Placenta accreta and methotrexate therapy: three case reports.

Placenta accreta is a complication that is rising in incidence. The reported experience of methotrexate treatment in the conservative management of placenta accreta is scant. Three cases of placenta accreta managed with methotrexate are presented. Case 1: A woman had an antenatal diagnosis of placenta percreta. A successful manual placental removal occurred on post-cesarean day 16. Case 2: A woman had retention of a placenta accreta after a term vaginal delivery. Successful dilation and curettage were performed on postpartum day 37. Case 3: A woman had an antenatal diagnosis of placenta previa-percreta with bladder invasion. A simple hysterectomy was performed on post-cesarean day 46. Conservative management and methotrexate treatment resulted in uterine preservation in two of our three patients; however, this treatment did not prevent significant delayed hemorrhage. In view of the rapid resolution of vascular invasion of the bladder, methotrexate may have an important role in the management of placenta percreta with bladder invasion. The utility of methotrexate treatment with the conservative management of placenta accreta requires further evaluation.

Fetal death after normal biophysical profile score: An eighteen-year experience.

OBJECTIVE: It was our goal to determine the false-negative rate of the biophysical profile, characterize an 18-year variation in the false-negative rate, examine the relationship between the last normal biophysical profile score and death, and compare the false-negative rate of 2 disparate populations. STUDY DESIGN: Biophysical profile scores of 86,955 patients at 2 medical centers were collected and recorded prospectively. All perinatal deaths occurring within 1 week of a normal score were similarly recorded. The annual false-negative rate, the cumulative false-negative rate, and the ratio of false-negative results in cases of subsequent fetal death to the perinatal mortality rate were calculated. RESULTS: There were 65 fetal deaths among 86,955 fetuses. Over an 18-year study period at one institution, the false-negative rate varied but not significantly. The cumulative false-negative rate was 0.708 per 1000 at one medical center studied and 2.289 per 1000 at the other center. The average interval between last normal score and fetal death was 3.62 days and did not vary significantly between the medical centers. CONCLUSIONS: False-negative results in cases of subsequent fetal death reflect events that are subsequent to the last normal test result. Fetomaternal hemorrhage was the single most identifiable fetal cause of false-negative results in cases of subsequent fetal death. The ratio of the false-negative rate in cases of subsequent fetal death to the perinatal mortality rate should be used as a more objective approach to reporting this value, because the false-negative rate likely reflects the underlying perinatal mortality.

Atraumatic fetal cervical spinal cord injury and cruciate paralysis.

BACKGROUND: Congenital cervical spinal cord injury usually is attributed to intrapartum mechanical trauma. CASE: A fetal cervical spinal cord hemorrhage presented as congenital isolated upper extremity ("cruciate") paralysis and muscle atrophy after an atraumatic delivery. Timely neonatal diagnosis and surgery resulted in complete recovery. CONCLUSION: Paralysis may result from atraumatic spinal cord injuries occurring in the antepartum period.

Fetal assessment based on fetal biophysical profile scoring. VIII. The incidence of cerebral palsy in tested and untested perinates.

OBJECTIVE: The intent of this comparative clinical study was fourfold: (1) to determine the incidence of cerebral palsy in a large obstetric population, (2) to compare the incidence of cerebral palsy in patients at high risk referred for and managed according to the fetal biophysical profile score result with the incidence among unreferred and untested patients, (3) to determine the relationship, if any, between the last fetal biophysical profile score and the incidence of cerebral palsy, and (4) to categorize cases of cerebral palsy according to the clinical parameters and the probable time and nature of the damaging insult. STUDY DESIGN: In this retrospective 5-year comparative study (1987 to 1991) the incidence of cerebral palsy was determined by analysis of International Classification of Diseases, Ninth Revision, -coded related medical services. The clinical records were then sought and reviewed in index cases and obstetric, neonatal, and postnatal clinical data were abstracted. Cross-correlation with partial registries was done to confirm completeness of capture of index cases. The population of referred high-risk patients who received serial fetal biophysical profile scoring and were managed according to test results was determined by review of a prospective computer-stored database and by review of patient log books. The population of untested patients was calculated as the residual of total cases minus tested cases. The rate of cerebral palsy for all patients and for the tested and untested population was calculated and compared. The tested and untested perinates were compared for birth age, weight, and assigned timing or etiology of cerebral palsy. In the tested population the distribution of test results by last recorded biophysical profile score was determined and the relationship between the last test result and cerebral palsy and predictive accuracy parameters of the fetal biophysical profile score were calculated. RESULTS: The incidence of cerebral palsy among the 84,947 live births was 3.68 per 1000 live births (313 cases). The rate of cerebral palsy in the 26,290 referred high-risk tested patients was 1.33 per 1000 (35 cases) compared with a rate of 4.74 per 1000 live births in the 58,657 untested mixed low-risk/high-risk patients (278 cases). These differences were highly significant. A significant declining trend in the annual incidence of cerebral palsy was observed in the total population and the untested population, whereas the rate in the tested population remained relatively constant over the 5-year study interval. The differences in the cerebral palsy rate between the tested and untested population were not related to differences in gestational age, birth weight, or assigned timing or etiology category. In the tested population the relationship between the incidence of cerebral palsy and the last test fetal biophysical profile score was inverse, exponential, and highly significant. CONCLUSIONS: Antepartum assessment by fetal biophysical profile scoring is associated with a significant reduction in the incidence of cerebral palsy compared with untested patients. The relationship between the last test score and the incidence of cerebral palsy is inverse and exponential, suggesting that antenatal asphyxia is an important and potentially avoidable cause of cerebral palsy.

