McDonald cerclage under pudendal nerve block.

OBJECTIVE: The purpose of our study was to evaluate McDonald cerclage placement with pudendal anesthesia. Patient pain and hospital charges were analyzed and compared with a control group. STUDY DESIGN: This was a prospective, nonrandomized study. Pain was evaluated with a visual analog scale. Two groups were compared with the Student t test. RESULTS: Of 69 patients, 20 had cerclage with pudendal anesthesia; 49 served as control and had cerclage with regional anesthesia. There were no statistical differences in pain between the two groups or complications from pudendal anesthesia, and there was a large cost savings. CONCLUSION: All 20 patients had McDonald cerclage placed successfully with pudendal anesthesia. McDonald cerclage can be easily and safely placed under pudendal anesthesia, resulting in cost savings and improved use of time and resources for the patient and her physician.

Postpartum hemolytic uremic syndrome associated with antiphospholipid antibodies. A case report and review of the literature.

Postpartum hemolytic uremic syndrome (HUS) is described in a woman with a history of spontaneous abortions and both circulating lupus anticoagulant and anticardiolipin antibody (ACA). After termination of her pregnancy because of severe preeclampsia, ACA blood levels increased simultaneously with the onset of a microangiopathic process associated with severe hypertension and renal failure. Plasma exchange resulted in a rapid decline in ACA levels and immediate improvement in her clinical condition. This case strongly suggests an important causal relationship between ACA and postpartum HUS. The possible mechanisms of ACA-related postpartum HUS and the potential role of plasmapheresis in its treatment are reviewed and discussed.

Natural killing (NK) potential of cord blood lymphocytes.

Different parameters of natural killing were evaluated in newborn cord lymphocytes using a 51Cr-release assay, a single cell cytotoxicity technique and an immuno-fluorescence method with HNK-1 monoclonal antibody. Cord blood lymphocytes expressed a positive natural killer (NK) activity although the level of this overall NK activity was lower than that of adult control (p less than 0.05). In neonates the number of cells bearing surface HNK-1 differentiation was very low (0.7 +/- 0.3). Contrary to this finding, newborns showed only a marginal decrease in the percentage of cells capable of recognizing and binding NK-sensitive target cells. However, the killing potential of these lymphocytes was impaired more profoundly (p less than 0.05) compared to adult controls. We conclude that in the neonate two distinct populations of effector cells participate in spontaneous killing. The first group is represented by classically defined NK cells (HNK-1 positive) while the second group represents. NK-like effector cells which lack the HNK-1 antigen. It seems that in newborns the latter type of cells represents the larger factor in spontaneous killing.

Studies of natural killer cells in pregnancy. II. The immunoregulatory effect of pregnancy substances.

This study was performed utilizing a standard 51Cr-release cytotoxicity and a single cell assay against K-562 NK-sensitive target cells. Pregnancy sera and amniotic fluids, were found to decrease human natural killer (NK) activity. Pregnancy sera were able to inhibit overall NK activity of partly purified peripheral blood lymphocytes in a dose dependent fashion. However, the exposure of effector cells to concentrations higher than 20% did not further increase the serum's suppressive activity. Sera taken from preeclamptic pregnancies had a similar inhibitory effect as those from normal pregnancies. Amniotic fluid was found to be even more suppressive than pregnancy serum. Using a single cell cytotoxicity assay we determined that neither serum nor amniotic fluid affected potentially cytotoxic target binding cells ("pre"-NK). The relative number of conjugates with dead target was, however, significantly depressed under the influence of pregnancy serum and to an even greater extent by amniotic fluid. Both pregnancy substances were also able to decrease the number of conjugates with dead target in an interferon-augmented population of lymphocytes. Our investigation indicates that the suppressive effect of amniotic fluid and pregnancy serum on NK activity is based on a blocking effect exerted at the killing capability of the active NK cells.

Direct diagnosis of unruptured ectopic pregnancy by real-time ultrasonography.

Real-time sonography was used in a prospective study of 32 patients as the sole diagnostic parameter for ectopic pregnancy. The minimal finding for diagnosis was an identifiable gestational sac with a circular pattern of echoes. Neither the presence or absence of an intrauterine sac nor the knowledge of either a positive or negative pregnancy test was used in the diagnosis. Among the 32 study patients, the diagnosis of ectopic pregnancy was made by sonography in nine (28.4%). Follow-up surgery confirmed the diagnosis in eight (89%). Among 23 patients with negative findings on sonography, only one was found on follow-up to have an ectopic pregnancy, for a 96% diagnostic accuracy for the negative group. Thus, of 32 patients with the potential diagnosis of ectopic pregnancy, 30 (94%) were correctly diagnosed using real-time sonography alone.

Effects of acetylsalicylic-acid ingestion on maternal and neonatal hemostasis.

