Successful pregnancy after cardiac transplantation.

A case report of a successful pregnancy after cardiac allotransplantation is presented. The patient underwent transplantation for an inoperable cardiac tumor 5 years before conception. Cardiac function before and during all stages of pregnancy was normal. Maintenance immunosuppressive therapy consisting of prednisone and azathioprine was continued through gestation. The pregnancy was complicated by a primary herpes virus infection requiring parenteral acyclovir treatment and a single episode of preterm labor that was successfully treated. The infant was born at term, weighed 3278 gm, and has developed normally during the first 3 years of life. The patient died 5 months after delivery as a result of an acute immunologic rejection 5 months post partum caused by self-initiated discontinuation of immunosuppressive therapy. Preconceptional counseling and pregnancy care guidelines are discussed.

Ultrasonographic assessment of early fetal growth in insulin-treated diabetic pregnancies.

Early fetal growth aberrations have been suggested in diabetic gestations. To characterize such aberrations sonographically, longitudinal crown-rump length measurements were made in a group of 20 control and 20 diabetic pregnancies. The study evaluated growth between 40 and 100 days of amenorrhea. The best-fit curve of growth as a function of gestational age was that of a nonlinear polynomial regression curve for both the control and the diabetic groups. The correlation coefficients were 0.997 and 0.887 for the control and diabetic groups, respectively; the standard error of the estimate was 0.054 and 0.19, respectively. A log10 linear transformation was performed successfully on each curve. Comparison of the slopes and the intercepts of the transformed control and diabetic curves revealed no significant differences. To evaluate the possibility of a transient fetal growth delay, interval growths and interval growth velocities were compared between groups. No significant differences were observed. The control and diabetic groups' mean (+/- SD) growth velocities were 0.043 +/- 0.023 and 0.040 +/- 0.022 mm/day/mm total, respectively (p = NS). The growth of two anomalous fetuses in the diabetic group was studied individually. Their growth characteristics could not be distinguished from the control fetuses' growth profiles. The present study fails to confirm the presence of early fetal growth delay in diabetic pregnancies. Moreover, the data suggest that the fetuses' early growth in the mother with poorly controlled diabetes is similar to that of control fetuses.

Predictive value of early pregnancy glycohemoglobin in the insulin-treated diabetic patient.

The influence of early pregnancy glycemic control as measured by hemoglobin A1c concentration and the incidence of congenital anomalies and spontaneous abortions were evaluated in women presenting for prenatal care with insulin-treated diabetes in a population whose glycemic control was poor. Thirty-one abnormal outcomes were seen in 83 pregnancies (37%). There were 22 spontaneous abortions and nine major congenital anomalies. No woman with an early pregnancy hemoglobin A1C value less than 9.5% had an infant with a congenital anomaly and a single woman experienced a spontaneous abortion (4%). Conversely, in women with an early pregnancy hemoglobin A1C value greater than or equal to 9.5%, congenital anomalies occurred in 24% and spontaneous abortion in 35%. Outcomes of pregnancies in type 1 and type 11 diabetic women were comparable. A strong statistical relationship between hemoglobin A1C and adverse pregnancy outcomes was demonstrated. These results strongly suggest that poor glycemic control during early pregnancy adversely influences pregnancy outcomes; the greater the degree of poor control, the greater the impact on pregnancy outcome. The data further justify the need for preconceptional control in diabetic woman and for careful evaluation of the fetus during pregnancy in the woman with insulin-treated diabetes.

Cervical ripening and labor outcome with preinduction intracervical prostaglandin E2 (Prepidil) gel.

Delivery with an unfavorable cervix using oxytocin is frequently unsuccessful. Used widely in Europe and increasingly in this country, locally applied prostaglandin E2 appears to improve labor induction. The present study prospectively evaluated the efficacy and safety of a prostaglandin gel (0.5 mg) placed intracervically. The use of the gel, when compared to a control group who received no pretreatment prior to labor induction, resulted in improved Bishop scores (7.5 +/- 1.0 vs. 1.8 +/- 0.3, P less than 0.0001), reduced induction to delivery intervals (10.1 +/- 2.1 vs. 20.6 +/- 2.0 hours), reduced oxytocin infusion duration (10.0 +/- 2.1 vs. 20.0 +/- 2.3 hours. P less than 0.0001) resulting in a lower cesarean delivery rate, 26 vs. 47 per cent (P greater than 0.05). Thirty-two per cent of patients receiving the prostaglandin gel labored and delivered within 12 hours and required no oxytocin. In addition, the use of prostaglandin E2 gel appeared safe in that no patient experienced an untoward reaction. Two cases of uterine hyperstimulation occurred that required uterine tocolysis but were not associated with fetal distress. The use of prostaglandin gel appears to be a safe and effective method to improve cervical inducibility in patients undergoing induction for a variety of maternal and fetal indications.

