Calciuria in symptom-free primigravid women remote from term: is the response to an oral calcium challenge predictable?

OBJECTIVE: This study was undertaken to compare the calciuric response in symptom-free primigravid women to an oral calcium load between those with normal urinary calcium excretions and those with relatively low urinary calcium excretions. STUDY DESIGN: This was a prospective clinical trial. Eligible primigravid women between 16 and 20 weeks' gestation provided a 24-hour urine sample for determination of urinary calcium/urinary creatinine ratio. On the basis of these results the patients were divided into 2 groups: a relatively hypocalciuric group, in which the urinary calcium excretion was 3.4 mg. kg-1. 24 h-1. All participants undertook a 3-day low calcium dietary regimen. On the fourth day women underwent an oral calcium challenge. A 2-hour urine sample was collected before ingestion of 1 g calcium carbonate (preload). One hour after ingestion the women again collected a 2-hour urine sample (postload). The urinary calcium/urinary creatinine ratios in the preload and postload samples were determined and compared within and between the groups. RESULTS: The mean change (+/-SD) between the preload and postload urinary calcium/urinary creatinine ratios in the relatively hypocalciuric group was 0.60 +/- 1.44 (P =.04); that in the normocalciuric group was 3.09 +/- 2.26 (P =.11 ). There was a 5-fold difference in the response to calcium load between the hypocalciuric women and the normocalciuric women (0.60 vs 3.09), although this difference was not statistically significant (P =.20). CONCLUSIONS: Both hypocalciuric and normocalciuric women responded to an oral calcium challenge by an increase in the calcium excretion. The cause of the hypocalciuria in women at increased risk for preeclampsia is therefore not simply poor absorption of calcium.

Trauma in pregnancy: normal Revised Trauma Score in relation to other markers of maternofetal status--a preliminary study.

OBJECTIVE: Our goal was to examine whether a correlation exists between the Revised Trauma Score assigned on admission and pregnancy outcome, as well as whether the Revised Trauma Score has any predictive value for optimal duration of cardiotocographic monitoring necessary to detect immediate adverse pregnancy outcome. STUDY DESIGN: A retrospective chart review was performed of 30 pregnant trauma patients admitted during a 1-year period. Evaluation of cardiotocographic data for either contractions or decelerations or both was performed without knowledge of Revised Trauma Score or maternofetal outcome at discharge. RESULTS: Review of uterine activity and fetal decelerations did not detect useful predictive patterns unless the tracing was immediately ominous, although uterine activity did initially decrease over time. CONCLUSIONS: The Revised Trauma Score lacks predictive value for both risk of adverse pregnancy outcome and need for prolonged cardiotocographic monitoring. A larger patient population needs to be studied for an accurate determination of whether the Revised Trauma Score has potential as a predictive tool.

Effect of chronic tocolytic therapy on maternal ventricular function in pregnant rabbits.

OBJECTIVE: Our purpose was to determine whether peripartum cardiomyopathy may be associated with chronic beta-mimetic tocolytic therapy. STUDY DESIGN: On gestational day 20 (term 31 days), two 200 microliter Alzet miniosmotic pumps were implanted in the subcutaneous tissue of pregnant New Zealand White rabbits. Each pump was filled with terbutaline (20 micrograms/microliter, n = 7) or saline solution (0.9%, n = 7) and infused continuously for 7 days. The rabbits were killed on the twenty-eighth gestational day. Maternal hearts were placed on a Langendorff (nonejecting) perfusion apparatus for assessment of cardiac function. At a constant perfusion pressure and heart rate left ventricular diastolic pressure was varied while left ventricular developed pressure and left ventricular +/- rate of pressure rise, index values of left ventricular contractility and relaxation, were continuously recorded. Comparisons between groups at each preload were made by analysis of variance. RESULTS: Hearts taken from terbutaline-treated rabbits exhibited periodic arrhythmias and mechanical alternans in five of seven hearts versus one of seven in the saline solution group. At a preload of 0 mm Hg both left ventricular developed pressure (88.0 vs 48.4 mm Hg, p < 0.001) and left ventricular rate of pressure rise (1406 vs 653 mm Hg/sec, p < 0.001) were less in terbutaline-treated rabbits. At a preload of 10 mm Hg left ventricular developed pressure (104.4 vs 56.7 mm Hg, p < 0.01) and rate of pressure rise (1424 vs 694 mm Hg/sec, p < 0.001) were also significantly less in terbutaline-treated rabbits. Left ventricular relaxation was also impaired at all preloads. CONCLUSIONS: In this model chronic administration of terbutaline during late pregnancy significantly depresses global maternal cardiac function.