Role of Doppler ultrasonography in the prediction of pregnancy outcome in women with recurrent spontaneous abortion.

We prospectively studied 96 patients with a history of recurrent spontaneous abortion to determine whether the resistive index of the main uterine artery or subchorionic vessels can allow prediction of pregnancy outcome. The subchorionic RI declined progressively for a mean of 0.54 at 6 weeks to 0.42 at 13 weeks (P < 10(-8), F-test). No significant difference was found in subchorionic RI values between outcomes for liveborn infants versus loss. Uterine artery RI values also declined significantly through the first trimester (P < 10(-8), F-test). Uterine artery RI values tended to be lower in pregnancies ending in loss than in successful gestations; however, there was too much overlap for this index to be clinically useful. In conclusion, first trimester RI does not allow prediction of pregnancy outcome in patients with recurrent abortion.

Microcomputer-assisted densitometer for quantitative receptor autoradiography.

We describe here a simple, inexpensive microcomputer-assisted densitometer for use with quantitative receptor autoradiography. The resolution of this system is approximately 100 micron. With this system, and an accompanying program DENSIT, it is relatively easy to convert density values of autoradiograms into molar quantities of bound ligand. The general design of the system and the logic of the DENSIT program are applicable to a variety of hardware systems.

Correlation of muscarinic receptor induction in the ventromedial hypothalamic nucleus with the activation of feminine sexual behavior by estradiol.

The administration of the steroid hormone, 17 beta-estradiol (E2) to ovariectomized rats increases the levels of muscarinic cholinergic receptors by 20-40% in the hypothalamic area. Using microdissection techniques, this increase has been shown to occur in hypothalamic subregions that possess high levels of intracellular receptors for E2. Among these regions is the ventromedial nucleus (VMN), which may be the principal target site in the rat brain for the activation of feminine sexual behavior by E2. In this study, we have further characterized the increase in muscarinic binding within the VMN after E2 and show that it satisfies many of the criteria for an important regulatory mechanism by which E2 could activate sexual behavior: (1) Using quantitative receptor autoradiography, it was determined that the increase in [3H]-QNB binding in the VMN after E2 results from an increase in the number of receptors rather than a change in the affinity of the binding. (2) The increase in VMN muscarinic receptors as determined by the binding of [3H]-QNB to microdissected homogenates occurred by 18-24 h after exposure to E2, the earliest time at which sexual behavior is facilitated. (3) Increased muscarinic receptors did not occur in the VMN of male rats, which show little activation of feminine sexual behavior after E2 exposure. (4) Muscarinic receptors in the VMN of female rats are induced at 24 h by a 6 h exposure to E2, the minimum length of time that is sufficient for E2 to activate sexual behavior. A 4 h exposure to E2 is insufficient to activate both sexual behavior and induce muscarinic receptors.(ABSTRACT TRUNCATED AT 250 WORDS)

Quantitative receptor autoradiography with tritium-labeled ligands: comparison of biochemical and densitometric measurements.

Tritium-labeled receptor ligands are commonly used for quantitative receptor autoradiography with LKB Ultrofilm. In this study, we compared estimates of tritium concentrations by optical density measurements with direct measurements of tritium concentrations by scintillation counting. We found that predominantly grey matter regions of rat brain showed similar tritium concentrations when measured by either method, but that optical density reading of white matter regions indicated a lower tritium concentration than determined by direct measurement with scintillation counting. We also compared measurements of receptor density by quantitative autoradiography with radioligand-binding measurements on microdissected brain regions. Higher per milligram protein levels of muscarinic receptors were obtained by quantitative autoradiography, comparable to the specific activity of receptors found in purified membranes.