ISSN:0029-7828    

出版商:OVID    

年代:1987

数据来源: OVID

摘要:

AbstractsElectronic fetal heart rate (FHR) monitoring was developed to improve detection of intrapartum fetal distress, but its efficacy has never been fully demonstrated. In 1979, a national task force recommended randomized clinical trials of patients with high-risk pregnancies (particularly preterm labor) to determine the effect of fetal heart rate monitoring on perinatal mortality and morbidity and maternal morbidity. In 1981, the present authors began such a trial, combining electronic fetal heart rate monitoring with fetal scalp sampling, in patients with preterm labor. They compared the results with those obtained by auscultation alone. The purpose of the trial was to determine whether electronic fetal heart rate monitoring was associated with a clinically important improvement in perinatal mortality and neurodevelopment at 18 months of (corrected) age.The study was conducted at three different referral centers, and a total of 376 patients were enrolled (188 for electronic monitoring and 188 for auscultation). Of these patients, 246 delivered infants weighing 1750 gm or less. The investigation was confined to this group of infants.There were no significant differences between the electronic monitoring and the auscultation groups in the number of patients exposed to tocolytic agents (65 vs. 77, respectively), antenatal glucocorticoids (48 in each group), oxytocin (41 vs. 50), or regional anesthesia (56 vs. 53). Monitoring technique was not associated with premature rupture of membranes, which occurred in 68 of 122 patients (56 per cent) in the electronic monitoring group and in 58 of 124 patients (47 per cent) in the auscultation group. Monitoring technique did not influence medical intervention during labor.The primary cesarean section rate was 16 per cent with electronic fetal heart rate monitoring and 15 per cent with periodic auscultation. These levels are compatible with the institutional cesarean section rates for cephalic pregnancies in the birth weight range. Fetal distress (ominous fetal heart rate) was the most common indication for cesarean section. The operation was performed for that reason in 8.2 per cent of the patients with electronic monitoring and in 5.6 per cent of those with periodic auscultation. Fetal distress was observed more frequently in the electronic monitoring group (27 per cent) than in the auscultation group (15 per cent), but the difference was not significant (P = 0.08). The second most common indication for cesarean section was noncephalic presentation.The condition of the infant, as judged by Apgar score and the acid-base characteristics of blood specimens obtained from the umbilical cord at birth, was not significantly different in the two monitoring techniques. Fetal acidosis and low 5-minute Apgar scores were uncommon (less than 10 per cent), regardless of monitoring technique. The frequency of neonatal seizures, severe respiratory distress syndrome, and intracranial hemorrhage were not significantly different in the two groups.Thirty-five perinatal or infant deaths occurred: 17 after electronic fetal heart rate monitoring (13.9 per cent) and 18 after auscultation (14.5 per cent). All deaths occurred in infants with birth weights less than 1500 gm. Monitoring technique was not associated with a significant difference in mortality in any birth weight category. Of the 35 deaths, 28 were associated with cardiopulmonary failure and hyaline membrane disease. Of the seven remaining deaths, three were due to congenital anomalies that were unrecognized antenatally, two in the electronic monitoring group (renal agenesis and trisomy 18) and one in the auscultation group (diaphragmatic hernia and omphalocele). There were two infant deaths in the auscultation group due to pneumonia, and there was one stillbirth in each group.There were 14 perinatal deaths among 119 electronic fetal heart rate monitoring patients (11.8 per cent) and 14 among 120 auscultated patients (11.7 per cent).Thirty per cent of the patients with electronic fetal heart rate monitoring had significant maternal morbidity, as compared with 36 per cent of those with periodic auscultation (a nonsignificant difference). Nonsignificant differences also were found for specific causes of maternal morbidity, including blood transfusion, endometritis, laceration, wound infection, and urinary tract infection. There was no fetal morbidity directly attributable to either monitoring technique.

