Rate of spontaneous abortion after first trimester sonographic demonstration of fetal cardiac activity.

The incidence of spontaneous abortion once embryonic development has reached the stage of sonographically demonstrable cardiac activity has not been precisely determined in a large population. This retrospective study was designed to determine the risk of pregnancy loss after first trimester sonographic confirmation of fetal cardiac activity. A total of 840 patients were referred for ultrasound examination to the Perinatal Center, University of Cincinnati, between January 1, 1979 and December 31, 1985 who fulfilled the criteria of singleton pregnancy with sonographically visible fetal cardiac activity and crown-rump length consistent with gestational age less than or equal to 12 weeks. Patients were grouped into two categories based on the absence (control) or presence of vaginal bleeding (bleeding) prior to or at the time of the ultrasound examination. The abortion rates for the two groups were 5.2 and 16.4%, respectively (P less than 0.001). The relative risk of abortion in patients with vaginal bleeding was nearly four-fold greater than the control population. In the control group there was a significantly greater incidence of pregnancy loss in the greater than or equal to 34 years age group compared to less than 34 years age patients (4.4 versus 11.1%, P less than 0.05). Although there was no significant effect of race on abortion rates, low socioeconomic status almost doubled the relative risk of miscarriage. We conclude that the presence of visible fetal cardiac activity in the first trimester predicts a decreased risk for spontaneous abortion compared to generally reported rates. The significant risk factors for increased chance of abortion are vaginal bleeding, advanced maternal age, and low socioeconomic status.

The effect of different intravenous nutritional regimens on renal function during acute renal failure in the rat.

Acute renal failure in the surgical patient is accompanied by a state of hypermetabolism and increased catabolism. Nutritional therapy is therefore directed at the preservation of body cell mass and protein synthesis for repair of wounds and damaged renal tubuli and for maintenance of host defense mechanisms. We examined the effect of two levels of protein intake (18.4 +/- 1.4 and 30.8 +/- 2.4 mg N/100 g BW/day) and three different amino acid formulations (Freamine III, Nephramine, and a made-up mixture of Nephramine + Freamine HBC) on renal function following mercury chloride-induced acute renal failure in the rat. All animals suffered severe renal failure manifested by increased plasma urea and creatinine levels, decreased creatinine clearance, and increased fractional excretion of sodium. On day 4 of acute renal failure, rats receiving low dose amino acids had better-preserved renal function than those receiving high dose amino acids. However, the type of solution infused did not affect recovery of renal function.

Short-term, high-dose, systemic steroids in children with asthma: the effect on the hypothalamic-pituitary-adrenal axis.

Children with chronic asthma frequently receive "bursts" (less than 7 days) of short-term, high-dose prednisone (1 to 2 mg/kg/day) for acute exacerbations of their disease. Certain of these patients may also require inhaled corticosteroids (IC) for control. The effect of these "bursts" on the hypothalamic-pituitary-adrenal axis (HPAA) is unclear. To test the integrity of the HPAA in such patients, we measured plasma cortisol (F) in response to serial administration of insulin-induced hypoglycemia (nadir = 34 +/- 1.2 mg/dl; mean +/- SE), followed by 250 micrograms/1.73 m2 of synthetic ACTH in the following children with asthma: group I, seven patients who received no more than one "burst" per year (0.71 +/- 0.2); group II, six individuals who received more than one "burst" per year (3.6 +/- 0.2) and no IC; and group III, 10 subjects who received more than one "burst" per year (4.7 +/- 0.3) plus IC. All patients received daily theophylline and beta-agonists; seven patients were taking sodium cromolyn. No patients received troleandomycin. Compared to group I (control subjects), 16% of group II had a subnormal response of F to hypoglycemia. In addition, a subnormal response of F to hypoglycemia or ACTH was documented in 20% and 10% of group III, respectively. All individuals with a subnormal response of F to either hypoglycemia or ACTH received four or more "bursts" per year. We conclude that as a group, children affected by asthma treated with "bursts" alone or "bursts" plus IC appear to have a normal HPAA.(ABSTRACT TRUNCATED AT 250 WORDS)

Decreased maternal serum magnesium concentration and adverse fetal outcome in insulin-dependent diabetic women.

