Patterns of uterine activity. Using oxytocin after intracervical PGE2.

OBJECTIVE: To compare patterns of uterine activity from low-dose oxytocin begun immediately or six hours after intracervical placement of prostaglandin E2 (PGE2) gel for the induction of labor. STUDY DESIGN: A total of 50 nonlaboring women at term with an unfavorable cervix (Bishop score < or = 4) were given a 0.5-mg dose of PGE2 gel. Each was then randomized either to be observed or to receive a low dose of oxytocin (2 mU/min, increased by 2 mU/min at 30-minute intervals, as necessary). After the six-hour observation, the patient was reexamined, and a low dose of oxytocin was either begun or continued. An adequate sample size (21 per group) was calculated for evaluating uterine activity changes. Comparisons were made using chi 2 testing, Student's t test and analysis of variance, as appropriate. RESULTS: There were no differences between the two groups in maternal race, gestational age, predose Bishop score, predose uterine activity or indication for induction. Uterine contractions became more frequent (P < .01) and were judged to be more intense (P < .02) and earlier when oxytocin was used immediately after PGE2 placement. No uterine hyperstimulation or abnormal fetal heart rate pattern was observed that required discontinuation of the oxytocin. The percentages of cases delivering vaginally within 24, 36 and 48 hours were greater when oxytocin was begun immediately in nullipara (P < .01). CONCLUSION: Low-dose oxytocin may be started immediately after instilling intracervical PGE2, with shortened time until the onset of adequate contractions.

Managing pregnancy-related nocturnal nasal congestion. The external nasal dilator.

OBJECTIVE: To assess the efficacy of an over-the-counter mechanical nasal dilator during sleep in pregnant women with nasal congestion. STUDY DESIGN: Pregnant women with symptoms of nocturnal nasal congestion not attributed to allergies or "cold" symptoms were randomized in a double-blind manner to receive either a spring-loaded device or placebo device without a spring. Each patient assessed breathing and sleep quality for a three-day baseline and three-day treatment period. A 10-question diary was utilized to assess breathing, ease of falling asleep, sleep quality, and continuity and depth of sleep. Averaged scores for each question were computed for baseline and treatment periods, and differences were calculated. Statistical analyses were by the sign test, Fisher's exact test and Student's test. RESULTS: Thirty-four (21%) of 160 screened patients were enrolled into the study; 24 (15%) completed the study. All agreed to being assigned to receive either the spring-loaded device (n = 12) or a placebo (n = 12) device. Responses to 8 of the 10 questions favored the former as compared with the placebo (P = .05, sign test). Moreover, patients treated with the spring-loaded device gave more favorable responses to the question, "Overall, compared with most nights, how easy was your breathing through-out last night?" (P = .02, t test). CONCLUSION: Use of this drug-free external nasal dilator improved the ease of breathing among patients with pregnancy-related nocturnal congestion.

Blood pressure monitoring during pregnancy. Accuracy of portable devices designed for obese patients.

OBJECTIVE: To compare the accuracy of three commercially available blood pressure monitoring devices having cuffs placed at different anatomic sites on obese pregnant women with large arms. STUDY DESIGN: Fifty-five obese pregnant women (body mass index > 27.3) were eligible for participation; each had an upper arm circumferences > 35 cm. The three different portable devices compared had cuffs that fit easily around either the index finger, wrist or large arm. Two recordings using each device were compared with those obtained simultaneously using a well calibrated monitor. RESULTS: Systolic, diastolic and mean arterial pressure recordings did not correlate between the monitor and devices with the cuff around the finger (r2 = .17, .17, .22), wrist (.30, .24, .33) or large arm (.44, .26, .40). The percentages of measurement differences within 5 mm Hg for the systolic, diastolic and mean arterial pressure were low for the device with the cuff around the finger (11.0%, 25.5%, 23.6%), wrist (33.0%, 46.4%, 35.5%) or large arm (38.5%, 29.4%, 46.7%). CONCLUSION: Despite their commercial appeal, none of these portable blood pressure monitoring devices was accurate for use by obese pregnant patients with large arms.

Effects of intracervical prostaglandin E2 on fetal heart rate and uterine activity patterns in the presence of oligohydramnios.

