Myocardial function and hemoglobin oxygen affinity during hyperglycemia in the fetal lamb.

To determine the effects of maternal hyperglycemia on fetal hemodynamic and cardiac function, a study was carried out on nine chronically catheterized fetal sheep. In six fetuses, glucose was infused intravenously with an initial dose of 5 mg/kg per min. Data were compared with controls. This dose was gradually increased to 16 mg/kg per min by the fifth day. The initial blood glucose was 14.7 +/- 3.0 mg/dl and increased to 54.6 +/- 16.4 mg/dl by the last day of the infusion period (P less than 0.001). The PO2 decreased from a baseline of 20.25 +/- 3.40 to 15.88 +/- 5.24 mmHg (P less than 0.01). Similarly significant decreases were also observed for the blood O2 content and O2 hemoglobin saturation: 8.5 +/- 1.7 to 6.4 +/- 2.2 ml/dl and 62.3 +/- 13.6 to 46.1 +/- 17.6%, respectively, during hyperglycemia (P less than 0.01). The duration of the preejection period (PEP) before the start of the experiment was 45 +/- 4 ms; a final value of 57 +/- 10 ms was obtained (P less than 0.01). However, the electromechanical delay and ejection time (ET) showed no significant variation. The ratio of the PEP/ET increased from 0.31 +/- 0.04 to 0.38 +/- 0.07 (P less than 0.01) during hyperglycemia. The reticulocytes increased from 1.4 +/- 1.8 to 3.1 +/- 2.9% (P less than 0.05) and the 2,3-diphosphoglycerate decreased from 4.4 +/- 1.1 to 2.8 +/- 1.2 mumol/g hemoglobin (P less than 0.005). This study demonstrated that fetal hyperglycemia depresses myocardial function in the fetal lamb. The changes in cardiac function could not be explained by the small drop in O2 saturation.

[A myocardial infarction during pregnancy treated by percutaneous transluminal coronary angioplasty and stent implantation. Case report]. / Infarctus myocardique durant la grossesse: à propos d'un cas traité par angioplastie transluminale percutanée et implantation d'un stent coronarien.

Acute myocardial infarction is an un-frequent event during pregnancy. It clearly causes an increase in both maternal and fetal mortality. We describe a case of pregnancy complicated during the second trimester by an acute myocardial infarction witch was treated by percutaneous transluminal coronary angioplasty combined with stenting. The challenge involved in managing this condition during pregnancy is briefly discussed.

The immunocytochemical versus cytosol measurement of the oestrogen receptor in invasive breast cancer tissue.

To compare two methods of measurement of oestrogen receptor (ER)-expression in invasive breast cancer tissue. Sections from 299 breast cancer cases were stained for the ER by immunocytochemical assay (ICA), using mouse monoclonal antibody (MAb) NCL-ER-6SF11, and by the dextran-coated charcoal assay (DCC). Concordant results were observed in 230 of the 299 cases (77%), 69 patients had discordant results (kappa=0.537). We found a moderate concordance between ICA and DCC for ER measurement in breast cancer tissue. If we change the golden standard from DCC to ICA, 23% of patients would receive a different therapeutic approach.

Circulatory changes in newborn lambs with experimental polycythemia: comparison between fetal and adult type blood.

Hemodynamic effects of increased hematocrit were compared in two groups of newborn lambs. In the first group (fetal type blood), exchange transfusions were carried out using packed red blood cells obtained from newborn lambs within one to two hours after birth. In the second group (adult type blood), the same procedure was carried out using adult sheep blood. In both groups, hematocrit values ranging between 70% and 80% were reached. The increase in hematocrit caused a decrease in cardiac output due to an increase in peripheral resistance. Pulmonary resistance increased more than systemic resistance. However, the increase in pulmonary resistance was significantly greater in the polycythemic newborn lambs with adult blood. A right-to-left shunt through a patent ductus or a foramen ovale was noted in six of the eight lambs included in this group. On the other hand, none of the seven polycythemic newborn lambs with fetal blood developed signs of right-to-left shunting. It is concluded that during neonatal polycythemia, the level of hematocrit is not the sole factor responsible for the hemodynamic changes observed. Other unknown influences related either to the red cells or the plasma must impinge upon the pulmonary circulation to alter vascular resistance.

Pregnancy and dialysis.