Effect of dual tocolysis on the incidence of severe intraventricular hemorrhage among extremely low-birth-weight infants.

OBJECTIVE: Our purpose was to evaluate the null hypothesis that dual tocolysis with magnesium sulfate and indomethacin does not alter the rate of grade III or IV intraventricular hemorrhage. STUDY DESIGN: Fifty-six neonates weighing 500 to 800 gm from mothers who received tocolytic therapy with magnesium sulfate alone or in combination with indomethacin were the subjects of this retrospective study. Demographic variables were evaluated with a Student t test, chi(2) analysis, Fisher exact test, or Mantel-Haenszel chi(2) as appropriate. RESULTS: There was an increased incidence of grade III to IV intraventricular hemorrhage among patients treated with dual therapy (p = 0.02). Logistic regression showed that fetal age and dual tocolysis with indomethacin were the only independent prognostic factors for severe intraventricular hemorrhage. CONCLUSION: The results indicate that dual tocolysis with indomethacin may place extremely low-birth-weight infants at increased risk for grade III to IV intraventricular hemorrhage.

Etiology and outcome of extremely low-birth-weight infants.

OBJECTIVE: Our purpose was to determine whether the reason for delivery of extremely low-birth-weight infants influenced the immediate neonatal outcome. STUDY DESIGN: At a regional perinatal center a retrospective analysis of 111 neonates with birth weights between 500 and 800 gm and their respective mothers was performed. The mother-infant pairs were grouped according to the reason for delivery. Group 1 included those with idiopathic preterm labor. Group 2 included mothers with preterm rupture of membranes. Group 3 included those delivered for maternal or fetal indications. Group 4 included all multiple gestations. Maternal, intrapartum, and neonatal outcome variables were then evaluated for statistical significance by analysis of variance and chi2 methods and a p value of 0.05. RESULTS: The neonatal outcome variables (survival and incidence of major intraventricular hemorrhage, hyaline membrane disease, and fetal sepsis) were not found to be significantly different among the four groups tested. CONCLUSION: The reason for the delivery of extremely low-birth-weight infants does not have an impact on the immediate neonatal outcome in these neonates.

The maternal and neonatal outcome of triplet gestations.

OBJECTIVE: Our purpose was to determine the contemporary maternal and neonatal outcome of triplet gestations. STUDY DESIGN: A retrospective review of 57 triplet deliveries between April 1, 1989, and July 31, 1994, was performed. RESULTS: The mean gestational age at delivery was 33.0 +/- 2.7 weeks, and the mean birth weight was 1820 +/- 513 gm. The most common maternal complications were preterm labor (86.0%), anemia (58.1%), preeclampsia (33.3%), preterm premature rupture of the membranes (17.5%), postpartum hemorrhage (12.3%), and HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome (10.5%). Neonatal complications included hyaline membrane disease (29.6%), transient tachypnea of the newborn (20.1%), intraventricular hemorrhage (7.7%), and major congenital anomalies (7.1%). The perinatal mortality was 41 per 1000. Birth order had no significant effect on the incidence of neonatal complications. CONCLUSION: Perinatal mortality rates have improved in recent years but remain higher than for singleton gestations. Despite increasing experience with triplets, the rate of maternal complications is high.

Central hemodynamic changes associated with pregnancy in a long-term cardiac transplant recipient.

