Interrelationships of circulating maternal steroid concentrations in third trimester pregnancies. II. C18 and C19 steroids: estradiol, estriol, dehydroepiandrosterone, dehydroepiandrosterone sulfate, delta 5-androstenediol, delta 4-androstenedione, testosterone, and dihydrotestosterone.

This report describes aggregate time trend effects of advancing gestational age on circulating maternal concentrations of 17beta-estradiol (E2), estriol (E3), dehydroepiandrosterone (D), dehydroepiandrosterone sulfate (D-S), delta 5-androstenediol (delta 5 diol), delta 4-androstenedione (delta 4 A), testosterone (T), and dihydrotestosterone (DHT) in a sequential series of 155 blood samples obtained from 19 normal pregnant women ranging from 26-40 weeks gestational age. Only E2, E3, and D-S show aggregate time trend effects. Log (E2) plots as a linear positive sloping curve from 26-40 weeks. Log (E3) plots as a positive sloping curve that is significantly steeper than log (E2) (P less than 0.05). Log (D-S) plots into a negative sloping curve which mirrors the pattern for log (E2) but cannot be statistically associated with log (E2) except for the opposite sign of their slopes, which are both significantly different from a zero slope (P less than 0.05). delta 4 A, T, DHT, delta 5 diol, and D show no aggregate time trends; however wide, comoving undulations for delta 4 A, T, DHT, and delta 5 diol between 26-28 and 38-40 weeks are confirmed in time by comparison of log mean plots and in magnitude by regressing the C19 steroids on one another. D shows virtually no association with the other C19 steroids. All C19 steroids, except for T, circulate at nonpregnant concentrations, implying that there is little placental secretion of these steroids into the maternal circulation.

Cerebral vasoconstriction in toxemia.

Three patients with toxemia developed acute neurologic deterioration postpartum. In all, cerebral angiography revealed widespread arterial vasoconstriction. Cerebral vasoconstriction may be an important cause of neurologic complications in toxemia.

Pre-cesarean blood bank orders: a safe and less expensive approach.

OBJECTIVES: To 1) characterize pre-cesarean blood bank testing, 2) describe the transfusion experience in a large series of cesarean patients, and 3) evaluate safety and cost implications of a "hold clot" order for patients at low risk for transfusion. METHODS: A review of 1111 consecutive cesarean patients used computerized perinatal and blood bank data bases and a detailed chart review of all cross-matched patients. Information collected included indications for cesarean and transfusion, etiology of hemorrhage, transfusion number and type, admission and lowest hemoglobin level, and information regarding the events leading to transfusion. A blinded review of the cross-matched patient's information assessed whether a cross-match was appropriate or could have been replaced safely by a "hold clot" (current clot tube in blood bank) order. RESULTS: Nineteen patients (1.7%) were transfused. The only patients requiring a transfusion were diagnosed with placenta previa, placenta accreta, anemia, preeclampsia/hemolysis, elevated liver enzymes, low platelets (HELLP syndrome), or hemorrhage. A comparison of two blood banking approaches (routine pre-cesarean type and screen testing versus a "hold clot" order for cesarean patients at low risk for transfusion) indicated that the latter would reduce costs by $45 per cesarean, or $95,000 annually. CONCLUSIONS: The incidence of transfusion was low (1.7%) and associated with specific diagnoses (previa, accreta, anemia, preeclampsia/HELLP, or hemorrhage). The data support the replacement of pre-cesarean type and screen testing with a "hold clot" order for patients at low risk for transfusion with negative prenatal antibody screen. This approach is safe and would reduce cost substantially.

Nitroglycerin facilitates therapeutic cerclage placement.

Therapeutic cerclage placement may be complicated by prolapsing of the fetal membranes. A gravida presented with incompetent cervix and prolapse of fetal membranes. The membranes were not reduced by Trendelenburg position, decompressive amniocentesis, and spinal anesthesia. Intravenous nitroglycerin promptly reduced the prolapse and allowed cerclage placement. This is the first report of intravenous nitroglycerin tocolysis used to facilitate cerclage placement.

Pregnancies in a patient with congenital absence of prothrombin activity: case report.