ISSN:0029-7828    

出版商:OVID    

年代:1987

数据来源: OVID

摘要:

AbstractsThe present authors currently are studying 95 breastfeeding women to find predictors of ovulation. In preparation for these studies, they investigated the return of ovarian activity in 22 postpartum nonbreast-feeding women, using steroid and LH assays on daily early morning urine samples and twice weekly blood samples as measures of endocrine status. In addition, they observed steroid excretion in 16 regularly menstruating nonpostpartum women to establish the normal range of values.The 16 regularly menstruating women ranged in age from 21 to 44 years and had an average of 0 to 2 children. The 22 nonbreast-feeding women had a mean age of 24.9 years and a mean parity of 2.6 children. Urine samples were collected daily, and blood samples were collected twice a week. Pregnanediol 3α-glucuronide (PdG) and estradiol-17β-glucuronide (E2G) were measured in unex-tracted urine. The occurrence of ovulation was inferred from a rise in urinary LH and/or an increase in urinary PdG greater than 2 SD from baseline and a reversal of the E2G:PdG ratio. Two statistical indices were used to define the normal limits of PdG excretion during the luteal phase: 1) the mean peak level of the PdG rise was defined as the highest smoothed daily luteal phase PdG values, and the lower limit of normal was defined as the lowest 10th percentile; and 2) the area under the PdG curve was used to measure overall luteal phase PdG excretion.The 16 regularly menstruating nonpostpartum women had ovulatory cycles and thus provided data to establish normal values for luteal phase PdG excretion. Median peak PdG excretion during the luteal phase was 8.13 μg/ml, and the lower 10th percentile was 4.0 μg/ml. The median area under the luteal phase PdG curve was 36 μg/ml, and the lower 10th percentile was 20 μg/ml. Therefore, the lower limit of normal for luteal phase PdG excretion was set at 4.0 μg/ml for the mean peak level and at 20 μg/ml for the area under the curve.The 22 nonbreast-feeding women contributed information on 49 menstrual episodes, which were classified as ovulatory on the basis of a significant rise in LH and/or PdG and a reversal of the E2G:PdG ratio. The luteal phase was classified as normal if all measures of luteal phase PdG excretion were within the normal ranges, and luteal phase length was greater than 8 days; as abnormal if PdG excretion was less than the lower limit of normal, or luteal phase length was 8 days or less; and as equivocal if there were contradictions between the criteria for PdG excretion.Thirty-two per cent of the postpartum women had no ovulation before their first postpartum menstrual episodes, whereas only 15 per cent of the second and subsequent menstrual episodes were anovulatory. The mean time from delivery to first menses was 45.0 ± 10.1 (SD) days, and the mean time from parturition until first inferred ovulation was 45.2 ± 16.9 days. This reflects the high proportion of anovulatory first menses. No woman ovulated before 25 days after delivery. Eleven of the 15 ovulatory first postpartum cycles had clearly abnormal luteal phases (7.3 per cent), as compared to six of 23 ovulatory second or subsequent cycles (26.1 per cent). The three equivocal luteal phases had mean PdG excretion within the normal range, but a marginal area under the PdG curve.These data indicate an excess of abnormal first cycles postpartum, and if all abnormalities are considered, 81.8 per cent (18 of 22) of first postpartum cycles and 37.0 per cent (10 of 27) of second or subsequent cycles had unequivocal evidence of disturbance in ovulation, luteal phase PdG excretion, and/or luteal phase length. Although two women failed to ovulate throughout the study, there was no propensity for individual women to have repeated abnormal cycles. A high proportion (50.0 per cent) of abnormal luteal phases were deficient in PdG excretion but of normal length, whereas one-quarter of the abnormal phases were deficient in PdG excretion and of short duration. These distributions were similar for first and subsequent ovulatory cycles.Among the normal luteal phase cycles, there was a progressive increase in PdG excretion from the first to the third postpartum cycles. The mean peak smoothed PdG value for the normal postpartum cycles was 5.64 ± 0.14 μg/ml, which is significantly lower than the peak values for the second and third normal postpartum cycles. Such a progressive rise in PdG excretion was not found in the abnormal luteal phase cycles.The correlation coefficients between serum and urinary concentrations are tabulated by lag time between blood and urine collections in Table 1. All correlation coefficients were highly significant (P < 0.001). The coefficients were highest for progesterone to PdG, and least satisfactory for serum and urinary LH. The coefficients for progesterone to PdG were maximum for the 1− and 2-day lag periods between serum and urine collections, but the estradiol to E2G correlation was highest on the same day and the 1-day lag. These differences in lag times, however, are not significant. The lower correlation coefficients for LH result from failure to obtain serum samples at the time of the LH peak due to the twice weekly venipuncture regimen.

