Collection of fetal blood for stem cell research and therapy.

Stem cell research has generated novel therapeutic opportunities at the expense of new ethical and legal problems. Its promoters recommended early clamping of the umbilical cord to maximize the amount of acquired fetal blood. Fear has been expressed, therefore, that the donor could be compromised by this approach. Actually, the problem is more complex than generally assumed. In certain clinical situations the neonate may benefit from or become harmed by additional blood volume. Gravity influences the direction of umbilical blood flow and, thus the consequences of early or delayed cord clamping. Therefore, vaginal birth promotes blood flow from the placenta to the fetus, whereas delivery by cesarean section usually has the opposite effect. Largely ignored in the course of the relevant debates, the above facts require consideration. The controversy may be beneficial in the long run by drawing attention to this relatively neglected aspect of perinatal medicine.

The role of hypertension in bromocriptine-related puerperal intracranial hemorrhage.

The spate of medicolegal inquiries following the disqualification of Parlodel (bromocriptine mesylate) by the Food and Drug Administration for postpartum ablactation, uncovered previously unreported side effects associated with its postpartum administration. In 1994, bromocriptine mesylate was withdrawn from the market as a milk suppressant. Since this time, over a dozen cases of postpartum intracranial hemorrhages associated with its use have been reported. We describe three additional cases of postpartum intracranial hemorrhage related to bromocriptine usage. One patient, previously normotensive, developed hypertension and a headache; initial CT was normal, but CT 24 h later demonstrated intracranial hemorrhage. This suggests that the blood-pressure elevation was drug-induced and was the cause, rather than the consequence, of bromocriptine-related intracranial hemorrhage.

Untoward neonatal sequelae deriving from cutting of the umbilical cord before delivery.

Four cases are reported where, following the delivery of the fetal head, the physician electively cut the nuchal cord of the fetus. The extraction of the body entailed difficulties and the babies suffered irreversible damage in the process. Not unlike 5 previously described similar cases, these incidents came to the attention of the authors in connection with medico-legal reviews. The writers conclude that the practice of severing the umbilical cord prior to the delivery of the body of the fetus, proposed in some textbooks as a routine procedure, is a dangerous technique, which should be avoided. They also point out that the medical literature has not discussed this problem. Reviews of potential malpractice cases frequently provide important research data that cannot be elicited in the course of traditional clinical investigations.

Maternal weight and fetal injury at birth: data deriving from medico-legal research.

The relationships among maternal weight, gestational weight gain, fetal birth weight and birth injuries have been investigated in connection with 62 cases of shoulder dystocia that involved permanent impairment of the newborn or neonatal demise. A high prevalence of > 13.5 kgs. gestational weight increase between the first and last office visits (62%) obesity expressed as > or = 87 kg. body weight at term (64.1%) and > or = 4000 gm. birth weight (80%) was found in this group of patients. The results indicate that the relationship between excessive maternal and fetal body weights and shoulder dystocia related fetal or neonatal impairment is closer than previous studies have suggested. These results underline the importance of appropriate and intensive nutritional counselling of the mother throughout pregnancy, noting that arrest of the shoulders is only one of those obstetric complications that are closely related to maternal obesity. The findings underline the usefulness of medico-legal reviews in clinical research.

Severe cardiac dysrhythmia in patients using bromocriptine postpartum.

Used worldwide since 1980 for the prevention of breast engorgement in the puerperium, in 1994 bromocriptine mesylate was withdrawn from the American market as an agent suitable for ablactation. The relevant recommendation of the Food and Drug Administration rested on case reports that described severe vasospastic reactions among users of the drug. Some patients so affected suffered stroke, intracranial bleeding, cerebral edema, convulsions, myocardial infarction, and puerperal psychosis. More recently, it has been suggested that the side effects of the drug may also include circulatory collapse secondary to cardiac dysrhythmia. This report describes two additional cases in this category. The antepartum clinical evaluation of these women suggested that they were predisposed to arrhythmias.

Postpartum intracranial haemorrhage in normotensive users of bromocriptine for ablactation.