Insulin-dependent diabetic pregnant women are at risk for magnesium deficiency, predominantly because of increased urinary magnesium losses. They also have a high incidence of spontaneous abortion, possibly related to major lethal malformations. We tested the hypothesis that adverse fetal outcome (fetal loss before 20 weeks' gestation and/or congenital major malformations) is related to magnesium status (as assessed by determining serum magnesium levels) in insulin-dependent diabetic pregnant women, even after sonographic documentation of fetal viability. Eighty-four insulin-dependent diabetic women (class B to RT) with 96 pregnancies were recruited prospectively in a program project. Serum magnesium and blood glycohemoglobin were measured at about nine weeks' gestation. Blood glycohemoglobin was higher (P = .039) and serum magnesium concentration lower (P = .05) in the 21 pregnancies that ended in adverse fetal outcome, compared with the other (75) successful pregnancies. When compared with the "successful pregnancy" group, blood glycohemoglobin was higher (P = .012) and serum magnesium lower (P = .037) in the subgroup of nine pregnancies with fetal cardiac activity present by ten weeks and ending in adverse fetal outcome, compared with the 64 equivalent pregnancies in the "successful" group. We speculate that decreased magnesium status may contribute to the high spontaneous abortion and malformation rate in insulin-dependent diabetic pregnant women.

Management of the insulin-dependent diabetic during labor and delivery. Influences on neonatal outcome.

Infants of insulin-dependent diabetic mothers are at risk for neonatal polycythemia, hyperbilirubinemia, respiratory distress syndrome (RDS), and hypoglycemia. The purpose of this study was to determine whether labor and delivery management of diabetes may influence the rate of these complications. We hypothesized a priori that: infants of diabetic mothers delivered by cesarean section have a lower rate of neonatal polycythemia and hyperbilirubinemia, but a higher rate of RDS, than infants of diabetic mothers delivered by vaginal route, and poor glycemic control during labor increases the rate of neonatal hypoglycemia. We therefore prospectively studied 122 pregnancies in 100 well-controlled insulin-dependent diabetic mothers. Intravenous glucose and/or insulin was infused during labor to maintain capillary glucose concentration between 70 and 100 mg/dl. Fifty-six pregnancies were concluded by primary or elective cesarean section (group 1), 36 by cesarean section following spontaneous or induced labor (group 2), and 30 by spontaneous or induced vaginal delivery (group 3). Hemoglobin A1, birthweight, and gestational age were similar in all three groups. The rate of neonatal polycythemia was significantly lower in the cesarean section subjects, groups 1 and 2, as compared to group 3 (P less than 0.04). The rate of neonatal hyperbilirubinemia was significantly lower in group 1 (P less than 0.05) as compared to groups 2 and 3. The rate of RDS was higher in group 1 (versus groups 2 or 3), but did not reach significance on initial analysis (P = 0.06); however, group 1 was associated with a significant risk for RDS when corrected for the confounding variables of gestational age and neonatal asphyxia as defined by Apgar scores.(ABSTRACT TRUNCATED AT 250 WORDS)

Respiratory distress syndrome in infants of diabetic mothers in the 1980s: no direct adverse effect of maternal diabetes with modern management.