We present a case of pregnancy in a woman who had undergone cardiac transplantation and was monitored by "surveillance" biopsy at intervals during the entire course of pregnancy and the immediate postpartum period. Exercise reserve remained normal during these periods despite angiographic evidence of coronary disease and episodes of rejection. Central hemodynamic changes were similar to those expected during normal pregnancy. Hemodynamic stability was maintained during epidural anesthesia for labor and subsequent cesarean section.

The effect of tocolytic use in the management of symptomatic placenta previa.

OBJECTIVE: The null hypothesis is that tocolysis has no effect on pregnancy prolongation in the aggressive expectant management of symptomatic preterm placenta previa. STUDY DESIGN: One hundred twelve preterm pregnancies with confirmed placenta previa and an initial episode of acute vaginal bleeding were selected for this retrospective analysis. Exclusion criteria included gestational age > or = 35 weeks, delivery within 24 hours of admission, prior treatment for bleeding or preterm labor, and contraindications to tocolytic use. Tocolysis was prescribed, at the discretion of the treating clinical staff, in selected pregnancies with significant uterine contractions after admission of the patient. The majority of treated patients (85%) received intravenous magnesium sulfate and/or oral or subcutaneous beta-sympathomimetics within 24 hours of admission. Most patients remained hospitalized until delivery under this aggressive expectant management protocol. Both treated and untreated control study groups were similar at inclusion with regard to parity, gestational age, contraction frequency, and degree of initial bleeding. Outcome variables for each treatment group were obtained from final chart review. Continuous and categoric variables were compared with Student t test or chi 2 analysis-Fisher's exact test, respectively. RESULTS: The clinical use of tocolysis in symptomatic placenta previa was associated with a clinically significant delay of preterm delivery. Significant improvement in clinical parameters such as interval from admission to delivery (39.2 vs 26.9 days, p < 0.02) and birth weight (2520 vs 2124 gm, p < 0.03) was observed in the tocolysis group. There was no observed statistical difference between the two treatment groups with regard to incidence of recurrent bleeding, interval from admission to first recurrent bleeding, and need for transfusion. There was a trend for patients with multiple bleeding episodes to have been receiving tocolytic therapy (p < 0.10). A trend for requiring a postpartum transfusion was also noted in the tocolysis group (p < 0.09). Treated pregnancies receiving long-term maintenance tocolysis with oral or subcutaneous terbutaline exhibited a greater degree of pregnancy prolongation than those treated with short-term intravenous magnesium alone (43.7 vs 15.3 days, p < 0.02). CONCLUSIONS: This retrospective analysis suggests that tocolytic intervention in cases of symptomatic preterm previa may be associated with clinically significant prolongation of pregnancy and increased birth weight. Tocolytic therapy in these cases does not appear to have an impact on frequency or severity of recurrent vaginal bleeding. Further prospective analysis may delineate the role of tocolysis in the aggressive expectant management of symptomatic placenta previa.

Effect of amnioinfusion on the incidence of postpartum endometritis in patients undergoing cesarean delivery.

We reviewed records from 251 consecutive cesarean deliveries performed over a six-month period to evaluate the effect of amnioinfusion during labor on the incidence of postpartum endometritis in patients who delivered by cesarean section. One hundred fifty-four patients were excluded because they were not in labor, were at less than 35 weeks' gestation or received antibiotics during labor. Twenty-three of the remaining 97 patients received amnioinfusion during labor and represented the study group. Seventy-four patients did not receive amnioinfusion during labor and were used as controls. The incidence of postpartum endometritis in the amnioinfusion group was 13%, while the incidence in the group not receiving amnioinfusion was 38% (relative risk, 0.34; 95% confidence interval, 0.13-0.88; P = .026). Amnioinfusion during labor appears to significantly decrease the incidence of postpartum endometritis in patients subsequently undergoing cesarean delivery.

Analysis of a maternal transport service within a perinatal region.