OBJECTIVE: Our purpose was to compare fetal heart rate patterns and uterine activity before and after preinduction prostaglandin E2 administration in the presence or absence of oligohydramnios. STUDY DESIGN: In a retrospective case-controlled review we examined cases in which prostaglandin E2 (Prepidil) was inserted intracervically for gravid women requiring an induction of labor in the presence of either oligohydramnios (amniotic fluid index < or = 5.0) or adequate fluid (amniotic fluid index 5.1 to 23.9). Uterine activity and fetal heart rate tracings that were begun 1 hour before and continued for 6 hours after dosing were interpreted without knowledge of amniotic fluid volume. RESULTS: Cases in the oligohydramnios (n = 51) and adequate fluid (n = 49) groups were the same for maternal age, race, parity, gestational age, and predose Bishop score. Patients with oligohydramnios had more high-amplitude contractions in the first hour after dosing (9.0 +/- 1.2 vs 6.1 +/- 0.9, p < 0.05), but there were no significant differences in the frequency or duration of contractions during the subsequent 5 hours. Uterine hyperstimulation was not seen, and there were no differences in the frequency of variable or late fetal heart rate decelerations. CONCLUSION: For pregnancies undergoing preinduction cervical ripening with intracervical prostaglandin E2, the presence of oligohydramnios was not associated with a greater risk of fetal heart rate decelerations, although contractions were more common during the first hour after dosing.

Off-label drug prescribing on a state university obstetric service.

Off-label drug use occurs when physicians prescribe a drug recommended for indications other than those listed on the prescription labeling. The purpose of the present investigation was to describe patterns of off-label drug use during pregnancy, including the types of drugs and their timing of use. All study pregnancies had to receive prenatal care at our state university clinics before 14 weeks' gestation and deliver at our institution during a five-month period. Prenatal records were reviewed, and subjects were interviewed after delivery. A total of 165 (22.6%) of the 731 eligible subjects took > or = 1 (average 1.7, 95% confidence interval 1.3-3.8) drugs for off-label indications. Nearly all drugs were taken for a short term during the third trimester. The primary purposes were to avoid an obstetric complication (premature labor and delivery, preeclampsia/eclampsia) or improve the capacity for eventual postnatal adaptation. Despite discussions with patients, on no occasion was it recorded on the chart that the patient was informed that the drug was recommended for an off-label indication. Results from this study should help drug manufacturers, insurance companies and federal regulatory agencies understand the common use of recommending certain drugs for off-label indications during pregnancy.

Diagnosis of Menètrier's disease with Tc-99m human serum albumin scintigraphy.

Technetium-99m labeled human serum albumin has been shown to detect protein leakage into the bowel. A case of a young adult is presented with endoscopic and pathological correlation of scintigraphic findings supporting Menètrier's disease.

Double-blind comparison of intracervical and intravaginal prostaglandin E2 for cervical ripening and induction of labor.

OBJECTIVE: Our purpose was to compare the safety and effectiveness of prostaglandin E2 delivered sequentially as an intracervical (0.5 mg) or intravaginal (2.5 mg) gel. STUDY DESIGN: Hospitalized patients with an unfavorable cervix (Bishop score < or = 4) at > or = 35 weeks and requiring induction of labor were assigned to receive two 2.5 ml doses of gel intracervically and intravaginally in a double-blind, placebo-controlled manner. Second and third doses were given at 6-hour intervals until there were either regular uterine contractions or a Bishop score change > 3 points. RESULTS: The 100 evaluable cases received prostaglandin E2 either intracervically (n = 52) or intravaginally (n = 48). Difficulty with exact gel instillation was present with intracervical gel only, where spillage occurred in 85% of cases. Compared with intracervical therapy prostaglandin E2 given intravaginally was more likely to significantly change the Bishop score (60.4% vs 40.4%, p = 0.04) and stimulate regular contractions (72.9% vs 48.1%, p = 0.01). Uterine hyperstimulation was present in one case in each group. CONCLUSION: Although each was safe, instillation of prostaglandin E2 gel was better at a higher intravaginal dose than a lower intracervical dose because of its greater ease of administration and higher likelihood of cervical change.