The outcome of pregnancy in patients with end-stage renal failure has long been considered to be extremely poor, and the literature concerning pregnancy while on dialysis is rather scarce. We reviewed the records of five pregnancies in dialysis patients and performed a national survey on this topic. The dialysis technique and dialysis dose, the effects of erythropoietin (EPO), and the evolution of blood pressure levels in our patients are presented. The dose of EPO had to be increased to maintain the hemoglobin level at 10 to 11 g/dL. There was no case of EPO-related hypertension and no need for transfusion. The obstetric data of the national survey, including our own patients, were analyzed. The incidence of pregnancy going beyond the first trimester was 0.3 per 100 patient-years (15 cases in 1,472 females of childbearing age treated, for a total of 4,545 patient-years). In all but one patient initiating pregnancy while already on dialysis, the frequency and dose of dialysis were increased (to a weekly Kt/V of six to eight in our personal cases). The outcome was successful in 50% of pregnancies occurring in hemodialyzed patients and in 80% of patients who started dialysis after initiation of pregnancy. Polyhydramnios was found in eight of 13 cases and growth retardation in two of nine cases. The incidence of low birth weight and prematurity was 100%, and cesarean section was performed in 66% of successful pregnancies. In successful pregnancies, we found a correlation between birth weight and dose of dialysis. Our findings confirm the remarkable improvement in the prognosis of pregnancy in dialysis patients in recent years.

The cesarean delivery rate can be safely reduced in a developing country.

In an attempt to reduce the cesarean rate without adverse effect on outcome, new guidelines for the management of dystocia, previous cesarean delivery, fetal distress, and breech presentation were introduced in September 1984 in a provincial hospital in Zimbabwe, Africa. Comparison of the 2-year periods before and after September 1984 showed that the cesarean rate had dropped from 16.8 to 8.0%, the maternal mortality rate from 202 to 57 per 100,000 births, and the perinatal mortality rate from 71.9 to 56.2 per 1000 births. During the latter period, use of oxytocin increased from 3.4 to 17.4%. These findings suggest that the adoption of strict guidelines can lead to a decrease in the cesarean rate and an improvement in obstetric outcome.

Low levels of blood alcohol and fetal myocardial function.

In ten experiments carried out on five chronically catheterized pregnant ewes (130 to 140 gestational days), 0.8 ml/kg absolute ethyl alcohol was injected into the mothers over a ten-minute period. Peak maternal and fetal alcoholemia levels were 1.1 +/- 0.1 and 0.9 +/- 0.04 g/L, respectively. Blood gases (arterial PO2, PCO2, pH, and arterial O2 content), cardiovascular parameters (heart rate, arterial pressures), and fetal myocardial function (systolic time intervals) were studied at basal state and during the four hours after injection. To observe changes in fetal O2 affinity, 2-3 diphosphoglycerate concentration and P50 were assessed before and at the peak of blood alcohol level. Maternal and fetal blood ethyl alcohol levels correlated closely (r2 = 0.9512) during all experiments. A small increase in the fetal arterial pH and a decrease in maternal PCO2 was observed just after the injection. This low level of fetal blood alcohol caused a moderate but significant decrease in myocardial contractility as judged by the changes in systolic time intervals. There was no alteration of other cardiovascular parameters and of hemoglobin oxygen affinity.

Perinatal complications of gestational diabetes: the influence of the timing of the diagnosis.

One hundred and thirty-nine single pregnancies complicated by gestational diabetes (GD) were reviewed. All pregnancies were treated by dietary counselling and insulin was restricted to those who presented an abnormal fasting or postprandial glycemia. Obstetrical and neonatal morbidity were evaluated according to the timing of the diagnosis of GD. Preterm labor, preeclampsia, cesarean section, macrosomia, depressed apgar at 1 min and hyperbilirubinemia were more frequent when the diagnosis was made later. Neonatal hypoglycemia was statistically more frequent among the infants of the insulin-treated mothers compared to those of the diet-treated mothers. Our data suggest that early diagnosis of GD might be important to reduce perinatal morbidity further.

Heterotopic ovarian pregnancy after clomiphene ovulation induction.

Heterotopic pregnancy is a life threatening condition which seems to occur more frequently than previously estimated. We report a case of combined ovarian and intrauterine pregnancy after clomiphene treatment. Diagnosis was delayed because clinical presentation was atypical and ultrasound was falsely reassuring. The neonate was healthy but presented with a single umbilical artery. When an ectopic gestation is suspected after induction of ovulation or assisted reproductive technologies the presence of an intrauterine pregnancy can no longer be considered reassuring and an heterotopic pregnancy has to be ruled out.

Usefulness of urodynamic investigations in female incontinence.