Hemodynamic effects of intravenous cocaine on the pregnant ewe and fetus.

Cocaine is a potent vasoconstrictive agent that is currently the subject of widespread drug abuse. Because little is known of the physiologic responses to cocaine in pregnancy, the effects of intravenous cocaine on uterine blood flow and other maternal and fetal cardiovascular parameters were studied. Eight ewes in late pregnancy were equipped with electromagnetic flow probes around both uterine arteries and catheters were placed in the maternal and fetal inferior vena cavae and aortas. Bolus intravenous infusion of 0.5 and 1.0 mg/kg of maternal body weight achieved peak plasma cocaine levels similar to those observed in human subjects after abuse of the drug (mean level = 229 to 400 ng/ml, n = 8). After bolus infusion of 0.5 or 1.0 mg/kg of cocaine, mean maternal arterial pressure increased 32% and 37%, respectively (p less than 0.005). Fetal blood pressure rose 12.6% after a dosage of 0.5 mg/kg of cocaine. These cocaine infusions significantly decreased uterine blood flow by 36% and 42% for a duration of 15 minutes (p less than 0.005). Analysis of maternal catecholamine responses demonstrated a significant (210%) rise in plasma norepinephrine levels after cocaine infusion. These studies demonstrate that cocaine, when administered in doses that produce plasma levels observed in humans, significantly decreases uterine blood flow for a duration of greater than or equal to 15 minutes while inducing a hypertensive response in the pregnant ewe and fetus.

The perinatal and economic impact of prenatal care in a low-socioeconomic population.

Reductions in publicly funded prenatal care programs in 1981 to 1984 resulted in an increase in unregistered patient deliveries from 7.8% to 14.9% of births at University of California San Diego Medical Center. To assess the economic and perinatal impact of the increasing number of deliveries of women without prenatal care, 100 consecutive patients with fewer than three prenatal visits were studied. Each "no care" patient was matched by age, parity, and week of delivery with a control patient who received care in a state-funded perinatal project (Comprehensive Perinatal Program). Maternal antenatal risk factors were equally distributed between the two groups when maternal age, parity, history of substance abuse, prior preterm delivery, hypertension, and abortion were compared. Maternal obstetric outcomes were similar, including cesarean section rate and incidence of postpartum fever and hemorrhage. However, neonates delivered of women receiving no care experienced significantly greater morbidity than the neonates of women in the Comprehensive Perinatal Program, including an increased incidence of premature rupture of the membranes and preterm delivery (13% versus 2%, p less than 0.05), low birth weight (21% versus 6% less than 2500 gm, p less than 0.002), and intensive care unit admissions (24% versus 10%, p less than 0.005). When the total inpatient hospital charges were tabulated for each mother-baby pair, the cost of perinatal care for the group receiving no care ($5168 per pair) was significantly higher than the cost for patients in the Comprehensive Perinatal Program ($2974 per pair, p less than 0.001) including an antenatal charge of $600 in the Comprehensive Perinatal Program. The excess cost for delivery of 400 women receiving no care per year in the study hospital was $877,600. These results suggest that extension of prenatal care programs to medically indigent women is likely to result in a net reduction in perinatal morbidity and health care expenditures.

Evaluation of the use of continuous lumbar epidural anesthesia for hypertensive pregnant women in labor.