The purpose of this study was to test the hypothesis that diabetes in pregnancy in the 1980s no longer represents a direct risk factor for the development of respiratory distress syndrome (RDS) independent of gestational age, race, sex, mode of delivery, and neonatal asphyxia. We pair-matched 127 infants of diabetic mothers (diabetic group) with 127 infants of nondiabetic mothers (controls) for the above factors. Diabetic mothers enrolled before nine weeks' gestation were randomly assigned to one of two groups: I. "strict management," to achieve euglycemic (fasting blood glucose less than 80 mg/dL, 1.5-hour-postprandial blood glucose less than 120 mg/dL); II. "customary management," to provide care "as practiced in the community" (fasting blood glucose 100 mg/dL or less, postprandial blood glucose less than 140 mg/dL). A group enrolled after the first trimester (III) was managed identically to group II. Infants of diabetic mothers had a rate of RDS of 13.4%, not significantly different from the rate of 15% in controls (P greater than .05). When analyzed by gestational age groups of less than 36, or 36 or more weeks' gestation, there was also no difference in frequency of RDS between the diabetic group and controls. By logistic regression analysis, the presence of RDS in infants of diabetic mothers significantly correlated with lower gestational age (P less than .0001), and delivery by cesarean section not preceded by labor (P less than .01)(ABSTRACT TRUNCATED AT 250 WORDS)

Pediatric predictive index for hospitalization in acute asthma.

To develop a pediatric predictor index (PPI) for the outcome of emergency management of acute asthma, 156 children were studied prospectively and grouped by outcome. Of 193 episodes, 130 (67.4%) resulted in successful treatment, 39 (20.2%) in relapse, and 24 (12.4%) in admission. Measured and observed variables from before and after initial therapy were analyzed for the three groups. There were no significant differences between the relapse and successful treatment groups, which were combined for analysis and termed the discharge group. Significant differences were noted between the admission and discharge groups only for dyspnea before and after therapy, accessory muscle use, inspiratory breath sounds and wheezing, and post-respiratory rates, but not for pulse or peak expiratory flow rates before or after therapy. The PPI was determined with multivariate logistic regression and is calculated using the following variables: inspiratory breath sounds, wheezing, and respiratory rates. A score of 0 correctly categorized 95% of admissions, but incorrectly categorized 34% of those discharged. Despite low specificity and limited usefulness as early predictors of admission, PPI variables may serve as valuable adjuncts to the physician in determining the outcome of acute asthma in children.

Neonatal polycythemia in infants of insulin-dependent diabetic mothers.

The rate of neonatal polycythemia was determined prospectively in 34 infants of diabetic mothers pair-matched to 34 infants of nondiabetic mothers (control group) for site of sampling, time of sampling, time of cord clamping, gestational age, mode of delivery, and one- and five-minute Apgar scores. Polycythemia (venous hematocrit greater than or equal to 65%) was present in 29.4% of infants of diabetic mothers and 5.9% of control subjects (P less than .03). Mean nucleated red blood cell counts were significantly higher in infants of diabetic mothers than in controls. Polycythemia did not correlate with higher maternal hemoglobin A1 concentration or with increased infant weight percentile, but did correlate with neonatal hypoglycemia. The authors speculate that increased erythropoiesis exists in infants of diabetic mothers and might be subsequent to fetal hypoxemia due to fetal hyperglycemia, hyperinsulinism, and hyperketonemia.

Cardiac function during protein malnutrition and refeeding in the isolated rat heart.

In an attempt to elucidate the effect of protein restriction and subsequent refeeding on cardiac muscle function, 133 rat hearts were studied on a Langendorff perfusion apparatus: 19 normal controls, 55 rats during 6 weeks of protein restriction, and 59 rats during 6 weeks of refeeding following starvation. During starvation animals lost 14.3% of body weight and 12.8% in heart weight, both to be gained upon refeeding. Both developed force and force velocity tended to decrease in starving rats compared to control or refeeding rats. This trend was present at time 0, but more so after 60 min of perfusion. Furthermore, these differences became even more obvious and significantly different at the higher heart rates of 300 and 400 beats/min, and less so at 100 or 200 beats/min. These protein malnutrition-associated cardiac function derangements reversed almost completely to normal upon refeeding.

Regional brain amino acid and neurotransmitter derangements during abdominal sepsis and septic encephalopathy in the rat. The effect of amino acid infusions.

