil therapy effectively reduces maternal blood pressure in preeclampsia, without adversely affecting uteroplacental or umbilical artery resistance. Uterine artery waveform changes may be associated with improved fetal outcome.

Effects of chronic exercise on blood volume expansion and hematologic indices during pregnancy.

OBJECTIVE: To compare blood volumes and hematologic indices between nine aerobically trained, physically active pregnant women who continued to exercise throughout gestation and five healthy yet sedentary gravidas. METHODS: Subjects were tested on three occasions: 25 and 36 weeks of pregnancy and 12 weeks postpartum. Plasma volumes were estimated by dye dilution with Evans blue. Blood samples were taken from the antecubital vein with the subjects resting in a seated, semirecumbent position. In addition to plasma volume estimations, blood samples were analyzed for hematocrit ratio, hemoglobin concentration, red cell count, and plasma protein concentration. Blood volumes and red cell volumes were calculated from plasma volume estimates and hematocrit ratios. RESULTS: Average birth weight and length of gestation did not differ between the subject groups. Analysis of variance indicated that absolute blood volume measures were significantly greater (P < .01) in the physically active compared to sedentary subjects at all three test times. Similar results were found for plasma and red cell volumes (P < .01). Blood volumes relative to body weight were significantly higher in physically active subjects (P < .01) than in their sedentary counterparts at 25 weeks (88.5 versus 75.5 mL/kg) and at 36 weeks (88.4 versus 70.9 mL/kg), as well as at 12 weeks postpartum (72.2 versus 57.6 mL/kg). All vascular volumes were significantly (P < .001) lower at 12 weeks postpartum compared to those seen during pregnancy in both subject groups. Hematologic indices of hematocrit ratio, hemoglobin concentration, red cell count, and plasma protein concentration were all greater (P < .001) at 12 weeks postpartum than during pregnancy. CONCLUSIONS: Physically active women possessed significantly greater vascular volumes than their sedentary counterparts. Although this difference was maintained throughout gestation as the active gravidas continued to exercise, there was no apparent effect on pregnancy outcome.

Amniotic fluid index. Gestational age-specific values for normal human pregnancy.

Amniotic fluid volume is an important parameter in the assessment of fetal well-being. The purpose of this study was to define the values of the amniotic fluid index for normal pregnancy by week of gestation in our population. The amniotic fluid index was measured prospectively in 892 patients with a normal singleton pregnancy between 15 and 40 weeks and an estimated fetal weight between the 10th and 90th percentile. The results were stratified by week of gestation. From a median of 10.3 cm (range, 8.7-13.7, 5th-95th percentile) at 15 weeks' gestation, the amniotic fluid index rose progressively to a maximum median of 14.0 cm (range, 4.0-18.6) at 30 weeks. The index then gradually declined to a median of 9.1 cm (range, 4.8-14.2) by 40 weeks' gestation. The difference between the median index for preterm patients (11.9 cm) and that for the term group (10.8 cm) was found to be statistically significant (P < .05). The difference between the median amniotic fluid index for the total group and the medians for the preterm and term patients was also significant (P < .05). Gestational age-specific values of amniotic fluid index should be used, and the 5th and 95th percentiles serve as the lower and upper limits, respectively, of normal.

Maternal death from severe retroperitoneal fibrosis.

Idiopathic retroperitoneal fibrosis is uncommon in pregnancy. We have described the case of a pregnant patient with a benign retroperitoneal spindle cell tumor involving the distal duodenum, right ureter, and right iliac artery and vein. She was treated with a left ureteral stent and a right percutaneous nephrostomy. Ultimate cause of death was electrolyte imbalance due to bowel obstruction.

Effects of maternal aerobic fitness on cardiorespiratory responses to exercise.

We hypothesized that aerobically fit women who continued to exercise throughout pregnancy would have enhanced cardiorespiratory responses to exercise. Physically active (N = 10) and sedentary (N = 6) subjects were compared during steady-state (15 min) semi-recumbent cycle exercise performed at a given heart rate (HR; 140 b.min-1) twice during pregnancy (25 wk, 36 wk) and 12 wk postpartum. Indirect calorimetry was used to measure volumes and fractional concentrations of expired gases. Cardiac output was estimated via CO2 rebreathing. Data were analyzed with repeated measures ANOVA. Caloric expenditure during exercise was significantly (P < 0.001) greater in the physically active (7.2 kcal.min-1) compared with sedentary (4.7 kcal.min-1) subjects. Alveolar ventilation and cardiac output responses to exercise were proportionally greater (P < 0.001) in the aerobically fit subjects. Ventilatory equivalents for O2 and physiological dead space/tidal volume ratios were significantly (P < 0.01) lower in the physically active subjects during exercise. In contrast, ratings of perceived exertion during exercise did not differ between subject groups. It appears that a physically active woman's enhanced cardiorespiratory responses to acute exercise are maintained during pregnancy if she continues her aerobic fitness program throughout gestation.

Ruptured ovarian artery aneurysm complicating a term vaginal delivery.

