Surgical treatment of uterine atony employing the B-Lynch technique.

Postpartum hemorrhage remains a major cause of maternal morbidity and mortality. Four cases utilizing the B-Lynch technique for control of hemorrhage secondary to uterine atony are presented. The B-Lynch technique appears to be effective in controlling postpartum hemorrhage. More experience is needed before the B-Lynch technique can be accepted as routine practice.

Activated protein C resistance and lupus anticoagulant in pregnancy.

Thrombophilias, both inherited and acquired, have been reported to be associated with thromboembolic events and severe obstetric complications. This case report examines the case of a patient with two thrombophilias, activated protein C resistance secondary to Factor V Leiden mutation and lupus anticoagulant.

Hyperparathyroidism in pregnancy: diagnostic dilemma?

Primary hyperparathyroidism is rarely encountered in pregnancy. Because the symptoms may be variable in nature, the diagnosis may be delayed with an increase in maternal and perinatal morbidity or mortality. Several of the symptoms and clinical findings in hyperparathyroidism may also be present with preeclampsia, thus causing difficulty in distinguishing one from the other. Our case report describes a pregnant patient in the third trimester with HELLP syndrome and primary hyperparathyroidism.

Gestational diabetes: postpartum glucose tolerance testing.

OBJECTIVE: Our purpose was to determine the incidence of and evaluate risk factors for postpartum glucose intolerance among predominantly black gestational diabetic women. STUDY DESIGN: One hundred forty-five gestational diabetics underwent a standard 2-hour glucose tolerance test in the early puerperium according to the criteria of the National Diabetes Data Group. RESULTS: Fourteen patients (10%) were diabetic and eight (5%) showed impaired glucose tolerance. Maternal age, race, or obesity did not predict abnormal postpartum glucose tolerance testing. The requirement of insulin for glucose control during gestation and gestational age at diagnosis were significantly associated with abnormal postpartum glucose tolerance (p < 0.0001 and p = 0.012, respectively). Multivariate analysis showed that only a requirement for insulin for glucose control was significant (p < 0.001). CONCLUSION: Pregnancies complicated by gestational diabetes are at increased risk of glucose intolerance during the early postpartum period. Abnormal glucose tolerance occurs predominantly among those patients requiring insulin therapy during gestation or those diagnosed before 24 weeks' gestation.

Mode of ascertainment is critical in assessing safety of percutaneous umbilical blood sampling.

Percutaneous umbilical blood sampling (PUBS) is increasingly utilized for cytogenetic assessment of the fetus. In the present study, outcome of 109 PUBS-derived fetal blood samples were analyzed according to mode of ascertainment: ultrasound-detected anatomic anomalies or intrauterine growth retardation (IUGR). Abnormal chromosome complements were found in 6 of 47 (12.8%) fetuses with anomalies but in only 1 of 62 (1.6%) fetuses with IUGR alone. Perinatal loss in fetuses with anatomic anomalies was 64.4%, compared with only 1.6% in fetuses with IUGR alone. Mode of patient ascertainment is an important factor that must be considered in determining procedure-related risks for PUBS.

A conference on ethics for obstetric and gynaecological clerkship students.

Integrating the teaching of medical ethics into medical students' clinical education is challenging, given the competing demands on students' time and the need for teaching to be clinically relevant. This paper describes a model programme for incorporating ethics teaching into the obstetrics and gynaecology clerkship for third-year medical students. The programme is taught by two attending teachers and a medical ethicist with experience teaching in the clinical setting of obstetrics and gynaecology. Objective pretests and posttests showed substantial improvement in students' knowledge, and student feedback has been very positive.

Prenatal counselling and diagnosis in progressively deforming osteogenesis imperfecta: a case of autosomal dominant transmission.

A 21-year-old woman with progressively deforming or type III osteogenesis imperfecta (OI) presented for prenatal counselling and diagnosis at 10 weeks' gestation. Family history was non-contributory. At 14.8 weeks' gestation, ultrasonographic examination revealed fetal skeletal hypomineralization, easily compressible fetal cranium, and thickened long bones, indicating that the fetus was also affected. Confirmation of the prenatal diagnosis of OI type III was made following a Caesarean section birth of a male infant with multiple skeletal deformities and blue sclerae implying, in this case, autosomal dominant inheritance.