Regional amino acids and brain neurotransmitters were studied in 33 normal and 32 rats with sepsis (induced by cecal ligation and puncture) infused with different amino acid formulations. The brain amino acid pattern during sepsis showed increased concentrations of most essential and six of the nonessential amino acids. The most consistent finding was the accumulation of indoleamines in all six brain regions studied during sepsis; increased brain tryptophan levels presumably resulted in enhanced metabolism of serotonin (5HT), increased production of 5-hydroxyindoleacetic acid (5HIAA), and a high 5HT/5HIAA ratio. Infusion of branched-chain amino acid-enriched formulas restored brain amino acid and neurotransmitter profiles, decreasing levels of tryptophan, tyrosine, 5HIAA, and 5HT/5HIAA ratios while increasing norepinephrine levels in some regions. These alterations in brain neurotransmitter metabolism may be at least partially responsible for the development of septic encephalopathy.

Elevated maternal glycohemoglobin in early pregnancy and spontaneous abortion among insulin-dependent diabetic women.

Insulin-dependent diabetic women without adequate glucose control have a higher rate of spontaneous abortions than does the general population of pregnant women. The present study examined whether insulin-dependent diabetic women who experienced spontaneous abortions had higher levels of glycohemoglobin in the first trimester than did insulin-dependent diabetic women who had normal pregnancy outcomes. Measurement of glycohemoglobin during the first trimester provides an integrated, retrospective index of glucose control during the phase of organogenesis. This study evaluated 116 pregnancies in 75 insulin-dependent diabetic women. Ninety pregnancies progressed beyond 20 weeks, with normal outcome. Twenty-six pregnancies terminated in spontaneous abortions before 20 weeks. The mean gestational ages for sampling of glycohemoglobin for the women who experienced spontaneous abortion and those for the women with pregnancies of more than 20 weeks were not significantly different. The mean level of glycohemoglobin for the women who experienced spontaneous abortions was significantly greater than that for the women with pregnancies of more than 20 weeks (p less than 0.05). Individual levels of glycohemoglobin of less than 12% at 8 to 9 weeks' gestation were associated with favorable outcomes, whereas levels of glycohemoglobin of more than 12% were predictive of a greater incidence of spontaneous abortions (p less than 0.05). These data suggest that the poorly controlled pregnant diabetic patient, as reflected by high levels of glycohemoglobin early in pregnancy, has an increased risk of spontaneous abortion.

Treatment of premature labor in insulin-dependent diabetic women.

This retrospective study was designed to analyze the safety and efficacy of beta-sympathomimetic agents used to treat premature labor in insulin-dependent diabetic women. The study evaluated 12 insulin-dependent diabetic women who experienced 15 pregnancies complicated by premature labor. A group of 30 insulin-dependent diabetic women who delivered at term served as matched controls. Treatment consisted of parenteral and oral administration of beta-sympathomimetic drugs (ritodrine and isoxsuprine). Premature labor was diagnosed, and tocolytic treatment was initiated at a mean gestational age of 31.5 +/- 0.9 weeks. The mean gestational age at the time of delivery was 35.8 +/- 0.5 weeks. Delivery was delayed in the study group by a mean of 30.5 +/- 6.6 days. No fetal or infant deaths occurred in the study group, and there was no difference between the two groups in the incidence of neonatal morbidity. No maternal complications occurred. There were no significant differences in hemoglobin A1 levels between the two groups at any period of gestation. Thus, beta-sympathomimetic drugs may be used safely to treat premature labor in patients with insulin-dependent diabetes, provided they are administered under strictly controlled clinical settings.

Spontaneous abortion among insulin-dependent diabetic women.

A prospective study was undertaken to evaluate the frequency of spontaneous abortion in clinically apparent pregnancies among insulin-dependent diabetic women evaluated prior to pregnancy. The study was done in 132 pregnancies occurring in 91 diabetic women. The spontaneous abortion rate was 30%; 70% of the pregnancies progressed beyond 20 weeks. The abortion rates for Classes B, C, D, and F through RT were 0%, 25%, 44%, and 22%, respectively. Initial serum levels of the beta-subunit of human chorionic gonadotropin above 6000 mIU were usually associated with favorable outcome while levels below 6000 mIU were not predictive of outcome. Data from this study suggest that the risk of spontaneous abortion among insulin-dependent diabetic women may be substantially higher than for the general population. Higher abortion rates were generally associated with more advanced White classification of diabetes. Age at diagnosis was the only factor which showed a significant contribution to the risk of abortion.

