Expression of platelet-derived growth factor-A mRNA in human placenta: effect of magnesium infusion in pre-eclampsia.

The expression of platelet-derived growth factor-A (PDGF-A) mRNA was examined in the cotyledons of normal human placentae and those from patients with pre-eclampsia. These patients exhibited pre-delivery blood pressure of 154+/-4/99+/-4 mmHg (mean+/-SEM) and met the criteria established for pre-eclampsia. During labour they received MgSO4 infusion for various time intervals (4-25 h). The PDGF-A message was quantitated to beta-actin by the solution hybridization nuclease protection assay. Since the two groups differed in two parameters (pre-eclampsia and MgSO4 treatment), the direct comparison was not feasible. An analysis of covariance revealed a significant difference in the message between the pre-eclamptic and control groups (P<0.01); the gestational age was not a significant covariate for either group but the time on MgSO4 in pre-eclampsia group was significant (P<0.002). A linear regression analysis of PDGF-A mRNA values for the pre-eclamptic group showed a time-dependent downregulation of the message by MgSO4 (P<0.01, r=- 0.796). These results show a uniform expression of PDGF-A mRNA in cotyledons of normal human placenta between 35 and 40 weeks of gestation. Furthermore, MgSO4 has an inhibitory effect on the expression of this message which may have aside from its anticonvulsive action beneficial effect on the function of pre-eclamptic placenta.

Successful magnesium sulfate tocolysis: is "weaning" the drug necessary?

OBJECTIVE: Magnesium sulfate is the most commonly used tocolytic agent for preterm labor. A common clinical practice is to slowly discontinue the drug (wean) after successful tocolysis. Our objective was to determine the necessity of this practice. STUDY DESIGN: A prospective, randomized clinical trial was performed from June 1993 to July 1996. After successful magnesium sulfate tocolysis, patients with preterm labor were randomized to two groups: stopping the drug abruptly (no weaning) or gradually weaning the drug (approximately 1 gm every 4 hours). Preterm labor was defined as documented cervical change with regular uterine contractions or regular uterine contractions with a cervix of 2 cm and 75% effacement. The primary outcome variable was the necessity to reinstitute magnesium sulfate therapy within 24 hours of discontinuation of successful tocolysis. RESULTS: One hundred forty-one patients completed the study. No patient in the no-wean group required retocolysis within 24 hours of magnesium discontinuation. However, eight patients in the wean group required retocolysis within 24 hours of magnesium discontinuation (p = 0.01). Significantly more patients in the wean group had retocolysis during pregnancy (3 vs 12, p = 0.03). Patients in the wean group were also in the labor and delivery unit longer and, as would be anticipated, received magnesium sulfate significantly longer. No differences in the neonatal outcomes were noted between the two groups. Seventy-seven percent of the patients in the study were delivered prematurely. CONCLUSION: This study demonstrated an increased need for retocolysis in the group weaned from magnesium sulfate. We also found that patients in the wean group had an increased labor and delivery time and a longer administration time of magnesium sulfate. Thus weaning magnesium sulfate increases health care cost. The practice of weaning magnesium sulfate does not appear beneficial.

Preterm delivery from 34 to 37 weeks of gestation: is respiratory distress syndrome a problem?

Our purpose was to evaluate the necessity of using tocolytic agents for preterm labor and the benefit of conservative management for preterm premature rupture of membranes from 34 to 37 weeks' gestation. All patients who had accurate obstetric dates and were delivered between 34 and 37 weeks' gestation with no other medical or obstetric problems were retrospectively evaluated for inclusion in the study. The rates of respiratory distress syndrome and other neonatal outcomes were evaluated. A total of 416 patients met criteria for admission into the study. During the thirty-fourth week of pregnancy the incidence of respiratory distress syndrome was 14.9% (p<0.05). Other neonatal complications were also more frequent in deliveries occurring during the thirty-fourth week of pregnancy than in those occurring in the thirty-fifth or thirty-sixth week. Fetal lung maturity studies should be considered and delivery possibly delayed through the thirty-fourth week of gestation to decrease neonatal morbidity in our population.

Latency period after preterm premature rupture of membranes: a comparison of ampicillin with and without sulbactam.