In a case-control study, we evaluated the effects of maternal ingestion of acetylsalicylic acid (aspirin) within 10 days of delivery on maternal and neonatal hemostasis. Only one of 34 control maternal-neonatal pairs (3 per cent) had hemostatic abnormalities. In 10 pairs, when maternal aspirin ingestion occurred within five days of delivery, 6 of 10 mothers and 9 of the 10 infants had bleeding tendencies. Seven maternal-neonatal pairs in which aspirin was ingested 6 to 10 days before delivery were free of clinical bleeding. Among seven other mothers who ingested aspirin in the immediate post-partum period four of the seven (57 per cent) also had impaired hemostasis. Neonatal hemostatic abnormalities included numerous petechiae over the presenting part, hematuria, a cephalhematoma, subconjunctival hemorrhage, and bleeding from a circumcision. Maternal bleeding was confined to excessive intrapartum or post-partum blood loss. We conclude that aspirin should be avoided during pregnancy. If ingestion has occurred within five days of delivery, the neonate should be evaluated for the presence of bleeding.

Decrease prostacyclin production: a characteristic of chronic placental insufficiency syndromes.

Prostacyclin production in neonates born at various gestational ages (28 weeks to term) was compared with that in neonates born of pregnancies complicated by various acute and chronic placental insufficiency states. Prostacyclin levels were reflected by the amount of conversion of 14C arachidonic acid to 6-keto-PGF1 alpha (the stable end-product of prostacyclin) by umbilical arteries. The uptake of 14C arachidonic acid by the umbilical arteries was also determined, and since this was similar for all groups it was not the cause of the differences noted in prostacyclin production. Neonates born of normal pregnancies had similar levels of prostacyclin production regardless of gestational age. Prostacyclin production was very low in neonates born of pregnancies complicated by chronic placental insufficiency (intrauterine growth retardation, essential hypertension, and pre-eclampsia), but normal with acute placental insufficiency (abruptio placentae). Hence the decrease in fetal prostacyclin production in pre-eclampsia is not related to gestational age; furthermore, it is also seen in other chronic placental insufficiency states.

Glucagon-induced hypocalcemia in the rat: effects of maturation and insulin.

In adults of several species including man, a small transient decrease in serum calcium concentration follows glucagon administration in doses of 1 to 10 mg/kg. The effects of maturation and insulin on this phenomenon were assessed by comparing the response of newborn and adult rats to equivalent doses of glucagon with and without prior insulin administration. After injection of 1 microgram/g of glucagon, the decrease in serum calcium concentration at 60 min was significant in the newborn rats (-1.75 mg/dl; P less than 0.001) and not significant in the intact adults (-0.07 mg/dl; P greater than 0.1). In pancreatomized adults, the decrease in serum calcium after the same dose of glucagon became significant (-1.23 mg/dl; P less than or equal to 0.01). This hypocalcemic effect was prevented in the pancreatectomized adult rat if insulin in a dose of 0.01 micron/g was given 15 min before glucagon. In the newborn rats, the same dose of insulin decreased the hypocalcemic effect, but the change was still significant (-0.74 mg/dl; P less than 0.01). Glucagon decreased serum calcium at one hr in newborn rats but not in adults. After pancreatectomy, the adult response to glucagon was significant and similar to that of the newborn. Insulin cancelled this effect of glucagon in the pancreatectomized adults and reduced it in the newborns.

Congenital, complete heart block in the infant of a woman with collagen vascular disease. A case report.

Persistent fetal bradycardia may have multiple etiologies. The following represents a case of persistent fetal bradycardia due to congenital heart block in the infant of a woman with suspected collagen vascular disease. A review of the literature and a discussion of the association of maternal collagen vascular disease and congenital heart block is presented. The prognosis of infants with congenital heart block is reviewed and the possible association with growth retardation discussed.

Further investigation on the predictive value of human placental lactogen in high-risk pregnancies.

Blood samples were taken from 254 women with pregnancies with various complications and 119 completely normal pregnant women for measurement of serum human placental lactogen (hPL) during the third trimester. The value of this test in the management of these pregnancies was retrospectively evaluated through details of outcome. Serum hPL and urinary estriol were compared as tools for assessment of fetal condition. Serum hPL was found to be very efficient in the prenatal diagnosis of intrauterine growth retardation associated with maternal hypertension. Low hPL levels were recorded in all severely hypertensive patients who were delivered of small-for-dates infants (a 100 per cent prediction rate), while 30 per cent of these patients had normal estriol values. Prediction rate of postmature infants by serum hPL level was 70 per cent as compared to 50 per cent by urinary estriol level. The diagnostic significance of low hPL levels is emphasized, with stress upon its value in early detection of unfavorable intrauterine environment. The importance of preterm deliveries in pregnancies involving intrauterine growth retardation and low hPL levels is discussed and demonstration cases are presented.