In 1979, the State of Illinois legislated regionalization of perinatal care. Analysis of perinatal statistics from the Loyola University Perinatal Center from 1979 to 1986 supports: (1) increasing numbers of maternal and neonatal transports, with the number of maternal transports exceeding the number of neonatal transports since 1982; (2) increasing proportion of low birthweight and very low birthweight infants delivered at the perinatal center; (3) a decrease in the number of infants less than 1500 gm sent as neonatal transports; and (4) increasing proportion of neonatal transports with a birthweight greater than 2500 gm. With the change in utilization by local physicians, the perinatal center has expanded its obstetric and neonatal service areas and hired additional staff to meet the increased demand for its services. The perinatal mortality rate for the region has decreased from 1981 to 1986.

Mexilitene use in pregnancy.

Mexilitene, a class 1b antiarrhythmic, was used throughout an entire pregnancy to treat symptomatic premature ventricular contractions in a patient with mitral valve prolapse. Cord blood and maternal serum mexilitene levels at the time of delivery are given. The following conclusions were reached. (1) Mexilitene may have a future in treating pregnant patients with arrhythmias unresponsive to currently approved antiarrhythmic drugs. (2) Evidence to date has shown no adverse affects in infants of mothers breast-feeding while taking mexilitene. (3) Dosages need to be monitored carefully during pregnancy and the postpartum period to ensure that therapeutic drug levels are maintained.

Diagnosis of vasa previa with ultrasonography.

An antepartum diagnosis of vasa previa was considered in a patient in whom ultrasound revealed pulsatile loops of cord overlying the cervical os. This diagnosis was confirmed at the time of cesarean delivery. We offer a literature review of vasa previa and make recommendations for using ultrasonography to diagnose vasa previa.

Prolonged use of tocolytic agents in the expectant management of placenta previa.

The effects of the prolonged use (greater than seven days) of tocolytic agents, along with other established procedures of conservative, expectant management, were studied in 45 patients with either total or marginal-partial placenta previa. Our regimen prolonged pregnancy for seven days or more in 81.2% of total placenta previas and 91.7% of marginal-partial ones. Antepartum hospitalization and shortened neonatal length of stay resulted in a total saving of $18,175 per case. The prolonged use of tocolytic agents, in addition to expectant management, in patients with placenta previa increased the length of pregnancy, decreased neonatal morbidity and was cost effective.

Ultrasonic methods of predicting the estimated date of confinement.

The present study examines the relative accuracy of 2 ultrasonic methods of predicting the estimated date of confinement (EDC). The first technique, mean projected gestational age (MPGA), utilizes 2 fetal biparietal diameter (BPD) readings between 19 and 30 weeks' gestation with at least a 3-week interval between examinations. The 2 values are fitted to the mean of the standard curve as closely as possible and an EDC is predicted. The second method, growth adjusted sonographic age (GASA), is based on 1 BPD measurement in the second trimester and another in the third. The first is plotted on the mean and then readjusted depending on the percentile into which the second falls (below 25, 25 to 75, above 75). The EDC was blindly predicted in 120 patients, 60 by the MPGA method and 60 by the GASA technique. These were compared with 60 controls whose EDCs were predicted on the basis of excellent clinical dates. The interval between the predicted EDC and the actual delivery date was calculated for each patient and the results were compared. There was no statistical difference between the 2 techniques.

Ultrasonic growth patterns in normal and discordant twins.

Prior studies on twin biparietal growth have resulted in conflicting conclusions. This study was designed to establish definitive criteria based on both ultrasonic biparietal diameter (BPD) and newborn anthropometric data for normal versus abnormal growth in multiple pregnancies. Fetal BPD and newborn head circumference values among concordant twins were similar to those of appropriate for gestational age (AGA) singletons at all gestational ages. Singleton standards can therefore be applied to evaluate the adequacy of twin BPD growth even in the third trimester. Ultrasonic criteria for the diagnosis of discordancy include an intrapair difference in BPD of 5 mm or more and an intrapair difference greater than 5% in ultrasonically measured fetal head circumferences. Discordant BPD growth noted prior to the third trimester suggests twin-transfusion syndrome and is associated with a high perinatal mortality. In contrast, divergent BPD growth beginning after 30 weeks' gestation appears to have a better prognosis.