Maternal pre-pregnancy weight and placental weight determine birth weight in normal Jamaican infants

Birth weight is related to neonatal health and long-term risk of chronic disease. Since animal studies have shown that birth outcome is related to placental function, the present project was designed to explore the relationship between birth weight and placental growth and composition with factors during pregnancy among normal term pregnancies in 51 primiparous and 40 multiparous women delivering at the University Hospital of the West Indies. Both groups were followed by 15 weeks of gestation to term. The primiparous group was generally younger than the multiparous (mean age 22ñ4 versus 31ñ5 yr). They were significantly lighter (55ñ8 versus 61ñ9kg) with a lower body mass index (21ñ3 versus 23ñ4kg/m2) during early pregnancy, but gained more weight during pregnancy, 11kg compared with 8 kg, respectively. The duration of pregnancy was similar for both groups. Although the size of the placenta was not significantly different between the two groups, the mean weight of the multiparous placentae was more than that of the primiparous placentae. Also, for all mothers both placental weight and initial maternal weight related directly to birth weight. Placental non collagen protein (NCP), sodium and potassium contents were significantly higher for multiparous women and were related to birth weight. The primiparous group had babies who were significantly lighter, 3.03 kg compared with 3.36 kg, for the multiparous and this could be attributed to differences in placental function and maternal weight. When account was taken of the difference in maternal weight at the start of the pregnancy and the difference in placenta weight, parity no longer explained any of the differences in birth weight. It is concluded that maternal body weight at the time of becoming pregnant and the early development of the placenta determine the efficiency with which nutrients might be delivered to the foetus and hence foetal growth. The difference in birth weight between primiparous and multiparous women can be explained by the differences in maternal weight at the time of becoming pregnant.(AU)

Maternal nutritional status in pregnancy and blood pressure in childhood

OBJECTIVE: To examine the relation between indices of maternal nutrition during pregnancy, including haemoglobin concentration, skinfold thickness and body weight, and the child's blood pressure at 10 to 12 years of age. DESIGN: Follow up study of children whose mothers had haemoglobin estimations, weights and skinflod thickness recorded during pregnancy. SETTING: Kingston, Jamaica. SUBJECTS: Seventy-seven children whose mothers took part in a prospective study of nutrition during pregnancy in relation to fetal growth. MAIN OUTCOME MEASURE: Blood pressure at 10 to 12 years of age. RESULTS: The child's mean systolic pressure adjusted for current weight rose by 2.6 mmHg (95 percent CI 0.5-4.6, P = 0.01) for each 1 g/dl fall in the mothers's lowest haemoglobin suring pergnancy. Mothers with a lower haemoglobin had thinner skinfold thickness, especially over the triceps (P=0.005). In multiple regression analyses, taking account of the child's sex and current weight, there was a strong association between thin maternal triceps skinfold thickness at 15 weeks of gestation and raised blood pressure in the offspring. Taking account of the mother's tricep skinfold thickness abolished the relation between lower haemoglobin and raised blood pressure in the child. Lower weight gain between 15 and 35 weeks of gestation was independently associated with raised children's blood pressure. Systolic pressure rose by 10.7 mmHg (95 percent CI 5.7 to 15.6, P= 0.0001) for each log mm decrease in the mother's triceps skinfold thickness, and by 0.6 mmHg (95 percent CI 0.1 to 1.0, P = 0.02) for each 1 kg decrease in the mother's weight gain during pregnancy. CONCLUSION: These results parallel animal experiments suggesting that impaired maternal nutrition may underlie the programming of adult hypertension during fetal life (AU)

Experience with colposcopy and conization

110 cervical conizations were performed on patients from the University Hospital and the Jamaica Cancer Society following coloscopic biopsies. In the group of CIN III lesions (carcinoma-in-situ) the diagnostic accuracy of the biopsies was 92 percent compared to the cone biopsy diagnosis. The cone specimens revealed 2 cases of microinvasive, one case of frank invasion and 4 cases of "chronic cervicitis with moderate dyplasia (CIN II)" not recognized at colposcopy. The conization was reported as therapeutic in 71 cases (80.7 percent). Of those cases described as less than adequate total abdominal hysterectomy was performed on three patients: the histology on the specimens showed 1 case of persistent carcinoma-in-situ and no residual disease in the other two. In our clinics the colposcopic procedure has a diagnostic accuracy of 92 percent and cone biopsy of the cervix has proved a useful adjunct in selected cases in the management of intraepithelial lesions of the cervix. (AU)