ISSN:0029-7828    

出版商:OVID    

年代:1987

数据来源: OVID

摘要:

AbstractsCongenital goiter and (rarely) transient hypothyroidism have been reported to occur sporadically in infants whose mothers received iodides during pregnancy. The present authors report a case of prolonged but transient hypothyroidism without goiter in a girt whose mother used povi-done iodine preparations during pregnancy and lactation.A 6-week-old Jewish girl of Ashkenazi origin, the youngest of five healthy siblings, was referred to the authors' unit because of a low serum total thyroxine concentration of 3 μg/dl (normal value, more than 7 μg/dl), revealed by routine screening for congenital hypothyroidism. She was born at term after an uneventful pregnancy and delivery. Her birth weight was 4000 gm. During the pregnancy, the mother washed herself almost daily with a solution of povidone iodine, a complex of iodine and polyvinylpyrrolidone which releases free iodine in solution, with 1 per cent available iodine. She had also rubbed large areas of her skin with povidone iodine ointment (1 per cent) because of spreading furunculosis. These practices were continued during lactation until referral.The mother's aunt and uncle suffered from a thyroid disorder, the nature of which could not be determined.Physical examination revealed an infant in good condition, with mild jaundice. Her weight was 5.1 kg, her length was 54.5 cm, and her head circumference was 40 cm. Body temperature was normal. No goiter was palpable. The face was round, with a protruding tongue. Respiration was noisy, but there was no sign of respiratory distress. The abdomen was large, and the liver was palpated 3 cm below the costal margin. A large umbilical hernia was present. A neurological examination yielded normal results, except for moderately delayed deep tendon reflexes. Laboratory tests disclosed a free thyroxine serum concentration of 0.4 ng/dl (normal values, 0.7–2 ng/dl). Thyroid-stimulating hormone (TSH) was 99 μU/ml (normal values, 0.8–5 μU/ml). Indirect bilirubin was 95 μmol/liter. Thyroid antibodies were negative in the child and her mother. A thyroid scan yielded normal results.A diagnosis of primary hypothyroidism was made on the basis of raised TSH and decreased thyroxine concentrations, and treatment with t-thyroxine sodium was started. On follow-up, there was an increase in thyroxine and a decrease in TSH concentrations (Table 1).Growth and psychomotor development were normal, and treatment was stopped at the age of 7 months. At 1 year, growth and development were normal.

ISSN:0029-7828    

出版商:OVID    

年代:1987

数据来源: OVID

摘要:

AbstractsIn 1970, the International Commission on Radiological Protection established guidelines for the protection of pregnant patients and workers from overexposure to radiation. One of the major proposals has come to be known as “the 10-day rule.” The Commission recommended that physicians confine less urgent radiological examinations to the 10 days following the start of menstruation, this being the time when pregnancy is least probable.The 10-day rule was modified in 1984 to extend the period of relative safety. The Commission issued the following statement: “During the first 10 days following the onset of a menstrual period, there can be no risk to any conceptus since no conception will have occurred. The risk to a child who has been irradiated in utero during the remainder of a 4-week period after the onset of menstruation is likely to be so small that there need be no special limitation on exposure during these 4 weeks.”The National Radiological Protection Board in the United Kingdom issued new guidelines in 1985, conforming to those of the International Commission. The following comments appeared in two British medical journals.“The risk to the fetus from diagnostic radiological examinations seems to be insignificant. The cost of implementing the 10-day rule would be some 100 times greater than the possible benefit derived from it, assuming that a benefit exists.”“When a patient is regarded as pregnant, special care should be taken to ascertain whether the radiological procedure is necessary. Since the risk of irradiating the fetus may be much less than that of failing to make a correct diagnosis, the procedure should be carried out if a need is indicated, but with particular care to minimize the radiation dose to the fetus.”The U. S. Food and Drug Administration endorsed the new guidelines in 1985, recommending also that patients be cautioned against breast-feeding after nuclear irradiation. The FDA also suggested that patients be advised to postpone planned pregnancies after radkxiuclide procedures for a length of time specified by a nuclear medicine physician.Concern about the risk of radiation exposure to pregnant workers has received increasing attention. According to the American Association of Women Radiologists, the evidence is reassuring. There are misconceptions about the actual amounts of radiation that reach the conceptus during occupational exposure. The doses involved are often less than those from environmental sources. The spread of this information should help to alleviate the emotional trauma and guilt suffered by all radiation workers with affected children. It is suggested that each hospital establish a realistic policy that will allow pregnant workers to protect their jobs, safeguard their unborn children, and fulfill their professional obligations.

ISSN:0029-7828    

出版商:OVID    

年代:1987

数据来源: OVID

ISSN:0029-7828    

出版商:OVID    

年代:1987

数据来源: OVID

摘要:

AbstractsPartial mole is often associated with triploidy (69,XXY or 69,XXXY), the extra haploid set of chromosomes usually being paternal (Fig. 1). Although the benign nature of partial mole has been emphasized, cases of gestational trophoblastic tumor have been reported to follow. In this report, the authors present the pathological features of eight patients with partial mole (10 per cent of their total series of such patients) who had persistent trophoblastic tumor develop.The clinical histories, macroscopic descriptions of specimens, and slides of eight partial moles that resulted in persistent disease were reviewed and compared with 73 partial moles which did not persist.) After molar evacuation, all patients with molar pregnancies at the authors' institution are followed with weekly hCG assays until these have been normal for 3 consecutive weeks. Postmolar gestational trophoblastic tumor is diagnosed if the hCG level increases or levels off in a plateau for at least 3 consecutive weeksThe patients' ages ranged from 25 to 37 years (mean, 30.2 years). In each case, the initial clinical diagnosis was “missed abortion.” Preevacuation serum hCG levels, measured in four patients, varied from 440 to 70,000 lU/liter. Pelvic ultrasound examination was performed in each of the eight patients, and in seven cases, this study suggested missed abortion. One patient was considered to have a molar pregnancy. The time interval from initial molar evacuation to diagnosis of persistent gestational trophoblastic tumor ranged from 6 to 18 weeks. Pretreatment serum hCG levels ranged from 15 to 6,000 lU/liter. All eight patients achieved remission after single-agent chemotherapy (methotrexate and citrovorum factor).In five cases, molar vesicles 8 to 10 mm in diameter were observed in the original specimens. Intact autolyzed embryos were found in two specimens, and three others included autolyzed fetal fragments. Fetal membranes were noted in three cases. Scalloped villous outlines, stromal trophoblastic inclusions, and cavitated villi were present in all eight specimens. The degree of cavitation was more prominent than in villi of nonpersistent partial moles. The villi were focally covered by trophoblast, ranging from two to several layers in thickness, composed of both cytotrophoblast and syncytotrophoblast. The cytotrophoblast showed occasional mitotic activity. None of the initial specimens manifested unusual trophoblastic proliferation as compared with partial mole not followed by persistent disease.Villous vascular anomalies were noted in seven of eight cases. In four, dilated and anastomosing vascular channels were diffusely present (Fig. 2). Villous vascular anomalies were present in 17 per cent of nonpersistent partial moles. In most cases, intravascular nucleated red blood cells were present. Villous stroma of two partial moles with persistent tumor and 11 with no evidence of persistent disease contained bizarre stromal cells with large, round, or oval hyperchromatic nuclei and abundant eosinophilic cytoplasm. They manifested strong immunohistochemical staining for human placental lactogen and keratin (Fig. 3) and were negative for chorionic gonadotropin and lysozyme.

