Management and outcome of multiple pregnancies complicated by the antenatal death of one fetus.

Over a 15-year period, infants from 1,192 multiple gestations were delivered at Soroka Medical Center, Beer Sheva, Israel. In 21 patients the pregnancy was complicated by the antenatal death of one fetus. In 2 of the 4 cases of monochorionic placenta, both twins died in utero within a short time, while in the 17 cases of dichorionic placenta there was no second fetal death. It seems that in cases of monochorionic placenta, the surviving twin is exposed to a more dangerous environment, and death can occur imminently. The management protocol should be based, if possible, on the type of placentation.

Complications associated with the macrosomic fetus.

A retrospective study was done on 525 infants who weighed more than 4,500 g. The rates of grand multiparity, diabetes mellitus, pregnancy-induced hypertension, deliveries in women over 35 years of age, placenta previa and weight gain of more than 15 kg were higher than in a control group weighing 2,500-4,000 g. The rates of delivery with instruments and cesarean section were also significantly higher. The main indication for cesarean section in the study group was cephalopelvic disproportion, while in the control group it was repeat cesarean section. Rates of postpartum hemorrhage, shoulder dystocia, oxytocin augmentation of labor and tears in the birth canal far exceeded those in the control group. Maternal and fetal morbidity and perinatal mortality were significantly higher than in the control group. The complications were due to a difficult second stage of labor. Delivery of the macrosomic fetus by cesarean section is highly recommended except for the subgroup of women who already delivered a macrosomic child.

Thermodynamic properties of erythrocyte Li efflux may facilitate detection of essential hypertension in pregnant women.

Thermodynamic properties of red cell lithium efflux were examined in pregnant women in relation to hypertension. Twenty-two normotensive women, 15 women with essential hypertension, and 27 with pregnancy-induced hypertension were studied. The rates of Li efflux at 37 degrees C in the three groups of pregnant women were similar and nondiscriminatory. The temperature dependence of the Li efflux, known to be uniquely modified in essential hypertension, allowed the differentiation of most (73%) of the pregnant women with essential hypertension as well. Among the women with pregnancy-induced hypertension, 63% showed a temperature-dependence pattern typical for normotensives, and they may be classified as patients with toxemia of pregnancy. The others (37%) showed a thermodynamic pattern of essential hypertension, but a follow-up study is required to ascertain whether they will indeed develop essential hypertension in the future.

Absence of fetal movements and normal infants.

Pregnant women feel movements from about the fifth month of pregnancy. In cases of high-risk pregnancy daily recording of fetal movements is useful in monitoring fetal well-being. Complete cessation of fetal movements points to a severely distressed fetus and impending death. We report here five women in whom failure to experience fetal movements was present from the beginning of pregnancy, or occurred after fetal movements had been felt for several weeks during the pregnancy. All the women delivered normal infants with high Apgar score.

Uterine rupture during induced mid-trimester abortion.

Uterine rupture during induced mid-trimester abortion is infrequent. Often the diagnosis is established only after manual exploration of the uterus, exploratory laparotomy or even autopsy. It is crucial to establish the diagnosis rapidly and to offer efficient treatment, since the unexpected occurrence of this catastrophe adds to its inherent seriousness. Fourteen cases revealed by a Med-line search and two additional personal cases were reviewed. The most common complaint heralding the rupture was abdominal pain and secondary to it there were signs of blood loss, such as vaginal bleeding, decreased hematocrit level and decreased blood pressure. 72% of women with uterine rupture (10 out of 14) did not abort within 24 h after intra-amniotic injection, and 85% (11 out of 13) had large quantities of oxytocin administered for more than 12 h. The rupture occurred predominantly in the lower segment and there was no preference either for the right or left side of the uterus. It was shown that uterine rupture during mid-trimester induced abortion is not unique to women of high parity or old age. The major complications occurring in induced mid-trimester abortions are similar to those seen in patients who deliver in the third trimester.

PIP: Uterine rupture during induced midtrimester abortion is infrequent. Often the diagnosis is established only after manual exploration of the uterus, exploratory laparotomy, or even autopsy. It is crucial to establish, the diagnosis rapidly and to offer efficient treatment immediately to prevent further complications. 14 cases revealed by a Medline search and 2 additional personal cases were reviewed. The most common complaint accompanying the rupture was abdominal pain; secondary complaints were signs of blood loss, such as vaginal bleeding, decreased hematocrit level, and decreased blood pressure. 72% of women with uterine rupture (10 of 14) did not abort within 24 hours after intra-amniotic injection, and 85% (11 of 13) had large quantities of oxytocin administered for more than 12 hours. The rupture occurred predominantly in the lower segment and there was no preference either for the right or left side of the uterus. It was shown that uterine rupture during midtrimester induced abortion is not unique to women of high parity or old age. The major complications occurring in induced midtrimester abortions are similar to those seen in patients who deliver in the 3rd trimester.