OBJECTIVE: To compare ampicillin with and without sulbactam with respect to the effect on the latency period after preterm premature rupture of membranes (PROM). METHODS: Patients with PROM at 25-35 weeks' gestation were offered participation in a randomized blinded trial comparing ampicillin-sulbactam with ampicillin. Evaluations for cervical pathogens were performed on admission and patients were followed-up with daily maternal and fetal evaluation. Maternal and neonatal outcomes were analyzed using indicated techniques. RESULTS: Fifty-three women were studied, with 25 receiving ampicillin-sulbactam and 28 receiving ampicillin. The ampicillin-sulbactam group had a significantly longer latency period (433 +/- 625 versus 143 +/- 165 hours, P = .03) and significantly fewer neonatal complications (five versus 20, P < .001). Although no neonatal infectious complications were observed in sulbactam-treated cases, there were four cases of neonatal sepsis and two of neonatal pneumonia in the ampicillin group. Also, significantly more neonates in the ampicillin group required prolonged oxygen and ventilatory support. There was no significant difference in maternal morbidity. CONCLUSIONS: In our population with preterm PROM, a broad-spectrum antibiotic that provides anaerobic coverage appears to extend latency and decrease neonatal morbidity without increasing adverse maternal outcome.

Recurrence rate of shoulder dystocia.

OBJECTIVE: Shoulder dystocia continues to be a major complication of obstetrics, and several factors have been identified to help predict its occurrence. A previous shoulder dystocia is one of the risk factors. However, the recurrence rate is unknown. The purpose of this study is to report the recurrence rate of shoulder dystocia. STUDY DESIGN: Our obstetric database was used to identify all vaginal deliveries between January 1983 through December 1992. A subset of vaginal deliveries complicated by shoulder dystocia was selected from this database. These records were reviewed to identify subsequent pregnancies, outcomes, risk factors, and demographic data. RESULTS: During the study period there were 37,465 total vaginal deliveries, with shoulder dystocia complicating 747 (overall rate 2%). Of these 747 cases, 101 patients had 123 subsequent vaginal deliveries, with shoulder dystocia complicating 17 of these pregnancies (13.8% recurrence rate, p < 0.0001). Comparisons were made between those patients with recurrent shoulder dystocia. CONCLUSION: Shoulder dystocia recurred at a rate approximately seven times higher than our primary rate. Whether patients with a history of shoulder dystocia should be offered an elective abdominal delivery requires further investigation.

Snake bite poisoning in pregnancy. A review of the literature.

With our 2 cases, there are 30 reported cases in English of snake bite poisoning in pregnancy with some details presented and 20 cases without details, for a total of 50 cases. We reviewed the maternal and fetal outcomes in the 30 cases that had such information. Poisoning by members of the Crotalidae family (rattlesnakes, cotton-mouths [water moccasins] and copperheads) during pregnancy carries with it a fetal wastage rate of 43% and a maternal mortality rate of 10%. Pit viper bites cause a bleeding diathesis from the fact that the venom of these snakes contains a procoagulant that defibrinates the blood and leads to bleeding throughout the body.

Labor in the gravida with 10 or more years between pregnancies.

It has been suggested that women who have had a pregnancy interval of 10 or more years would have prolonged labor in pregnancies after the first, as do primigravidas. In a series of 94 multiparas with 10 or more years between pregnancies and 63 age-matched, multiparous controls, there was no significant difference in the length of the latent phase of labor or of the first, second and third stages of active labor in the two groups. The concept of a "physiologic primigravida" in these cases should be abandoned.

Hip pain in late pregnancy.

Hip pain in late pregnancy is quite common, and its etiology is rarely established unless acute demineralization occurs. We measured the bone mineral content of both hips in 26 women within 48 hours of delivery. Twelve of 36 densities (33%) were decreased in a group with severe pain when compared to 12 of 120 decreased densities (10%) in the remaining patients (P less than .05). Those data suggest that severe hip pain may be related to a decrease in bone mineral content.

Granular cell myoblastoma of the vulva in a 6-year-old girl.