Birth trauma: incidence and predisposing factors.

The authors retrospectively studied 13,870 singleton full-term consecutive live births at a major teaching hospital and assessed the frequency of brachial plexus injury, clavicular fracture, and facial nerve injury in newborns delivered from January 1974 through December 1977 and from January 1979 through September 1981. Predisposing factors relating to mechanical birth trauma were defined, and a risk assessment profile was developed to identify the fetus at risk. Mechanical injuries were identified according to the International Classification of Diseases codes 761. The incidence of selected birth injuries in the study group were: brachial plexus injury, 2.6 per 1000 or 1 in 385 single full-term live births; fractured clavicle, 2.0 per 1000 or 1 in 495 single full-term live births; and facial nerve injury, 7.5 per 1000 or 1 in 133 single full-term live births. There were 162 full-term infants born with 168 injuries relevant to this study. Of the six infants who incurred more than one injury, three had a combined fractured clavicle-brachial plexus injury, and three had facial nerve-branchial plexus injuries. Logistic regression analysis of fetal, maternal, and intrapartum complications in labor and delivery revealed that midforceps , shoulder dystocia, low forceps, infants greater than 3500 g, and second stage labor exceeding 60 minutes were the predominant events associated with fetal injury. The authors then applied a risk assessment profile to successfully identify over 50% of the injured and 84% of the uninjured groups. From their results, the authors suggest that obstetricians should alert the pediatricians when these predisposing factors exist to aid in the recognition and early treatment of these birth injuries.

High malformation rates and decreased mortality in infants of diabetic mothers managed after the first trimester of pregnancy (1956-1978).

Over a period of 23 years we accumulated data on 182 pregnant juvenile diabetic subjects during pregnancy, labor, and delivery. Diabetic subjects were evaluated generally after the first trimester of pregnancy. Data examined included diabetic class, maternal complications of pregnancy, and infant morbidity and mortality. Data were analyzed in two periods-before and after 1970. In the second period, maternal polyhydramnios and acidosis rates improved, neonatal problems of homeostasis did not change significantly, and combined fetal and neonatal losses fell from 34.7% to 16.4%. The neonatal malformation rate, however, increased from 1.4% to 16.8% and was not influenced by maternal age or diabetic class.

Infusion of branched-chain enriched amino acid solution in patients with hepatic encephalopathy.

Hospitalized patients with hepatic insufficiency often suffer from severe catabolic states and are in urgent need of nutritional support during their acute illness. Protein intolerence, however, remains a significant problem with respect to the provision of adequate nutrition, either enterally or parenterally. The following report is an anecdotal series of 63 consecutive patients in a large urban hospital treated prospectively with nutritional support using a prototype high branched-chain amino acid solution (FO80) given by technique of total parenteral nutrition by the subclavian or internal jugular route with hypertonic dextrose. Sixty-three patients, of which 42 had chronic liver disease (cirrhosis) with acute decompensation and 17 with acute hepatic injury as well as four with hepatorenal syndrome, are the subject of this report. All required intravenous nutritional support and were either intolerant to commercially available parenteral nutrition solutions or were in hepatic encephalopathy at the time they were initially seen. The cirrhotic patients had been hospitalized for a mean of 14.5 +/- 1.9 days before therapy, had a mean bilirubin of 13 mg/100 ml, and had been in coma for 4.8 +/- 0.7 days despite standard therapy. Patients with acute hepatitis had been in the hospital for 16.2 +/- 4.1 days before therapy, had a mean bilirubin of 25 mg/100 ml, and had been in coma 5.2 +/- 1.6 days before therapy. Routine tests of liver function, blood chemistries, amino acids, EEGs, and complex neurological testing including Reitan trailmaking tests were used in the evaluation of these patients. Up to 120 grams of synthetic amino acid solution with hypertonic dextrose was tolerated in these patients with improvement noted in encephalopathy of at least one grade in 87% of the patients with cirrhosis and 75% of the patients with hepatitis. Nitrogen balance was achieved when 75 to 80 grams of synthetic amino acids were administered. Survival was 45% in the cirrhotic group and 47% in the acute hepatitis group. Encephalopathy appeared to correlate with individual amino acids differentially in the various groups and with the ratio between the aromatic and the branched-chain amino acids. Ammonia did not correlate with either the degree of encephalopathy or improvement therefrom. In 24 Patients therapy for hepatic encephalopathy was limited to infusion of the branched-chain enriched amino acid solution only, with wake-up in 66% of this group. The results strongly suggest that in protein intolerant patients requiring nutritional support, infusion with branchedchain enriched amino acid solutions is well tolerated with either no worsening of or improvement in hepatic encephalopathy coincident with the achievement of nitrogen equilibrium and adequate nutritional support.