Lipolytic activity in the placentas of chronically deprived fetuses.

Intracellular lipolytic activity and lipoprotein lipase activity were determined in healthy human placental tissue, in placentas obtained from patients with severe pre-eclampsia, and from cases of intra-uterine growth retardation. The level of lipoprotein lipase, which is responsible for the transfer of fatty acids across membranes, was found to be much higher compared with the intracellular lipase and had increased further during pregnancy. Lipoprotein lipase activity was significantly greater in placentas of pre-eclamptic women and in the placentas of intra-uterine growth retarded fetuses. The intracellular lipolytic activity was significantly lower, however, than in controls. The levels of triglycerides and cholesterol were significantly higher in the cord blood of newbornes of women who had pre-eclampsia and in the intra-uterine growth retarded fetuses. The present study indicates that in situations causing fetal distress there are changes in the placenta leading to an increased supply of free fatty acids to the fetus. The role of lipids in fetal metabolism and their transfer across the placenta are poorly understood. The main precursor of fetal lipids in man is believed to be either carbohydrate (5) or maternal blood lipids (10). There is no evidence for the trans-placental flow of intact triglycerides. The plasma free fatty acids (FFA) constitute the only lipid fraction known to cross the placenta and could supply a significant proportion of the fetal requirements (8, 19).

Fetal heart rate tracings in fetuses with congenital malformations.

The fetal heart rate (FHR) tracings of 73 fetuses with gross congenital malformations were surveyed. Fifty-four percent of the tracings were pathologic. The most common pathologic tracing patterns were baseline bradycardia (30%), variable decelerations (25%), baseline tachycardia (22.5%) and decreased variability (20%). There was no characteristic tracing pattern for the whole group or any specific subgroup of malformations. The highest rates of pathologic FHR tracings were found in the groups with multiple malformations (83.3%), chromosomal aberrations (81.8%) and central nervous system lesions (71.4%). Twenty-three infants died neonatally, and 73.9% of them had pathologic FHR tracings. The rate of cesarean section was significantly higher in the group of malformed fetuses--17.8% as compared to 9.5% in the control group. Five of 13 malformed infants delivered by cesarean section died after delivery. Low birth weight and prematurity were more common in the group of malformed fetuses than in the control group. The fact that pathologic FHR tracing patterns occur both in the presence of a malformed fetus and as a result of fetal distress should suggest an early diagnosis of fetal malformation in order to avoid unnecessary obstetric interventions.

Feto-maternal relationships between vitamin D metabolites in Israeli Bedouins and Jews.

The major metabolites of vitamin D, 25-hydroxyvitamin D, 24,25-dihydroxyvitamin D, and 1,25-dihydroxyvitamin D were assayed in the blood of mothers at delivery and in the cord blood of their infants. Twelve Bedouin women and nine Jewish women were investigated; all lived in the Negev desert in Israel. All three vitamin D metabolites were significantly lower in cord than in maternal blood in both groups. Bedouin mothers and infants had significantly lower levels of 25-hydroxyvitamin D and 24,25-dihydroxyvitamin D than did Jewish mothers and infants. Concentrations of 1,25-dihydroxyvitamin D did not differ significantly between the ethnic groups and in both maternal groups were well above the normal range (Bedouins 83.6 pg/ml +/- 11.3; Jews 98.6 pg/ml +/- 12.3). Cord and maternal values for this metabolite were significantly correlated (r = 0.71, p less than 0.001).

Li efflux in erythrocytes of pregnant women: comparison of rates and temperature dependence for detection of hypertension.

Two determinants of lithium efflux in erythrocytes were compared, in relation to pregnancy: (a) efflux rates at 37 degrees C; (b) efflux temperature dependence, expressed by the 'break' of Arrhenius plots. Eighteen women were studied both at term and after delivery. While efflux rates were changed markedly, from 0.87 +/- 0.07 to 0.56 +/- 0.05 mmol/ (IRBC h) at term and post-partum, respectively, the characteristic break temperature of each woman remained essentially constant during and after pregnancy. The property of temperature dependence is more suitable than efflux rates for differentiation of hypertension during pregnancy.

Effect of folic acid supplementation on congenital malformations due to anticonvulsive drugs.