Thrombocytopenia in severe pre-eclampsia and eclampsia - abstract

A retrospective study was conducted on 15 cases of eclampsia and 9 cases of severe pre-eclampsia to record the incidence of thrombocytopenia in these cases and to evaluate its clinical significance. Thrombocytopenia occurred in 8 of the 15 eclamptics and 5 of 9 severe pre-eclamptics. Tests for other coagulation defects revealed the frequent association of thrombocytopenia, hypofrinogenaemia and prolonged prothrombin time. The clinical significance is discussed (AU)

Hyperinsulinaemia accompanies the development of pre-elcampsia - abstract

Hyperinsulinaemia with insulin resistance has been observed in pre-eclampsia. In this longitudinal study, we examined whether this state of insulin resistance preceded the development of eclampsia. At 12, 24 and 36 weeks of gestation and at 12 weeks post-partum in twenty-five primigravidae, insulin and glucose were measured in the fasting state and in samples collected during intravenous glucose tolerance tests (IVGTT). Five women were diagnosed as pre-eclamptic (PE) at 34 - 39 weeks' gestation. In these PE, there was hyperinsulinaemia in the fasting state at 24 weeks compared to the normal pregnant (NP) women, 20.07 ñ 8.31 mU/ml vs. 13.74 ñ 5.64 mU/ml, (p<0.05). The degree of hyperinsulinaemia increased and, at 36 weeks' gestation it was 26.4 ñ 7.7 mU/l in the PE compared to 13.1 ñ 6.1 mU/l in the NP, (p<0.0001). The sensitivity of this measure for predicting pre-eclampsia at mid-pregnancy (24 weeks) was 80 per cent which increased to 100 per cent in late pregnancy (36 weeks). The specificity of this measure went from 57 per cent in mid-pregnancy to 43 per cent in late pregnancy. The glucose levels in the fasting state were not different at any time in the study. In the IVGTT, the area under the insulin curve was significantly larger in the PE as a group compared to the NP, (p<0.05). The area under the glucose curve was not different between the two groups at any time. The rate of disappearance of glucose Kg was significantly larger in the PE as a group compared to the NP, (p<0.05). Hyperinsulinaemia in the fasting state precedes the development of pre-eclampsia. It has a high sensitivity but low specificity for predicting the development of pre-eclampsia. Hyperinsulinaemia in the fasting state may have some value in screening those primigravidae at risk for developing pre-eclampsia (AU)

Glanzmann's thrombasthenia and pregnancy

Glanzmann's thrombasthenia is a rare congenital disorder of platelet function manifesting as defective primary haemostasis. Bleeding episodes often require platelet transfusions, and allo-immunization to donor platelets may occur. The problems of ensuring adequate haemostatic potential for delivery of an allo-immunized pregnant female with Glanzmann's thrombasthenia are presented (AU)

Plasma zinc levels throughout pregnancy: a study in Jamaican women with relevant aspects of nutrition - abstract

In a prospective study, plasma zinc levels were determined by atomic absorption spectrophotometry in 135 Jamaican women over a two-year period. A total of 1,237 such determinations were made at fixed intervals throughout pregnancy. Zinc being an essential trace element with a wide physiological role in many aspects of metabolism, supplementary studies on the relationship between zinc, folic acid, vitamin A and dietary intake in general were undertaken. Results (Table) show that plasma zinc levels were lowered during pregnancy, moreso during the second trimester: the levels rise significantly during labour and then fall rapidly towards normal during the puerperium. Daily dietary zinc intake was of the order of 8-10 mg/day (the RDA for pregnancy being 15 mg/day) while protein intake averaged 67 gm/day (the RDA for protein being 80-90 gm/day). Clinical and laboratory investigations revealed no signs of any dietary deficiency among the patients. Average weight gain in pregnancy was 12 kg. Plasma, vitamin A and red cell folate levels were within normal ranges in all patients, indicating that there was no state of zinc deficiency interfering with the absorption of these vitamins. Viewed together, all the facts of this study suggest that the pattern of the fall of plasma zinc in pregnancy is a normal physiological change not related to socio-economic status, parity or age. It is concluded that the lowered plasma zinc observed in pregnancy does not reflect a state of true deficiency nor even a state of inadequate dietary zinc intake; it is most likely due to the heavy demand for zinc in the developing foetal tissues and by the expanding maternal blood volume (AU)