The use of continuous lumbar epidural anesthesia in women with pregnancy-induced hypertension remains controversial. We retrospectively reviewed the charts of 285 women with pregnancy-induced hypertension who were delivered in a 2-year period. Among 185 vaginally delivered patients who received continuous lumbar epidural or local anesthesia, there were no significant differences in the incidence of maternal hypotension, abnormal fetal heart rate tracings, low Apgar scores, or neonatal intensive care unit admissions. Of 100 patients delivered by cesarean section, the incidence of low Apgar scores, depressed umbilical cord pH values, and neonatal intensive care unit admission was increased among those who received general anesthesia (p less than 0.05). However, general anesthesia patients were more likely to have abnormal fetal heart rate tracings (27% versus 4%) requiring urgent delivery. Thus differences in outcome probably reflect poorer fetal condition prior to anesthesia induction rather than a specific anesthetic effect. These results demonstrate that continuous lumbar epidural anesthesia is safe and effective for both the fetus and the mother with pregnancy-induced hypertension.

Uterine blood flow and catecholamine response to repetitive nicotine exposure in the pregnant ewe.

In order to simulate human smoking, experiments were designed to determine what dose of nicotine in the pregnant sheep would produce those plasma nicotine concentrations observed in human smokers and to measure uterine blood flow and plasma catecholamines in response to repetitive exposure (every 30 minutes) to that nicotine dose. Utilizing seven chronically catheterized pregnant sheep equipped with electromagnetic flow probes around both uterine arteries, we observed that a nicotine dose of 0.2 mg/min for 5 minutes results in mean plasma nicotine concentrations of 23.1 +/- 1.1 ng/ml SEM (n = 17) immediately following infusion. This dose of nicotine was then infused every 30 minutes for 4 hours, and aliquots of blood were drawn immediately before and after nicotine infusion for determination of plasma catecholamines. No significant alterations in plasma epinephrine and norepinephrine were observed throughout the experiments (n = 8), and no significant changes in uterine blood flow occurred at any time during the experiment (n = 30). We conclude that there is a species difference between sheep and man with respect to the nicotinic threshold for catecholamine release.

Ritodrine inhibition of hypoxic pulmonary vasoconstriction.

The effect of ritodrine hydrochloride on hypoxic pulmonary vasoconstriction (HPV), the normal control mechanism for shunting blood flow away from nonventilated areas of the lung, was studied in nonpregnant dogs equipped with central monitors and electromagnetic flow probes. The systemic infusion of ritodrine at a dose of 4 micrograms/kg/min resulted in a 66.4% +/- 4.6% decrease in the HPV response, whether administered before or after the induction of isolated lobar hypoxia. These findings have significant implications for the patient who develops pulmonary edema during ritodrine therapy, in which inability to bypass nonventilated areas of the lung would serve to aggravate further the ventilation/perfusion inequalities that already exist.

The effects of maternally administered magnesium sulfate on the neonate.

The effects of parenterally administered magnesium sulfate on maternal and neonatal calcium and magnesium metabolism in nonasphyxiated, term pregnancies complicated by pregnancy-induced hypertension were studied prospectively. In addition, the neurobehavioral effects of neonatal hypermagnesemia were investigated by means of a neonatal assessment scale that specifically measures reflex activity and both passive and active muscle tone. Maternal magnesium sulfate infusion was associated with maternal and neonatal hypermagnesemia when compared with that of control subjects (1.8 +/- 0.10 to 3.6 +/- 0.5 mg/dl, p less than 0.001, and 1.75 +/- 0.2 to 3.6 +/- 0.5 mg/dl, p less than 0.005, respectively). Maternal serum calcium levels fell with magnesium therapy (9.3 +/- 0.18 to 7.9 +/- 0.1 mg/dl, p less than 0.001), while neonatal calcium levels were unaffected (10.8 +/- 0.44 to 10.5 +/- 0.38 mg/dl, p less than 0.05). Neurological status examinations in the neonate were similar in both the control and treatment groups. In addition, neurological performance of the neonate did not correlate with cord magnesium levels or to the total dose of magnesium administered.

Maternal cardiovascular response to caffeine infusion in the pregnant ewe.