Prenatal glucose screening.

Of 3,563 consecutive obstetric patients undergoing glucose screening, 517 (14.5%) were found to have plasma values of greater than or equal to 140 mg%, and 74 (14.3%) of 517 were found to be diabetic on standard oral glucose tolerance testing, for an overall incidence of 2.1%. There was no absolute value on the glucose screen that predicted an abnormal oral glucose tolerance test. Twenty-eight of the 74 diabetics demonstrated none of the classic risk factors for glucose intolerance during pregnancy. Only when combining those patients over 30 years of age and with a mean body weight greater than 120% of the ideal body weight was statistical significance reached when that group was compared to the overall group. Thus, our data support the recommendation for universal prenatal glucose screening.

Pruritus in pregnancy.

Diagnosis of the cause of pruritus in a pregnant patient should be approached systematically, beginning with a detailed history (especially drug exposure) and physical examination. Systemic diseases must be excluded. Liver function tests and hepatitis screen are in order if symptoms suggest liver dysfunction. Stool examination for ova and parasites may be included when there is no skin lesion. Biopsy of an obvious skin lesion or a specific radioimmunoassay may be helpful. A dermatologic consultation is warranted when the diagnosis is in doubt and skin lesions are present. An accurate diagnosis is imperative since certain dermatologic disorders may increase maternal and fetal morbidity and even mortality.

Comparison of capillary and plasma glucose values in screening and oral glucose tolerance testing in pregnancy.

The substitution of capillary reflectance meter glucose values for plasma or serum glucose values would be practical and cost saving. A direct comparison was performed of simultaneous capillary reflectance meter and plasma glucose values in routine screening and oral glucose tolerance testing in a pregnant population. The use of capillary glucose in 50-g glucola screening had a sensitivity of 82.6% and specificity of 98.1% as compared to the standard plasma method. Even though our data demonstrate a good correlation (r = 0.897) between capillary and plasma glucose values, our results do not support the direct substitution of plasma glucose values with capillary reflectance meter glucose values in screening for or diagnosing glucose intolerance in an obstetric population.

Intrauterine transfusion via umbilical vein in severe Rh isoimmunization.

Although the widespread use of anti-D immune globulin has dramatically reduced the incidence of Rh isoimmunization, an occasional pregnant patient becomes a candidate for intrauterine transfusion because of sensitization to Rh antigens or irregular red blood cell antigens. Current methods of ultrasonography provide needle guidance to the umbilical vein, permitting fetal intravascular transfusion. We have reported a case involving five separate intrauterine transfusions via the umbilical vein.

Computed tomography in acute fatty liver of pregnancy.

A case of the diagnosis of acute fatty liver of pregnancy proved by biopsy is described. In this case computed tomography showed decreased attenuation over the liver, and this attenuation is compatible with fatty infiltration. Computed tomography may be useful in the differential diagnosis of jaundice in pregnancy.

Ultrasonically guided direct umbilical cord blood sampling.

Ultrasonically guided umbilical cord blood sampling (funicentesis) allows rapid karyotyping and diagnosis of fetal viral infections and other fetal diseases. This technique may also aid in the management of fetal disease. One of three fetuses studied had a chromosomal abnormality, trisomy 18. None had evidence of viral infection.

Pruritus in pregnancy.

Pruritus occurs frequently during pregnancy; the reported incidence ranges from 3% to 14% of all pregnancies. Pruritus may occur with or without skin lesions, and may be an exaggerated response to a physiologic adaptation to pregnancy, a manifestation of a systemic disorder, or a primary skin disease. We review the most serious skin disorders associated with pregnancy and present an easy, logical approach to their diagnosis and management.

Attitudes of mothers of children with Down syndrome concerning amniocentesis, abortion, and prenatal genetic counseling techniques.