Dietary patterns and nutrition in pregnancy in Jamaica

During a study of nutrition in pregnancy, the diets of 108 Jamaican pregnant women were assessed by single 24-hour recalls. The women were 16-45 years old, of mixed parity (0-9), attended private (23 percent) and public (77 percent)antenatal clinics and differed in stage of pregnancy at interview. Mean energy intake (2110ñ739 kcal/d) was low, 83 per cent of the average Recommended Dietary Allowance for the Caribbean (CFNI 1976). Most (76 percent) women had low energy and dietary iron (75 percent) intakes. Fewer women had low riboflavin (42 percent) or protein intakes (29 percent). Maternal age, parity, obstetric performance, and unusual cravings influenced maternal nutrition to some extent. Dietary assessments overestimated the risk of maternal malnutrition. (AU)

Glucose tolerance in pre-eclampsia - abstract

In normal pregnancies (NP), carbohydrate metabolism as assessed by oral glucose tolerance is impaired. This study was aimed at assessing whether a complication of pregnancy, pre-eclampsia (PE), exacerbates this impairment of carbohydrate metabolism. Results showed that the fasting plasma glucose levels were not significantly different between the PE (4.62ñ0.27 mM/1) and the NP (4.12ñ0.08 mM/1). However, the fasting plasma insulin levels were significantly higher in the PE (28.4ñ5.9 uU/m1) than in the NP (9.6ñ2.3 uU/m1) (p<0.01). Analysis of the area under the curve showed that the glucose response curves were not significantly different. The insulin response curves displayed a trend of higher circulating insulin levels in the PE compared to the NP; (p<0.07). The insulin to glucose ratio, an index of insulin sensitivity, in the PE (6.21ñ1.37) was significantly higher than that of the NP (2.26ñ0.54) p<0.05). We suggest that the hypertensive complication of pregnancy, PE, is accompanied by hyperinsulinaemia in the basal or fasting state, with an accompanying insulin insensitivity (AU)

A technique of "limited" cone biopsy of the cervix under local anaesthesia - abstract

One hundred and fifteen biopsies of the cervix were performed by a new technique which can be described as "limited cone biopsy" used for the evaluation of the abnormal "Pap" smear. Patients were selected from those attending the Jamaica Cancer Society Screening Clinic for carcinoma of the cervix. The criteria for cone biopsy were (1) a history of repeated pap smear, (2) cases with colposcopic biopsies demonstrating a significant degree of dysplasia, and (3) colposcopic examination showing the squamo-columnar junction to be high up in the cervical canal. The new surgical technique "limits" the depth of excised tissue to 4 mm. This limitation, aided by special instruments, avoids troublesome haemorrhage and allows the procedure to be performed under local anaesthesia. It restricts hospital stay to two days. The study showed the following: (1) that intravenous Pethidine and Valium provided adequate analgesia for all but seven cases, (2) blood loss at operation was minimal, exceeding 20 ml in only 3 cases, (3) 97 per cent of the patients were fit to be discharged after 32 hours in hospital, (4) the tissue samples were adequate for full histological study in all but three cases and (5) the pathology reports on the specimens which showed the following results (shown in table). It is concluded that the "limited" cone biopsy carries less morbidity than the conventional technique. The use of local anaesthesia and the short hospital stay recommended it highly for developing countries with scarce medical and financial resources (AU)

Intrapartum infusion of oxytocin and glucose water and neonatal jaundice

Two hundred and seventy-eight deliveries were studied prospectively to determine the association between the use of oxytocin during labour and the incidence of neonatal jaundice. Jaundice was seen significantly more often in neonates following maternal infusion of oxytocin in dextrose water (OT) or dextrose water alone (DW) as compared to those whose mothers did not receive either. No significant difference was seen in the incidence of jaundice between OT or DW groups. Mean umbilical cord serum sodium levels were significantly lower in the OT and DW group neonates who became jaundiced, as compared to the rest of the neonates in the same group and the control group. Sixty per cent of the jaundiced neonates in the OT as well as the DW group had frank hyponatremia as compared to only 8 percent in the control group. These findings support a probable causative association between hyponatremia at birth and neonatal jaundice in the deliveries following dextrose water and/or oxytocin infusion (AU)