Urinary incontinence in females has been evaluated in a prospective series of 408 patients by comparing the clinical diagnosis and the subsequent urodynamic findings. The presenting symptoms or combination of symptoms were shown to have only a limited diagnostic predictive value as measured by urodynamic diagnostic criteria. The symptom of stress incontinence was a sensitive detector of genuine stress incontinence (94% sensitivity) but was not very specific (65%). The symptoms of urgency and urge incontinence were found to have limited sensitivity (62%) and specificity (47%) in the detection of detrusor instability. Even patients with isolated complaints of stress incontinence have an incidence of detrusor instability of 52%, whereas 76% of those with a history of isolated urgency and urge incontinence had detrusor instability. An urodynamic evaluation should be performed on most female patients suffering from urinary incontinence and is essential for patients who are being considered for surgery of stress incontinence.

Hysteroscopic follow-up during tamoxifen treatment.

In order to study the action of Tamoxifen upon the uterus, 16 breast cancer patients were prospectively evaluated by means of an hysteroscopy before Tamoxifen therapy and again after 6 to 36 months of treatment. The results show the occurrence of an endometrial polyp in four cases and of an adenocarcinoma in one case. Moreover, the previously atrophic mucosa became mildly proliferative in seven of the patients who were evaluated.

Ectopic pregnancy in Zimbabwe.

One hundred four consecutive ectopic pregnancies were systematically analysed. During the study period, the incidence rate was 110 per 100,000 14-44 year old females per year. A history of prior pelvic infection was given by 53.8% of the cases and was suggested by surgical findings or by histological analysis among 74.9%. Serological evidence of previous chlamydial infection was much more common when ectopic pregnancy occurred in abnormal tubes than in normal tubes or compared to intrauterine pregnancies. The influence of schistosomiasis, endometriosis and ovarian cyst was limited to a very few cases. The analysis of contraceptive habits shows a much higher number of extrauterine pregnancies when the woman is using progestin-only pill than when she is on combined oral tablets.

The kick chart in high-risk pregnancies: a two-year experience in Zimbabwe.

A kick chart has been recorded by 200 high-risk pregnancies during their antepartum hospitalization. Except for 19 mothers who presented with an unreliable count, this study suggests a good correlation between an abnormal kick chart and an increased risk of intrauterine death. The obstetrical outcome was much better among the patients with a normal kick chart compared to those with an abnormal count. This easy, cheap, low-technology test could be useful in developing countries when monitoring of fetal well-being is required.

PIP: A kick chart has been recorded by 200 high-risk pregnancies during their antepartum hospitalization. Except for 19 mothers who presented with an unreliable count, this study suggests a good correlation between abnormal kick chart and an increased risk of intrauterine death. Subjects were patients admitted to the antepartum ward at the Gweru Provincial Hospital, Zimbabwe during the period from January 1st, 1985 to December 12th, 1986. The Cardiff "Count-to-Ten" counting method was used to assess fetal activity. The obstetrical outcome was much better among the patients with a normal kick chart, compared to those with an abnormal count, in preventing stillbirths. This easy, cheap, low-technology test could be useful in developing countries when monitoring of fetal well-being is required.

Endometrial lesions in patients undergoing tamoxifen therapy.

Forty-six nonhysterectomized women treated with tamoxifen during 6-36 months as adjuvant therapy for breast cancer underwent a hysteroscopy to assess the endometrial effects of this drug. Whereas the endometrium was normal among 23 patients, 13 presented with endometrial polyps, 8 with hyperplasia and 2 with adenocarcinoma. The rate of endometrial lesions was directly related to the cumulative dose of tamoxifen but it was not statistically different among patients receiving progestational therapy compared to patients who did not receive this therapy.

A woman's attitude toward pregnancy. Can it predispose her to preterm labor?

A prospective study was designed to assess the relationship between a woman's attitude toward pregnancy, sociomedical factors and preterm labor among 434 consecutive pregnant women who filled out a self-reporting, multiple choice questionnaire at 24-28 weeks' gestation. The score on "poor investment in pregnancy," evaluating the maternal attitude toward pregnancy and the antepartum fetomaternal relationship, was the best predictor of preterm labor, followed by the risk score based upon sociomedical factors. Psychologic factors could play a significant role in the onset of preterm labor.

Maternity services in a general hospital. Part II: Perinatal data.