The effects of bupivacaine and chloroprocaine as local anesthetics for epidural anesthesia of fetal heart rate monitoring parameters.

The effects of saline-induced pressure-volume changes in the epidural space, and bupivacaine and chloroprocaine as local anesthetics for epidural anesthesia, on various fetal heart rate monitor parameters were investigated in 34 low-risk women. Epidural space pressure-volume changes, bupivacaine, and chloroprocaine had no effect on the incidence of pathologic periodic fetal heart rate changes, the level of the baseline fetal heart rate, or the level of uterine activity units. Epidural space pressure-volume changes and chloroprocaine did not affect fetal heart rate variability. The use of bupivacaine was associated with a significant increase in fetal heart rate variability

Plasma amino acids as predictors of the severity and outcome of sepsis.

Sepsis is a major catabolic insult resulting in a peripheral energy deficit which is made up in part by increased breakdown of lean body mass and oxidation of amino acids, principally the branched chain amino acids. The prognosis in any given case of sepsis is difficult to predict, but should theoretically be related to the degree of disturbance in peripheral energy deficit, which may in turn, be related to plasma amino acid pattern. In order to study whether this hypothesis was correct, plasma amino acids and some of their metabolic byproducts, the beta-hydroxyphenylethanolamines, were studied in 25 septic patients, and were used as discriminant variables in a series of computer performed discriminant analyses and multiple regressions. The two functions tested were the degree of metabolic septic encephalopathy as a determinant of the severity of sepsis and the final outcome in the septic patient. Plasma amino acid patterns exhibited elevated levels of the aromatic and sulfur containing amino acids, phenylalanine, tryosine, tryptophan, methionine, cysteine, and taurine, normal concentrations of alanine, and low normal concentrations of the branched chain amino acids, valine, leucine and isoleucine. Arginine levels, as previously noted, were very low. Patients not surviving the septic episode exhibited higher concentrations of aromatic and sulfur containing amino acids, while patients surviving sepsis had higher concentrations of the branched chain amino acids and arginine. When the degree of encephalopathy as a determinant of the severity of sepsis and step wise discriminant analysis with multiple crescent techniques were used, the best discriminant function between patients with and without encephalopathy was found to result from the interaction of cysteine, methionine, phenylalanine, isoleucine, leucine, and valine. These amino acids gave a correct classification in 82% of patients with no encephalopathy, and 80% of patients with septic encephalopathy. When the same amino acids were used for the discriminant analysis for patients dying of sepsis and patients surviving, the best discriminant function was achieved by using plasma concentrations of alanine, cysteine, methionine, isoleucine, arginine, tyrosine and phenylalanine resulting in 91% of the nonsurvivors, and 79% of the survivors correctly classified. The results suggest a close and significant relationship between the deranged energy metabolism and muscle protein breakdown in sepsis, and the outcome. This further suggests a central role for certain amino acids in perhaps predicting the severity of sepsis and its outcome.