Ruptured ovarian artery aneurysm is rare. Of the eight cases previously reported, seven were diagnosed postpartum. Our case of a ruptured right ovarian artery aneurysm was associated with massive retroperitoneal bleeding. The probable time of rupture could be traced to the second stage of labor. This case indicates the need for early evaluation of atypical flank pain during labor.

The use of nimodipine in a patient with eclampsia: color flow Doppler demonstration of retinal artery relaxation.

Color flow Doppler ultrasonography was used to demonstrate a significant and sustained reduction in the central retinal artery pulsatility index after administration of the calcium antagonist nimodipine to a patient with eclampsia. Nimodipine is an effective cerebral vasodilator and may be useful in the management of eclamptic patients with severe vasospasm.

Subjective ultrasonographic assessment of amniotic fluid depth: comparison with the amniotic fluid index.

The purpose of this study was to evaluate the ability to identify abnormalities in amniotic fluid volume by subjective ultrasonographic assessment compared to a semiobjective method. In 886 consecutive ultrasound examinations subjective assessment of the amniotic fluid volume was performed and graded into 3 categories: normal, decreased, and increased. Following that, a four-quadrant sum (amniotic fluid index) was performed by the same experienced ultrasonographer and divided into 3 categories using the 5th and 95th percentiles. The sensitivity of the subjective analysis to diagnose a decreased amniotic fluid volume when compared with the amniotic fluid index was 58% (95% confidence interval, CI: 40-70%), with a false-positive rate of 17% (CI 8-32%). The sensitivity of the subjective analysis to diagnose an increased amniotic fluid volume when compared with the amniotic fluid index was 100% (CI 70-100%). However, the false-positive rate was 74% (CI 55-85%). Diagnosis of a normal amount of amniotic fluid by the subjective technique had a sensitivity of 96% (CI 95-97%) and a false-positive rate of 3% (CI 2-4%). Subjective ultrasonographic assessment of the amniotic fluid volume may serve as a screening test for the experienced ultrasonographer. However, when a decreased or increased amount of amniotic fluid volume is suspected, one may elect to use the amniotic fluid index for confirmation of the subjective impression.

Fetal renal artery flow velocity waveforms in normal pregnancies and pregnancies complicated by polyhydramnios and oligohydramnios.

OBJECTIVES: To determine 1) flow velocity waveform patterns in the fetal renal artery in normal pregnancies and pregnancies complicated by polyhydramnios or oligohydramnios, and 2) fetal urine output in twin gestations complicated by polyhydramnios-oligohydramnios syndrome. METHODS: Doppler waveforms were recorded in 121 normal fetuses, ten fetuses with oligohydramnios, ten with polyhydramnios, and eight sets of diamnionic twins with polyhydramnios in one gestational sac and oligohydramnios in the second sac. In the twins, the fetal urine output was also estimated. RESULTS: The pulsatility index (PI) of the renal artery in normal fetuses decreased linearly with advancing gestation. Abnormal renal artery PIs were found in four fetuses with oligohydramnios. The values in the singleton pregnancies complicated by polyhydramnios were in the range of normality for our reference limits for gestation. The PI of the renal artery in the twins with polyhydramnios was significantly lower than that from the twins with oligohydramnios. The urine output was significantly higher in twins with polyhydramnios than in twins with oligohydramnios. CONCLUSIONS: Normal pregnancies are associated with changes in the renal artery flow velocity waveforms. In fetuses with oligohydramnios, the worst fetal outcome seems to be associated with abnormal renal artery flow velocity waveforms. In fetuses with polyhydramnios, no abnormal renal artery flow velocity waveforms were found. Changes in renal perfusion influence urine output in twin gestations complicated by polyhydramnios-oligohydramnios.

The use of color flow Doppler ultrasonography to diagnose umbilical cord entanglement in monoamniotic twin gestations.

OBJECTIVE: Our purpose was to investigate the use of color flow Doppler ultrasonography to identify umbilical cord entanglement. STUDY DESIGN: Our case series consisted of three monoamniotic twin gestations. Color flow Doppler was used prospectively to study the umbilical cords. RESULTS: Apparent "branching" of the umbilical artery, with evidence of two different heart rates in the two segments of the branch, was seen in all cases. Compression of the umbilical vein was identified by extremely high blood velocity. CONCLUSIONS: Color flow Doppler is useful in the identification of umbilical cord entanglement in monoamniotic twin pregnancies and may provide a method of monitoring the fetuses for evidence of cord compression.

The cardiovascular and intracranial effects of laryngoscopy and endotracheal intubation in hypercarbic neonatal piglets.