Double-blind comparison of intravenous butorphanol (Stadol) and fentanyl (Sublimaze) for analgesia during labor.

OBJECTIVE: Our purpose was to compare the analgesic properties, effect on labor, and maternal-fetal side effects of intravenous butorphanol and fentanyl. STUDY DESIGN: One hundred patients with uncomplicated term pregnancies were enrolled during early active labor. Each patient received standard doses of either fentanyl (50 to 100 micrograms) or butorphanol (1 to 2 mg) hourly on request in a double-blind manner. Pain was scored independently by the nurse and patient with a 10-point visual analog scale. Categoric and measurement data were collected for comparison of the effects on uterine activity, maternal and fetal well-being, and neonatal outcomes. RESULTS: The fentanyl (n = 50) and butorphanol (n = 50) groups were identical with respect to maternal age, race, parity, and weight. Greater improvement in pain relief was found after the first dose of butorphanol than after fentanyl (p < 0.05). When fentanyl was given, either more doses were necessary (3.2 +/- 1.3 vs 2.1 +/- 1.1, p < 0.01) or epidural analgesia was requested more often (16%, 32% vs 9%, 18%, p < 0.05). Uterine contraction patterns for the first hour after dosing were unchanged, and the duration of the first and second stages of labor were not different between the two groups. No differences in maternal or newborn adverse effects were observed. CONCLUSIONS: Both drugs were equally safe and without effect on active labor. Butorphanol provided better initial analgesia than fentanyl with fewer patient requests for more medication or epidural analgesia.

Short-term effects of inhaled albuterol on maternal and fetal circulations.

Short-term circulatory effects with the maximum recommended dose of inhaled albuterol (Proventil) were studied on 12 asthmatic patients between 33 and 39 weeks' gestation. The mean maternal blood pressures and heart rates, systolic/diastolic ratios of the uterine arcuate and umbilical arteries, and fetal heart rates and aortic velocities were unaffected during the first 2 hours after dosing.

Adenomyosis as seen on blood flow and blood pool imaging during bone scintigraphy.

A 42-year-old woman presented with intermittent low back and left lower extremity pain. The blood flow and blood pool images of bone scintigraphy showed a large focus of increased activity in the right lower abdomen. Computed tomography showed an enlarged uterus displaced to the right side of the pelvis. At surgery, the uterus was found to be involved with adenomyosis. Three-phase bone scintigraphy consisting of blood flow and blood pool images over the anterior pelvis may be a valuable diagnostic aid in the evaluation of lower back or pelvic pain of a woman.

Serendipitous finding of transitional cell carcinoma of the kidney on bone and gallium imaging.

A 50-year-old woman presented with low back pain. Bone scintigraphy showed a focus of increased activity in the upper pole of the left kidney. Subsequent Ga-67 citrate scintigraphy demonstrated this same abnormal focus as a region of increased activity. Ultrasonography showed a renal mass in the upper pole of the left kidney. At surgery a transitional cell carcinoma of the upper pole of the left kidney was found.

One-dose technetium-99m pertechnetate imaging in acute testicular torsion followed by manual detorsion.

The role of technetium-99m pertechnetate imaging in acute testicular torsion is well appreciated. Manual testicular detorsion under local anesthesia may be performed in the nuclear medicine clinic by the urology service immediately following initial diagnostic scintigraphy. Following manual testicular detorsion, continued images of the testes are obtained up to 30 minutes without having to reinject the patient with technetium-99m pertechnetate. Reperfusion of the affected testicle will be dramatically noted if the manual detorsion is successful. Four cases are presented to illustrate this.

Gallbladder perforation seen on hepatobiliary imaging following morphine sulfate injection.

A case of gallbladder perforation imaged during morphine-augmented cholescintigraphy is presented. Tc-99m DISIDA imaging dramatically demonstrated the bile leak. Whether morphine sulfate contributed to the perforation of the gallbladder is debatable.

Nuclear imaging in Coccidioidal osteomyelitis.

Six cases of osteomyelitis due to Coccidioides immitis are presented. The cases reported demonstrate the importance of performing both bone and gallium imaging to avoid missing the osseous coccidioidal lesions.