The authors describe three cases of severe intracranial haemorrhage, associated with marked blood pressure elevation, which occurred between the 6th and 10th days postpartum in women taking bromocriptine for ablactation. All of these patients were young, normotensive and apparently healthy during the pregnancy. These incidents probably present the 10-12th reported cases of gross intracranial bleeding among users of bromocriptine in the puerperium. The results suggest that early diagnosis and prompt surgical intervention may improve the outcome for this rare but potentially catastrophic postpartum complication.

Myocardial infarction postpartum in patients taking bromocriptine for the prevention of breast engorgement.

Three cases of myocardial infarction (MI) in women taking bromocriptine for milk suppression are presented. The incidents occurred in 1993 and 1994, the last only two weeks before the withdrawal of the drug from the American market as a drug suitable for ablactation. In one patient, the MI presented on the 12 day postpartum and was accompanied by signs and symptoms reminiscent to ergotism. Another mother suffered MI, accompanied by hypertension, six days after a vaginal delivery complicated by postpartum haemorrhage. The third patient began to take bromocriptine more than 2 weeks postpartum and died suddenly 24 days after her childbirth. To the knowledge of the authors, these are the 12th to 14th literary reports describing an apparent association between the use of bromocriptine for ablactation and the occurrence of MI in the puerperium.

Severe cerebral accidents postpartum in patients taking bromocriptine for milk suppression.

We report three recent cases of severe acute cerebral accident which occurred in the puerperium in women who received bromocriptine for milk suppression. Two patients experienced mild pregnancy-induced hypertension antepartum. Marked blood pressure elevation, above that which had prevailed previously, occurred postpartum in each case. The cerebral accidents manifested between the 6th and 14th days of the puerperium, the typical time for the occurrence of severe side effects from bromocriptine. These complications entailed lasting neurological sequelae in the three mothers who, based on their age, medical history and general state of health, were not significantly predisposed to cerebral accidents.

Acute myocardial infarction in a healthy mother using bromocriptine for milk suppression.

A 34-year-old mother developed acute myocardial infarction (MI) 10 days postpartum while taking bromocriptine for ablactation. Her only known risk factor was moderate hypercholesterolemia. The initial coronary arteriogram revealed minimal irregularities of the mid- and distal left anterior descending (LAD) artery, but severe narrowing of a large first diagonal branch of the LAD. Repeat coronary arteriography, performed two months later for recurrent chest pain, showed no significant change in the LAD. There was, however, a marked improvement in the first diagonal branch. To the authors' knowledge this is the 10th report of MI in a patient using bromocriptine postpartum for milk suppression and only the second one to implicate by its investigations the role of vasospasm in the coronary vessels at the cause of the infarction.

Intracerebral hemorrhage in normotensive mothers using bromocriptine postpartum.

Three cases of cerebral hemorrhage that occurred in the puerperium in normotensive women who used bromocriptine for milk suppression postpartum are described. Unlike in some other instances reported in the past, the extent of the bleeding was limited in these patients and the long range outcome was relatively benign. All episodes were associated with the development of hypertension. These incidents occurred between the 10th and 17th days postpartum; somewhat later than the usually observed peak time period (6th to 8th day) for the development of severe bromocriptine related side effects.

Bromocriptine related atypical vascular accidents postpartum identified through medicolegal reviews.

Recent literary case reports indicate that bromocriptine mesylate, when used for the suppression of lactation in the puerperium, can cause serious and even lethal side effects. The untoward sequelae are attributed to generalized or focal vasospasm affecting the cardiac and/or cerebral bold vessels. Apart from pre-existing hypertension and use in association with other ergot derivatives, the factors predisposing to such complications have not been elucidated, The authors present three atypical bromocriptine related postpartum accidents which may expand the understanding both of the predisposing factors and the potential consequences of bromocriptine related severe side effects. One of the cases raises the suspicion that the manifestations of hyperthyroidism may be aggravated by this method of pharmacologic ablactation. Another observation appears to imply that the drug may trigger the onset of chronic hypertension in women so predisposed. The development of cerebral infarcts, identified by MRI, in a clinically asymptomatic woman, exemplifies the threat of recurrent seizure activity in cases of bromocriptine related stroke.