PIP: Perinatal data at Gweru General Hospital was retrospectively reviewed over a 2-year period from September 1982 to September 1984. The overall perinatal mortality rate was 72/1000 with the rate being 3 times higher among unbooked mothers than booked mothers (those in an antenatal program). Unbooked mothers who accounted for 12% of the population provided 28% of the perinatal mortality cases. 2/3s of the perinatal deaths occurred before birth and were due mainly to twin pregnancy, breech delivery, malformations, and dystocia. The neonatal mortality rate was 29/1000 with the most important causes being low birthweight and perinatal asphyxia. Here the mortality rate was 5 to 6 times higher in unbooked mothers. The highest at-risk category were mothers whose baby's birthweight was less than 2kg, accounting for 44% of all perinatal deaths. The study overwhelmingly found that lack of antenatal care was significantly linked to increased perinatal mortality. However, it remains difficult to determine who will not attend antenatal clinics and why.^ieng

Pelvic inflammatory disease in Zimbabwe. Guidelines for diagnosis and treatment.

PIP: Pelvic inflammatory disease (PID) from the perspective of African practitioners is reviewed: diagnosis, staging and treatment. PID is the most common disorder treated in the gynecological department, and is a major public health problem because of the large number of patients, prolonged hospital stays, high mortality rate, and serious late sequelae of chronic pain, infertility and ectopic pregnancy. Diagnosis is difficult without confirmation by laparoscopy. PID is probable in complaints of acute abdominal pain, arising just after menses, with cervical excitation tenderness upon vaginal examination. The most reliable laboratory finding is accelerated sedimentation rate. State I is acute PID without peritoneal irritation; Stage II involves peritonitis and bilateral lower quadrant rebound tenderness; State III is a mass or abscess; Stage IV is rupture of the tubo-ovarian abscess. Culdocentesis producing gross pus suggests polymicrobial infection. The goals of treatment are to cure the patient and reach all of her partners, and to prevent late sequelae. Stage I patients can be treated with oral antibiotics as outpatients. Stage II can be effectively treated with penicillin and chloramphenicol in 80% in Zimbabwe. Stage III can sometimes be treated with antibiotics, but usually requires early surgery, by colpotomy if possible. Aggressive use of 3 antibiotics e.g., penicillin, clindamycin and gentamicin, will cover enteric organisms. Stage IV is life-threatening, with a mortality rate of 30-50% from septic shock. Total abdominal hysterectomy and bilateral adnexectomy are advised. A table depicting management of PID is included.^ieng

[Chronic pelvic pain: a psychoclinical approach]. / La douleur pelvienne chronique: cheminement psychoclinique.

To take care of a patient presenting with chronic pelvic pain requires a long-term approach considering all the organic, psychological and sexological aspects of the problem. To relieve the patient, it could be very useful to analyse the doctor-patient relationship. Most probably a multidisciplinary team with all the colleagues caring for the patient is the best place to discuss these items.

[Gestational diabetes: the urgent need for a consensus]. / Diabète gestationnel: l'urgent besoin d'un consensus.

About 2% of all pregnant women are affected by gestational diabetes. Unfortunately there is no unanimity in considering the criteria for the definition, classification and screening of these patients. This work tries to sort out the principal elements to be found in the literature that could help to work out a consensus in this field. At the present time, one of the best definitions seems to be "any pregnant women in whom the onset or recognition of diabetes or impaired glucose tolerance occurs during pregnancy". So, gestational diabetes is not synonymous of White's Class A and it is suggested to restrict the White classification to the diabetic women who subsequently become pregnant. The diagnostic test to establish glucose intolerance will be the oral glucose tolerance test with 100 g glucose. Various sets of criteria have been suggested for the interpretation of this test but it is advisable to use normal values established by one of the prospective studies, either by O'Sullivan in the USA or by Pinget in France or by Abell in Australia. As far as screening is concerned, the most sensible, specific and easy strategy appears to estimate, in every pregnant woman, the plasma glucose level one hour after a load of 50 g and to restrict oral glucose tolerance tests to the pregnant women whose results is above 150 mg%.

[Can neonatal anemia be predicted by analysis of the fetal cardiac rhythm?]. / Peut-on prédire l'anémie néonatale par l'analyse du rythme cardiaque foetal?

It is difficult to diagnose the severe pathological condition of fetal anaemia before birth. 30 cases of neonatal anaemia were compared with a control group who had normal haemoglobins after attempts at screening using fetal cardiotocography (CTG). Half all anaemic fetuses had a normal CTG trace and in 11 others (37%) though the abnormalities were serious they were not specific. Four fetuses (13%) had a sinusoidal cardiac rhythm which does seem to be the only specific sign of anaemia of any value as a predictive sign. Unfortunately this sign is not a sensitive one. It therefore appears that CTG is only of very limited value in screening for neonatal anaemia.