A study was conducted to determine the frequency of malformations among newborn infants of mothers receiving anticonvulsive therapy, with and without supplementation of folic acid. In the retrospective part of the study, the frequency of congenital malformations among the 66 newborn of 24 women who received anticonvulsive drugs without the supplementation of folic acid was 15% (10 children). The defects noted were congenital heart disease, cleft lip and palate, neural tube defects and skeletal abnormalities. Three out of the 10 children were stillborn or died immediately after delivery. In the prospective study of the 22 epileptic women with folic acid supplementation to their anticonvulsive regimen, 33 infants were born alive, without congenital malformations and of normal body weight. The teratogenic activity of anticonvulsant drugs seems to be mediated by interference with folic acid metabolism, and such activity might be influenced by hereditary and environmental factors. When an epileptic woman wishes to become pregnant, it is recommended that folic acid be added to her regimen.

Ethical dilemma of late pregnancy termination in cases of gross fetal malformations.

Modern diagnostic methods reveal an increased number of cases of gross fetal malformations, and physicians are faced with serious ethical considerations. The disclosure of data during conversations with the parents, the decision-making process and the different courses of action are discussed. Cases with defined diagnoses may be divided into three different clinical situations: 1) a malformation incompatible with extrauterine life; 2) increasing organ damage caused by a fetal defect; and 3) a severely handicapped fetus capable of short- or long-term survival. The recent concept of fetal abuse is emphasized. When pregnancy is allowed to continue to term in these cases, psychological and social aspects must be taken into consideration. Medical assessment, ethicolegal norms, and religious beliefs of parents and physicians should guide the course of action. We believe that the medical team should perform late termination of pregnancy when justified and approved by a court or a statutory committee.

Outcome of pregnancy in 31 triplet gestations.

The course of gestation and labor and the outcome of 31 triplet pregnancies were analyzed. Early diagnosis is very important for improving the rate of fetal salvage in multiple pregnancy. The outcome of triplet pregnancies was better in the group of patients with induced ovulation than in the group with spontaneous ovulation. The most frequent antenatal complications were preterm labor (97%), pregnancy-induced hypertension (46%), and anemia (20%). In this series the favorable results were due to earlier diagnosis, prolonged hospitalization, and planned delivery, usually by cesarean section.

Management of pregnancies with rare blood types.

Pregnant women with antibodies to high incidence blood group antigens should be diagnosed as early as possible and red blood cells should be stored frozen for future possible needs. Either autologous, compatible siblings or unrelated individuals' red blood cells should be frozen. The application of such a program is described in three pregnant women with exceedingly rare antibodies to high incidence blood group antigens (anti-Lutheranb, and PP1Pk, and anti c with blood type B CCddee Du negative).

The course of pregnancy in patients with artificial heart valves treated with dipyridamole.

Continuing improvements in cardiac surgery and a wider selection of young patients for prosthetic valve replacement mean that an increasing number of women of childbearing age will undergo such procedures and will also subsequently become pregnant. At present, most patients with prosthetic heart valves are treated with anticoagulant drugs for life. The main problem with anticoagulant therapy during pregnancy is fetal and maternal hemorrhage. Congenital anomalies have been described in infants born to mothers treated with coumarin derivatives during the first trimester of pregnancy. Dipyridamole is known to decrease the adhesiveness of platelets or their ability to aggregate. We report the successful outcome of four pregnancies in patients with Starr-Edwards prostheses who were treated with dipyridamole during their pregnancies.

25 Hydroxycholecalciferol levels in Beduin women in labor and in cord blood of their infants.

25 Hydroxycholecalciferol levels were measured in eight Beduin mothers in labor and in the cord blood of their infants, and compared with values in 42 Sephardi Israeli women in labor and the cord blood of their offspring. Beduin baby cord blood had a mean 25 hydroxycholecalciferol concentration of 3.78 ng/ml +/- 3.22 (SD) being about half of their mothers' level in labor. Values in Sephardi women and cord blood were 3 times higher. PTH levels were lower and calcium concentrations were higher in cord blood (P less than 0.001) in both groups when compared to their mothers' blood. The relevance of these findings to the high incidence of infantile rickets and hyypocalcemia in Beduin children is discussed.

Successful control of pheochromocytoma in pregnancy. Case report.

A patient found to have a pheochromocytoma in the 16th wk of pregnancy was successfully managed by medical treatment with phenoxybenzamine hydrochloride and propranolol. In the 38th wk of pregnancy she was electively delivered by cesarean section, and the tumor was simultaneously removed.

The successful treatment of a case of primary sterility resulting from Fredrickson's Type V hyperlipemia and panhypopituitarism.

Successful treatment of primary sterility in a woman having the rare association of panhypopituitarism with Fredrickson's Type V hyperlipemia is described. Replacement therapy with l-thyroxine, prednisone and a low fat diet cleared the patient's blood of the excessive chylomicrons and very low density lipoproteins. Ovulation was induced with human gonadotrophins, and triplets (two normal girls and a boy) were born.