Mothers of children with Down syndrome were surveyed by questionnaire concerning their attitudes about amniocentesis, prenatal genetic counseling, and abortion. Of the 101 who responded, 40 had borne children after giving birth to a child with Down syndrome. Half had amniocentesis in subsequent pregnancies but only half of these said they would abort the pregnancy if Down syndrome was confirmed. Extreme variations in opinions were noted among the replies. Recognizing patient ambivalence and attempting to provide counseling that represents both positive and negative data about Down syndrome may help physicians avoid conflicts with patients who request prenatal genetic counseling.

Immunoglobulin G subclasses and isoimmunized pregnancy outcome.

Immunoglobulin G antibodies are the most frequent type of red blood cell isoantibodies. They possess the ability to traverse the placenta and may cause hemolytic disease in newborn infants. Of the four subclasses, IgG1 and IgG3 are effective at binding erythrocytes to monocyte-macrophages and therefore are potentially destructive to erythrocytes. IgG2 and IgG4 are unable to react effectively with receptor sites on phagocytic cells and so are totally inactive relative to hemolysis. IgG subclasses were identified in 22 consecutive isoimmunized antepartum patients. Fifteen patients were subsequently delivered of babies who were either affected by or susceptible to hemolytic disease of the newborn. When maternal antibodies consisted of IgG1 only, hemolytic disease of the newborn developed in four of five cases. When only IgG3 was present, each of two patients developed hemolytic disease of the newborn. In eight cases both IgG1 and IgG3 were present and all the babies were born with hemolytic disease of the newborn. Determination of IgG subclasses might prove to be a useful adjunct in evaluating isoimmunized pregnancies. However, the limited information available does not permit the use of IgG subclasses exclusive of traditional means of diagnosis and management of isoimmunized pregnancies.

First trimester chorionic villi sampling and direct chromosome preparations.

Chorionic villi sampling was performed on 52 patients prior to elective termination of their pregnancies. Villi were obtained in 42, and direct chromosome preparations were successful in 41 of them. The use of a mixture of 0.075 M potassium chloride and 1% sodium citrate in the ratio of 2:1 for hypotonic treatment and 40% acetic acid for cell dispersal yielded chromosomes with good morphology and G-bands.

Genetic amniocentesis: a twelve years' experience.

The first 2,013 fetuses in 2,000 patients undergoing genetic amniocentesis at our institution were analyzed for the incidence of abnormal findings and for the safety and accuracy of the procedure. One percent of the patients were found to have aneuploid fetuses and another 1% were found to have elevated amniotic fluid concentrations of alpha-fetoprotein. Advanced maternal age was the indication for amniocentesis in 84% of the women with aneuploid fetuses. Thirty-two (1.6%) of the pregnancies ended in spontaneous abortion and 35 (1.7%) were terminated because of abnormal results of the prenatal diagnostic procedure. Our error rate was 0.15%, and tissue culture was successful in 97.7% of the procedures. During the latter part of our experience concurrent ultrasonography was utilized with the amniocentesis, resulting in a reduction in blood-tinged specimens from 15.0% to 5.2%. In experienced hands, midtrimester amniocentesis for the purpose of prenatal diagnosis of genetically determined defects is a safe, accurate, and valuable procedure for the identification of fetal abnormalities.

Late postpartum eclampsia: an update.

Eclampsia occurring more than 48 hours postpartum has been observed in an unusual number of patients. From August 1977 to November 1982 at E. H. Crump Women's Hospital and Perinatal Center (Memphis), there were 132 documented cases of eclampsia, of which 36 (27%) occurred postpartum. Seventeen (47%) of these occurred more than 48 hours postpartum. Preeclampsia was diagnosed before the onset of convulsions in 12 patients, all of whom received intravenous magnesium sulfate postpartum. The mean duration of postdelivery magnesium sulfate therapy was 32 hours (range 24 to 72 hours). Headaches and visual disturbances were reported by all 17 patients before onset of convulsions. Physical and laboratory findings immediately after the convulsions were consistent with eclampsia. Treatment consisted primarily of intravenous magnesium sulfate. Neurologic consultation was obtained to rule out a neurologic disorder, and metabolic studies were also done. Electroencephalograms were done on 15 patients; eight of them showed patterns consistent with encephalopathy.