Laryngoscopy and endotracheal intubation is a potent sympathetic stimulus in adults. Neonates are frequently intubated, but few data exist on the cerebral effects of this intervention. The cardiovascular and intracranial effects of laryngoscopy and endotracheal intubation were studied in 17 hypercarbic neonatal piglets. The mean arterial pressure in the study group (11 piglets) increased significantly within 2 minutes of the stimulus, and remained elevated for almost 14 minutes. The intubated animals showed significantly more haemorrhage in the basal area of the brain than the 6 control animals. The distribution suggests bleeding in the choroid plexus of the 4th ventricle. The significance of such bleeds is not immediately apparent, since none of the animals was grossly neurologically affected by the intervention. However, subtle long-term neurological deficits cannot be excluded and this aspect requires further study. Laryngoscopy and endotracheal intubation may cause non-lethal haemorrhage in the choroid plexus and central canal of the hindbrain in hypercarbic, neonatal piglets.

Reduction in the middle cerebral artery pulsatility index after decompression of polyhydramnios in twin gestation.

Amniotic fluid decompression was performed for symptomatic polyhydramnios complicating four sets of discordant twin gestations. Doppler ultrasound waveforms of the middle cerebral artery were determined before and after the procedure in seven of the eight fetuses. After amniocentesis, the pulsatility index of the middle cerebral artery (PIMCA) was reduced in all fetuses (p < 0.01). When one considers only the larger twin in each set, the magnitude of the change in PIMCA was relatively consistent among the different sets (-0.60 +/- 0.14; p < 0.01; range, -0.45 to -0.79). The smaller twins showed a much more variable response (-0.82 +/- 0.70; range, -0.05 to -1.75). The pulsatility index of the umbilical artery (PIUA) showed no consistent trend in the five subjects in which it was determined. In principle, the cerebrovascular dilation indicated by the PIMCA measurements may in part be due to acute increases in maternal and fetal carbon dioxide tensions following relief of maternal restrictive lung dysfunction. More importantly, the acute fall in amniotic fluid pressure--the external pressure to which the fetoplacental unit is exposed--leads to pooling of blood in fetal and placental veins, and thereby reduces the effective blood volume of the fetoplacental unit. This effective hypovolemia, functionally analogous to that produced by fetal hemorrhage, elicits changes in regional vascular resistances that favor cerebrovascular perfusion. The impact of acute amniotic fluid decompression on the fetal circulation reflected in the marked changes in PIMCA suggests a role for monitoring to avoid large acute changes in pressure during therapeutic amniocentesis.

Indomethacin for the treatment of symptomatic leiomyoma uteri during pregnancy.

Pain secondary to carneous degeneration is the most common complication of leiomyoma uteri during pregnancy. Conventional therapy utilizing bed rest and parenteral narcotic analgesics may often be ineffective. We retrospectively reviewed seven cases of degenerating fibroids complicating pregnancy where the prostaglandin synthetase inhibitor, indomethacin (25 mg orally every 6 hours), was used to treat symptoms of pain. In all cases, relief of symptoms was achieved within 48 hours of initiation of therapy. Two patients required a second course of therapy, and one patient required a third course. Mean duration of therapy was 12 days. One fetus developed transient constriction of the ductus arteriosus and transient oligohydramnios. Two pregnancies aborted, one at 22.9 and one at 22.3 weeks; however, no perinatal complications were directly attributable to indomethacin. The five term deliveries were of healthy normal infants. These retrospective data suggest that indomethacin may be effective in the treatment of pain associated with degenerating uterine leiomyomas in pregnancy.

Nisoldipine--a new orally administered calcium antagonist used in the treatment of severe postpartum pregnancy-induced hypertension. Preliminary results.

The calcium antagonist nisoldipine (Bayer-Miles) was given orally (20 mg, 8-hourly) in the management of 12 selected cases of severe postpartum pregnancy-induced hypertension (PIH). Each patient acted as her own control in this pilot study. A rapid fall in systolic (P less than 0.01) and diastolic (P less than 0.01) blood pressure was seen within 30 minutes of initiation of therapy, and significantly reduced levels of blood pressure were maintained with repeated nisoldipine administration for the duration of the study period (24 hours). There were no significant changes in the heart rate at any time during the study. There were no adverse reactions, despite the relatively high dose used. This is the first reported study on the use of nisoldipine in the management of severe PIH. The efficacy and the potential advantages of this oral calcium antagonist, as shown in these preliminary findings, should stimulate further controlled investigation of this agent in PIH.

Coagulation profile in severe preeclampsia.

One hundred women with severe preeclampsia or chronic hypertension with superimposed preeclampsia were seen during a 2-year period. We sought to determine whether a normal platelet count assures that no other clinically significant clotting abnormalities are present, and what level of thrombocytopenia predicts a risk of abnormalities in other coagulation indices. Fifty women had platelet counts below 150,000/microL, of whom 13 had a fibrinogen level below 300 mg/dL and two had a prolonged prothrombin time (PT) or partial thromboplastin time (PTT). The admission platelet count was an excellent predictor of subsequent thrombocytopenia (r = 0.829, P less than .001). No subject had an abnormal fibrinogen level or prolonged PT or PTT in the absence of thrombocytopenia. When monitoring intrapartum coagulation indices in preeclampsia, one can safely follow only the platelet count at admission and subsequently, reserving PT and PTT and fibrinogen levels for those cases complicated by counts less than 100,000/microL.