Granular cell myoblastomas are rare neoplasms thought to arise in neural tissue resembling Schwann cells. About 7% of these tumors are located on the vulva. This is the second reported case in a prepubertal girl with both cases having been found in 6 year olds. None of the vulvar lesions have been malignant. The treatment is wide surgical excision and observation for recurrence. Extragenital sites should be evaluated since multiple tumors are found in a number of patients.

Small bowel obstruction and previous gynecologic surgery.

We reviewed the cases of women admitted to LSU Medical Center in Shreveport with the diagnosis of "small bowel obstruction" from Jan 1, 1975 to June 30, 1981. Review of the charts of patients who had exploratory laparotomy for relief of the obstruction showed that 83% of them had had previous abdominal surgery. Furthermore, 67% of the patients had had an abdominal hysterectomy. In 100% of the cases of obstruction after abdominal hysterectomy, there were adhesions to the site of reperitonealization or to the anterior abdominal wall. This study shows a higher incidence of small bowel obstruction after gynecologic surgery than has been previously reported.

A retrospective study on the effectiveness of a screening effort to reduce the complications of gonorrhea.

In an effort to evaluate the effectiveness of a mass screening program for gonorrhea, a retrospective study was carried out on patients admitted to the hospital with the diagnosis of acute and chronic salpingitis. This study was done at the Confederate Memorial Medical Center in Shreveport, Louisiana. Admissions were reviewed for the year prior to the screening program, and compared to the numbers that were admitted after 2 years of screening. A 70% increase was found to have occurred despite extensive efforts to identify and treat asymptomatic women with gonorrhea, and their male contacts. This finding contrasts dramatically with the experience of others who have reported success in reducing the spread of gonorrhea by such a screening program.

Psychometric testing as a basis for counseling patients choosing a method of contraception. A retrospective survey.

To investigate the merits of using psychometric testing as a predictive adjunct to counseling patients in the choice of a contraceptive method, 134 family-planning patients using an oral contraceptive for one year or longer completed the Neuroticism Scale Questionnaire. Clinic records of these patients were examined to determine consistency of contraceptive usage. Patients who were inconsistent in contraceptive usage scored significantly higher on the anxiety and emotional immaturity for inconsistent users. Results of this study provided support for the findings of two similar studies but failed to provide support for others. However, the over-all predictive ability of the questionnaire scores proved to be low. Further study is recommended.

PIP: 134 family planning patients who had been using oral contraceptives for at least 1 year were administered the Neuroticism Scale Questionnaire (NSQ). This test measures the following factors: 1) sensitivity vs. practicality; 2) depressiveness vs. cheerfulness; 3) submissiveness vs. dominance; 4) anxiety; and 5) total neuroticism. For inconsistent contraceptive users, the anxiety scores were significantly (p less than .05) higher than for consistent users. Scores for the other measures were not significantly higher. Results of this study do not confirm findings of other similar studies. Further work is needed in order to isolate a personality characteristic which would indicate potential contraceptive performance level.

The surgical management of prolapsed pedunculated submucous leiomyomas.

Prolapsed pedunculated leiomyomas of the uterus can best be managed by simple vaginal myomectomy. It is safe, easily performed and generally requires no anesthesia. The risk of complications during and after a major abdominal surgical procedure in the face of infection and anemia is eliminated. Interval hysterectomy, if indicated, may be done four to six weeks after vaginal myomectomy without incurring the additional risk of increased operative morbidity. Additional surgical procedures are not indicated if the pelvic examination remains normal. When large leiomyomas are encountered, the pedicle may not be accessible. Confronted with such a situation and continued blood loss and sepsis, we elected in three patients to replace the tumor within the endometrial cavity and close the cervix. Immediate hysterectomy was then carried out. Blood replacementd antibiotic coverage were instituted in advance of any operative procedure. Other pathologic entities must be kept in mind as a source of uterine bleeding that may be found in association with pedunculated myomas.

Fetal blood lead values in a rural area.

Lead levels were determined from neonatal samples of blood collected at a general-care hospital. The cord blood lead values of babies from urban maternal residences were significantly higher than those from rural environments. The over-all cord blood lead value was (mean +/- S.D.) 9.4 +/- 3.7 micrograms of lead per 100 ml. of whole blood. This level represented a considerably lower value than others previously reported and suggests a lower "normal" value for our population.