Immunoglobulin synthesis in mice: suppression by anti-allotype antibody.

In the mouse, antibody directed against an immunoglobulin allotype, Ig-1b, passed from mother to offspring or injected into neonates, suppresses synthesis of immunoglobulin carrying Ig-1b. In allotype homozygotes as well as heterozygotes the allotype suppression is manifested both by a delay of several weeks in attaining initial detectable allotype levels and a reduction in allotype level continuing into adulthood. A possible mechanism for the differentiation of the immune system consistent with both the kinetics of suppression reported here for the mouse and the comparatively longer lived and more complete allotype suppression described for the rabbit is discussed. Evidence for a strong intralitter (as opposed to interlitter) correlation of age of onset of immunoglobulin allotype synthesis is presented.

Modified manual rotation in midpelvic delivery.

A relatively atraumatic and simple technique for forceps rotation of the vertex is described for use when spontaneous rotation has failed to occur. The technique consists of applying the Laufe forceps as in a Scanzoni application to achieve maximum flexion of the vertex. The forceps blade is used only as an attachment for the finger rotation. No twisting of the forceps handle is required.

On protection of the maternal perineum during birth.

The author's experience and a review of the medical literature suggest that prophylactic episiotomy is not indicated.

Cervical incompetence, hourglass membranes, and amniocentesis.

A method is described for treatment of cervical incompetence when there are bulging fetal membranes (hourglassing). The technique consists of abdominal amniocentesis and amniotic injection of antibiotics prior to closing the cervical defect.

Inappropriate fetal bradycardia.

Intrauterine life demands unique respiratory and nutrient mechanisms, and it seems reasonable that some cardiorespiratory responses developed for later extrauterine life would not necessarily be entirely appropriate for the fetal period. In other words, a human fetus may not always be acting in its own best interest when it responds to intrauterine stress with what are appropriate extrauterine responses, such as gasping or the baroreflex (bradycardia). The detrimental effects of in utero gasping of meconium are well known, but the potentially harmful effects of inappropriate fetal bradycardia are little appreciated. A review of this condition is presented.

Anterior vaginotomy: abdominal delivery without a uterine incision.

To determine whether planned anterior vaginotomy is a logical and safe means of avoiding a uterine scar with term abdominal delivery. I recorded the complications of the technique and whether vaginal birth after anterior vaginotomy occurred. Thirteen anterior vaginotomies were done when the vagina had advanced during prolonged second stage. The procedure appears safe, although one patient had a postpartum bladder flap hematoma and one had gross hematuria postpartum. Three had postpartum endometritis and one was given a blood transfusion. In the six with records of follow-up pregnancies, two had elective cesareans, four attempted vaginal birth after vaginotomy with two failures (delivered by cesarean). The two successful procedures were uncomplicated. I conclude that unintended anterior vaginotomy should be coded. Such coding and analysis are required before it can be recommended that anterior vaginotomy replace cesarean after considerable vaginal advancement occurs. Vaginal advancement (and cervical retraction) during the second stage of labor requires further study.

Fetal cardiovascular responses to distress. A review.

This review is designed to provide a broad view of fetal cardiovascular response to fetal distress. The presentation focuses on data obtained from laboratories working with fetal sheep, or occasionally fetal monkeys, instead of attempting to interpret data resulting from human fetal studies. Human fetal studies are unsatisfactory for any detailed analysis other than discussions of an occasional case history because of the difficulty of identifying controls and because cardiovascular experimentation is not ethically possible.

Cesarean section in the massively obese.

The case histories of 4 massively obese patients who underwent cesarean section are summarized. In all, a Pfannenstiel incision was made beneath the patient's huge panniculus, and a lower segment cesarean section was easily accomplished. There were no postoperative wound infections and all of the women had an essentially benign postoperative course.

Extraperitoneal cesarean section revisited.

A retrospective analysis was made of 186 consecutive primary cesarean sections performed on patients at high risk for infection to determine whether extraperitoneal cesarean section would have decreased the incidence of infections and other complications. Women who theoretically would have benefited most from extraperitoneal cesarean section were not candidates for the procedure because of technical reasons, while those who would have been candidates for the procedure did very well despite the fact that the procedure was not done. Except for somen with severe toxemia, prophylactic antibiotics markedly reduced febrile morbidity. A number of significant unsuspected pathologic conditions also would not have been diagnosed if the extraperitoneal cesarean section technique had been used. It is concluded that prophylactic antibiotics and intraperitoneal cesarean sections are the preferred techniques even for those women with apparent amnionitis.

Impending gestosis.

Five cases of pregnant woman with symptoms of right upper quadrant pain, hemoconcentration, liver dysfunction, and thrombocytopenia are presented as representative of impending gestosis. Plasma volume expansion achieved by either bed rest or intravenous albumin administration appeared to be effective therapy. It is presumed that impending gestosis represents an early form of severe toxemia (edema/proteinuria/hypertension [EPH[ gestosis).

Fetal cardiac interval recorder.