Follow-up of abnormal cervical cytology: a Jamaican experience - abstract

Prevalence rates for preclinical cancer in different countries depend upon efficiency of screening programmes, the quality of cytological services and the level of gynaecological expertise in colposcopy, cyrosurgery and cone biopsy of the cervix. The Jamaica Cancer Society, which screens over 6,000 patients annually, provides ample clinical material for the study of the effectiveness of these services in Jamaica. Of 202 patients, with Class III pap smear reports, referred for colposcopic evaluation, the repeat smears taken at colposcopy were reported as follows: 18 - Class I; 32 - Class II; 134 - Class III; and 18 - Class IV. That is, there was consistency in about 66 percent. In 46 cases of Class IV smears, the repeat smear was confirmatory in 26 cases (56 percent). These data argue strongly for early follow-up of all cases of Class III reports. Colposcopy revealed 8 cases of carcinoma-in-situ from 120 Class II smears; there were 15 cases of invasive cancer from 46 Class IV smears. Of 14 Class V smears, 10 were confirmed as invasive and four downgraded to carcinoma-in-situ. In 252 patients, cone biopsies were performed on those who had already had colposcopic biopsies done. In roughly 83 percent of these cases, the colposcopic and cone biopsy reports were in agreement. In our series, the relationship between cytology, colposcopy and cone biopsy gives a false-negative cytology rate of 16 percent and a false-positive rate of 4 percent. A review of the literature shows that the false-negative rate varies between 6 percent and 28 percent in some large series. Prevalence for carcinoma-in-situ in this study was 18/1000, compared with 3.7/1000 reported from the United States and 7.0/1000 from Scotland (AU)

Pregnancy in chronic active hepatitis with cirrhosis

Pregnancy in chronic active hepatitis and cirrhosis is rare. There is an appreciable perinatal mortality and the effect of pregnancy on the underlying liver disease remains uncertain. Two patients with autoimmune chronic active hepatitis with cirrhosis who became pregnant during an active stage of their disease while on therapy are described. Both had an uneventful pregnancy with successful deliveries. One of the patients had two other prenancies but the pregnancy had to be terminated because of clinical deterioration. With close supervision patients with chronic active hepatitis and cirrhosis may have successful pregnancies. (AU)

Rupture of uterus and bladder in vaginal delivery following previous caesarean section

A case of ruptured uterus and bladder in the fifth pregnancy with a previous uterine scar from the first pregnancy is presented. Though vaginal delivery post-Caesarean section is accepted, no criteria as to the number of such births be allowed have been established. We recommend that no more than three such births be allowed. Some guidelines for management are suggested (AU)

Whole-body protein turnover in Jamaican women during normal pregnancy

A cross-sectional study was carried out among 18 Jamaican pregnant women divided in three groups of 6 subjects according to the stage of pregnancy: group B, 12 weeks, group C, 24 weeks and group D, 33 weeks. A group (group A) of 6 non-pregnant women was selected as control. The rate of whole-body protein turnover was measured by continuous oral administration of 15N-glycine and the resting metabolic rate by the open circuit method. All subjects had a normal pregnancy outcome. The composition of the diet on the day of the study was comparable between the four groups (approximately 80 g protein and 9.45 MJ energy) and not significantly different from the composition of the diet during the 2 d prior to the experiment. The rates of protein synthesis and breakdown were higher in groups Band C compared to group A and lower in group D where they reached values slightly higher than in group A. Estimated from urea enrichment, these rates did not vary significantly among the groups, while estimated from ammonia enrichment the difference was significant (P less than 0.05) and there was a negative correlation between the gestational age and the rate of snythesis (r= -0.63) and breakdown (r= -0.69). Nitrogen retention was comparable between the three groups of pregnant women and significantly higher than in the group A. The resting metabolic rate was similar between the groups of pregnant women. These results suggest that the rates of protein turnover observed during gestation reflect more the changes that occur in maternal than those in fetal tissues. The values for protein synthesis and nitrogen retention indicate that the amount of protein deposited during pregnancy is greater than that expected on the basis of body composition analysis. It is also suggested that as pregnancy proceeds whole-body protein turnover represents a smaller part of the resting metabolic rate. (AU)