ISSN:0029-7828    

出版商:OVID    

年代:1987

数据来源: OVID

摘要:

AbstractsObstetrical complications, such as abruptio placentae and prolonged retention of a dead fetus, are often associated with coagulation changes that may extend to disseminated intravascular coagulation. The latter is secondary to passage into the maternal blood of thromboplastic or fibrinolysis-reducing material from the placenta or the amniotic fluid. Acute renal failure in the course of obstetrical complications is reported to be very severe, and disseminated intravascular coagulation is commonly implicated as a causative agent. The present paper reports a series of 10 cases of acute renal failure following obstetrical complications. Serial coagulation studies were made in an assessment of the mechanisms involved.Abruptio placentae was the complication in six cases. Retained placental fragments were discovered on review of the uterine cavity in three cases of persistent metrorrtiagia following vaginal delivery at term. In the 10th case, examination of a patient with retention of a dead fetus at

ISSN:0029-7828    

出版商:OVID    

年代:1987

数据来源: OVID

摘要:

AbstractsIt has been suggested that prostaglandin treatment might terminate some ectopic pregnancies. The present authors have previously analyzed the influence of various prostaglandins on smooth muscle of the human fallopian tube, including the blood vessels. Their results clearly demonstrate that prostaglandin F compounds, in contrast to other prostaglandins, invariably cause powerful contractions. Moreover, data from in vitro experiments on the human corpus luteum provide evidence of antigonadotropic action of prostaglandin F2α.Together, these experimental data indicate that prostaglandin F compounds could be useful in the treatment of selected cases of ectopic pregnancy. The authors report a test of this hypothesis in clinical practice.Nine patients (ages, 25–35 years) with ectopic pregnancies were selected for the study. Five of the pregnancies were situated in the right tube, and four were situated in the left tube. A corpus luteum of pregnancy was identified on the contralateral side in each of two patients and on the ipsilateral side in each of the remaining seven. All of the pregnancies had ampullary locations.Routine diagnostic laparoscopy was performed, with confirmation of the diagnosis according to established criteria. The affected oviduct and ovary were grasped and made accessible with 5-mm atraumatic forceps. A 15-cm injection needle with an outer diameter of 0.8 mm was introduced through the lower abdominal wall under laparoscopic guidance. The tip of the needle was inserted into the tubal wall over the ectopic pregnancy. Prostaglandin F2α(five cases, 0.5–1.5 mg) or 15-methyl-prostaglandin F2α(four cases, 75 μg) diluted in 3 to 10 ml of physiological saline was then gently injected, causing visible swelling of the tubal wall. In each patient except one, an identical dose of prostaglandin F2αwas injected subcapsulariy into the ovary containing the corpus luteum. After completion of the injections, visible blood and blood clots were evacuated from the pouch of Douglas by suction and irrigation. In six patients, serum hCG was measured more than once before the operation. All patients had serial determinations postoperatively.Nine patients underwent the procedure without any untoward reaction during or after operation and were discharged 1 to 2 days later. One woman had a second laparoscopy and injection of prostaglandin F2α(14 days after the first operation and injection) because her serum hCG had not declined sufficiently. The remaining eight resumed normal activities within 10 days.

ISSN:0029-7828    

出版商:OVID    

年代:1987

数据来源: OVID

ISSN:0029-7828    

出版商:OVID    

年代:1987

数据来源: OVID