A recorder is described which is capable of continuously measuring intervals between two events of the fetal cardiac cycle, as well as functioning as a routine intrapartum monitor. We have primarily measured the interval between the R wave of the fetal ECG and the second fetal heart sound (R-S2), but the recorder is also capable of measuring R-R, R-A0 (opening of aortic valve), R-Pl (placenta), and R-Sc (scalp) intervals. In the discussion, we endeavor to show that these intervals reflect fetal cardiac performance, which is altered by drugs and acidemia.

Pruritus and hyperplacentosis.

Hyperplacentosis refers to the maternal manifestations of increased placental activity, such as elevated human chorionic gonadotropin, theca luteal cysts, preeclampsia, and/or pruritus. Six cases of apparent hyperplacentosis were diagnosed in the third trimester because of maternal complaints of pruritus. The association of maternal or fetal complications with hyperplacentosis is described.

Rupture of low transverse cesarean scars during trial of labor.

We report eight cases of rupture of low transverse cesarean scars occurring during trials of labor. The cases occurred in five hospitals in the Denver metropolitan area during a 13-month period. The estimated incidence was 0.7% of planned trials of labor. Complications of rupture included one neonatal death, two cases of severe neonatal asphyxia, three maternal bladder lacerations, and one hysterectomy.

Evaluation of platelet function in pregnancy. Comparative studies in non-smokers and smokers.

We have evaluated the possible role of platelet functional abnormalities as a contributory cause of thrombosis during pregnancy and to the increased fetal mortality and morbidity among women who smoke. Fifty-three pregnant women were enrolled and evaluated on two separate prenatal visits held between the 20th and 36th week of pregnancy and, when possible, post partum. Smoking status was evaluated by personal statement and alveolar carbon monoxide levels. Women in the smoking group deliberately avoided cigarettes for at least 20 minutes before sampling. Plasma levels of beta-thromboglobulin, thromboxane B2, and 6-Keto PGF1 alpha were evaluated. A significant increase in 6-Keto PGF1 alpha was noted among smoking women as pregnancy advanced. 6-Keto PGF1 alpha levels decreased among non-smoking women while beta-thromboglobulin increased significantly between the 20th and 33rd week of pregnancy in non-smokers. Platelet aggregation, both in platelet rich plasma and in whole blood (by impedance aggregometry), was evaluated by five different parameters and four different aggregating agents. Significant differences between the non-smoking and smoking pregnant women were noted for selected age cohorts and aggregating agents. An increase in platelet reactivity among smokers was observed in whole blood by impedance aggregometry with adenosine diphosphate and in two age cohorts using platelet rich plasma. In two groups in which aggregation was significantly accelerated among non-smokers, epinephrine was used as the aggregating agent.

Renal artery stenosis during pregnancy: a review.

Renal artery stenosis in pregnancy may present as chronic hypertension with superimposed preeclampsia or as recurrent isolated preeclampsia. Renal angiography is the most sensitive and specific diagnostic technique available for this lesion, and therapeutic percutaneous transluminal angioplasty may be carried out in conjunction with angiography. We report a patient with renal artery stenosis diagnosed and treated with percutaneous transluminal angioplasty at 26 3/7 weeks gestation. The literature on renal artery stenosis in pregnancy is reviewed.

Fetal response decrement: true habituation?

Preliminary evidence suggests that fetal movement in response to vibrotactile stimulation "habituates" with repeated exposure. If demonstrated in fetuses, the habituation paradigm may be useful as a measure of fetal well-being or as a predictor of neonatal outcome. However, the ability of the fetal response decrement phenomenon to meet criteria for habituation which would distinguish it from simple receptor fatigue has not been evaluated. In this study, fetuses were exposed to two different frequencies of vibration applied to the maternal abdomen. Fetal movement was observed on an ultrasound monitor. An inverse relationship between the strength of the stimulus and rapidity of the response decrement was not observed. However, return of the response to presentation of a novel stimulus, response decrement to repetition of the second stimulus, and more rapid response decrement upon re-presentation of the original stimulus suggest that the fetal response decrement phenomenon is true habituation.

Will treatment with digoxin antibody benefit pregnant patients with toxemia and elevated digoxin like factor?

Some pregnant patients with toxemia, especially those with thrombocytopenia, liver or renal dysfunction have elevated serum DLF (digoxin like factor). Since antidigoxin serum reduces the hypertension of DOCA hypertensive rats, it is proposed that antidigoxin antibodies be tried in the treatment of these select patients with toxemia of pregnancy.

Effects of x-ray on a gravida with severe hemoconcentration: a case report.

A gravida with severe hemoconcentration was studied with intravenous urography because of right upper quadrant pain. She subsequently developed renal failure. The potential hazard of urography in the presence of a severe blood volume contraction state is noted.

Hypovolemic pregnant women and their risk determinants.

Among hypovolemic pregnant women there is a high risk of premature labor, fetal growth retardation, and/or hypertension. Arterial wave velocity was determined and Evan's blue disappearance rates measured in hypovolemic gravidas with complications. It appeared that those hypovolemic gravidas without increased cardiac performance are more likely to give birth prematurely, while those with increased cardiac performance and delayed in vivo mixing of Evan's blue dye develop hypertension.