Follow-up of cervical neoplasia using colposcopy and cytology - abstract

The natural history of cervical neoplasia is still not clearly determined. One way of clarifying the issue is to follow a cervical lesion with cytology and colposcopic biopsies over a period of time. Two hundred and fifty cases - mild dysplasia (110), moderate dysplasia (74), and severe dysplasia (66) - were reviewed at intervals over a period of time varying between three and five years. Biopsies were taken only when a cytological and/or colposcopic pattern suggested progression to a more severe lesion. Progression rates were follows: mild dysplasia - 15 percent; moderate dysplasia - 32 percent; severe dysplasia - 45 percent. The regression rates were as follows: mild dysplasia - 48 percent; moderate dysplasia - 32 percent; severe dysplasia - 20 percent. Fifteen patients had a hysterectomy for intraepithelial neoplasia diagnosed on colposcopic biopsy. Three of these with severe dysplasia had carcinoma-in-situ in the hysterectomy specimen. No case diagnosed as carcinoma-in-situ showed invasive cancer in the hysterectomy specimen. Twenty-seven cases underwent hysterectomy for treatment of carcinoma-in-situ diagnosed by cone biopsy and one of the hysterectomy specimens showed an invasive lesion. Twenty cases had therapeutic conization for a colposcopic diagnosis of severe dysplasia or carcinoma-in-situ. None had invasive cancer (AU)

Plasma zinc levels throughout pregnancy: a study in Jamaican women, with relevant aspects of nutrition

In a prospective study plasma zinc levels were determined by atomic absorption spectrophotometry in 135 Jamaican women over a two year period. A total of 1237 such determinations were made at fixed intervals throughout pregnancy. Each patient was investigated at 15, 20, 25, 30, 35 and 38 weeks gestation, in labour, and once in the early and in the late puerperium. Zinc being an essential trace element with a wide physiological role in many aspects of metabolism, supplementary studies on the relationship between zinc, folic acid, vitamin A, dietary intake in general, taste acuity and weight gain in pregnancy were undertaken. Results show that plasma zinc levels are lowered during pregnancy, moreso during the second trimester. The levels rise significantly during labour and then fall rapidly towards normal during the puerperium. Daily dietary zinc intake was of the order of 8-10 mg/day (the RDA for pregnancy being 15 mg/day) while protein intake averaged 67 g/day (the RDA being 80-90 g/day). Average weight gain in pregnancy was 12 kg. Plasma vitamin A and red cell folate levels were within normal range in all patients, indicating that there was no state of zinc deficiency interfering with the absorption of these vitamins. Clinical observations and laboratory investigations revealed no signs of any dietary deficiency among the patients. Viewed together, all the facets of this study suggest that the pattern of fall of plasma zinc in pregnancy is a normal physiological change not related to socio-economic status, parity or age. It is concluded that the lowered plasma zinc observed in pregnancy does not reflect a state of true zinc deficiency nor even a state of inadequate dietary zinc intake; it is most likely due to the heavy demand for zinc in the developing fetal tissues and by the expanding maternal blood volume (AU)

Intrapartum infusion of aquenous glucose solution, transplacental hyponatraemia and risk of neonatal jaundice

Cord serum sodium levels in three groups of 278 singleton infants, born vaginally at term, were correlated with the incidence of jaundice (serum bilirubin o85æmol/1) in the first 3 days of life. Of the 278 infants, 87 were born to mothers who were given infusions of 5 percent or 10 percent glucose in water during labour (group I), 90 were born to mothers who received glucose solution as a vehicle for oxytocin (group II), and 101 to mothers who did not receive any intravenous fluid therapy (control group). Jaundice was seen significantly more frequently in groups I (28/87, 32 percent) and II infants (30/90, 33 percent) than in the control group (12/101, 12 percent) (P<0.01), but when analysed in relation to cord serum sodium levels, the prevalence of jaundice in the normonatraemic infants (serum sodium o131 mmol/1) was similar in the three groups. On the other hand, in groups I and II jaundice occurred about 3.5 times more frequently in the hyponatraemic infants (group I (17/32, 53 percent) and II (20/39, 51 percent) than in the normonatraemic infants (P<0.01). The difference was not associated with any other perinatal or neonatal characteristic.(AU)