Congenital hypoprothrombinemias are very rare, inherited disorders in which factor II (prothrombin) levels and/or activity are extremely low or absent. We report eight pregnancies in a patient with this disorder. Obstetric complications attributed to the coagulation disturbance included first-trimester bleeding in each pregnancy, miscarriage in four of the pregnancies, spontaneous maternal subarachnoid hemorrhage in one, and postpartum hemorrhage in one of four term pregnancies despite administration of clotting factor concentrate. The management of pregnancy in congenital hypoprothrombinemia, and issues of coagulation factor replacement, are discussed.

Serum progesterone and estradiol-17beta levels in premature and term labor.

A total of 30 to 50 per cent of premature labors occur without identifiable predisposing conditions. To evaluate the hormonal status of these pregnancies, serum progesterone (P) and estradiol (E2) were measured by radioimmunoassay singly in 60 premature labor patients and serially in 19 normal pregnancies. Premature labor patients as a group have significantly lower P and E2 levels than controls. Pregnancies complcated by idiopathic premature labor (IPL) (p less than 0.01), premature labor secondary to abruptio-marginal separation (A-MS) (p less than 0.05), and premature rupture of membranes (PROM) (p less than 0.05) have significantly lower P levels than controls. Patients with IPL and A-MS have significantly lower P levels (p less than 0.01) than PROM patients. No significant change in P or E2 occurs immediately prior to normal term labor. Conclusions are that (1) premature labor patients have significantly lower Pand E2 levels than controls, (2) the degree of P depression varies according to the type of premature labor and (3) IPL is characterized by premature labor with no identifiable predisposing factors.

Severe preeclampsia with fulminant and extreme elevation of aspartate aminotransferase and lactate dehydrogenase levels: high risk for maternal death.

We report a subgroup of patients with fulminant hemolysis, elevated liver enzymes, low platelet count (HELLP) syndrome, manifesting extreme elevation of aspartate aminotransferase (AST; SGOT) and lactate dehydrogenase (LDH) levels and abnormal mental status. These gravidas are at high risk for mortality. Only four patients treated by the authors over a 10-year period have had AST more than 2000 IU/L and LDH more than 3000 IU/L in the HELLP syndrome. This report is based on retrospective chart review. All patients manifested disordered mental status, jaundice, intense hemolysis, and extreme hypertension. One patient had developed multiple organ system failure, was moribund at initial perinatal consultation, and died. The three others were treated with aggressive afterload reduction and plasma infusion or plasmapheresis; two survived. Fulminant HELLP syndrome occurs rarely, but marks a group of patients at high risk for mortality. Optimal therapy is unclear; early intervention, including afterload reduction, volume expansion, and consideration of plasma infusions or plasmapheresis, is recommended.

Increased serum gastrin concentrations and gastric acid hyposecretion in the immediate newborn period.

Thirty-two infants and their mothers were studied to determine the source of elevated serum gastrin concentrations in umbilical blood and to learn whether neonates hypersecreted acid in response to hypergastrinemia. Gastrin concentrations in the umbilical artery and vein were similar. Both were significantly higher than maternal gastrin concentrations. No significant amount of gastrin could be measured in placental extracts. These results suggest that the increased neonatal gastrin concentrations were fetal in origin. Continuous basal acid secretory studies done for 4 hr in 32 infants and for 8 hr in 9 infants demonstrated hyposecretion of gastric acid for the first 5 hr of life. Acid secretion from hour 6 to 8 was similar to that in older children. Increased gastrin levels were still present at hour 8 and were associated with normal gastric acid secretion.

Brain death during pregnancy: tocolytic therapy and aggressive maternal support on behalf of the fetus.

We report a case of maternal brain death at 25 weeks gestation in which aggressive maternal hemodynamic, respiratory, and metabolic support and tocolytic drug therapy resulted in prolongation of pregnancy for 25 days. The indication for delivery was torulopsis giabrata amnionitis, which may have occurred due to transmembrane or transplacental route. The baby was treated for fungal sepsis, and did well. Premature labor may occur spontaneously after maternal brain death, and may be precipitated by infection or by maternal drug therapy. The myriad of hemodynamic and endocrine issues associated with maternal brain death complicate the choice of tocolytic drugs, but this case illustrates that uterine activity can be successfully blocked, potentially diminishing risks to the newborn, following the tragedy of maternal brain death during pregnancy.