The effect of maternal caffeine infusion on uterine blood flow and fetal oxygenation was studied in chronically catheterized pregnant sheep equipped with electromagnetic flow probes. The systemic administration of caffeine in doses of 8 and 24 mg/kg of body weight resulted in peak maternal serum levels of 16.7 +/- 0.9 and 38.5 +/- 2.1 micrograms/ml and fetal serum levels of 10.9 +/- 0.7 and 34.9 +/- 4.5 micrograms/ml, respectively. While no significant effects were noted at the 8 mg/kg dose, administration of 24 mg/kg was associated with a 5% reduction in uterine blood flow (p less than 0.05) and a 7% increase in mean arterial pressure (p less than 0.05). No significant alteration in maternal or fetal oxygenation occurred at either dose. These findings suggest that any adverse effects on fetal development attributed to caffeine are not likely exerted by influencing uterine blood flow.

Maternal and fetal cardiovascular effects of nicotine infusion in pregnant sheep.

The effects of nicotine on uterine and umbilical hemodynamics were studied in seven pregnant ewes equipped with electromagnetic flow probes around the main uterine and common umbilical arteries, and with polyvinyl catheters inserted into the fetal aorta and maternal femoral vessels. Maternal systemic infusions of 1.0 to 1.5 mg/min significantly decreased uterine blood flow by 42% (p less than 0.001) and 32% (p less than 0.05), respectively. However, nicotine infusion rates of 0.5 mg/min, resulting in mean peak maternal nicotine concentrations of 130 +/- 5.0 ng/ml (SE), a value substantially higher than that reported in smoking humans, did not significantly alter uterine or umbilical vascular hemodynamics. Furthermore, at this lower nicotine dose, no alterations were observed in maternal or fetal plasma norepinephrine and epinephrine. The findings suggest either a species difference between sheep and humans in the threshold of catecholamine release to nicotine exposure or the need for repetitive nicotine infusions throughout the day to stimulate the human smoking experience.

Management of sickle hemoglobinopathies in pregnant patients.

During the past decade, pregnancy outcome has improved among patients with sickle hemoglobinopathies. The role of prophylactic exchange transfusion in this improvement is uncertain. This study reviews the experience in 64 pregnancies managed at the Medical University Hospital over a 7 year period. Prophylactic exchange transfusion was not associated with improved pregnancy outcome and was associated with significant antibody formation. Exchange transfusion may best be reserved as a treatment modality when infection, crisis, or symptomatic anemia occurs in patients with a sickle hemoglobinopathy.

Menstrual extraction in the adolescent.

Menstrual extraction or suction aspiration of the uterus with a flexible cannula within 2 weeks of a missed menstrual period is infrequently used in the adolescent. Eighty-two adolescents (39 private and 43 clinic patients) underwent 90 menstrual extractions at the Medical University of South Carolina from January 1977 through March 1979. The clinic population consisted of a higher percentage of blacks and more individuals who had previously been pregnant and carried pregnancies to term. Major complications occurred in only two patients. One pregnancy continued to term. This could have been prevented if vigorous attempts had been made to encourage all patients to return for follow-up exam. The patients' shift to the use of pills and IUDs after the procedure suggests that menstrual extraction may serve as an introduction to effective birth control methods. Results of menstrual extraction in the adolescent compare favorably with those reported in adults.

Automated erythrocytopheresis for sickle cell anemia during pregnancy.

Automated erythrocytopheresis allows for selective removal of erythrocytes from whole blood by means of extracorporeal centrifugation and separation. Remaining cellular and liquid fractions are returned to the patient, along with donor erythrocytes. Supertransfusion with the use of plasmapheresis and simultaneous direct transfusion of erythrocytes increases the hematocrit while maintaining stable intravascular volume. This technique was used in the prophylactic exchange transfusion in eight pregnant women with sickle hemoglobinopathies. Two patients required repeat procedures 7 and 13 weeks later for hemoglobin A concentration or hematocrit less than 25%. The results from the first five pregnancies are detailed. All pregnancies were carried to term, with the delivery of healthy infants. There was no fetal or neonatal morbidity, and the only maternal morbidity was a case of puerperal endometritis. Erythrocytopheresis has been established as a flexible and useful means of managing gravid patients with sickle hemoglobinopathies.

Evaluation of a continuous tissue pH monitor in the human fetus during labor.

Continuous tissue pH monitoring of the fetus was successfully conducted in 13 of 21 patients (61.9%) during labor. There was a significant correlation between the tissue pH and both the scalp capillary blood pH (r = 0.94, P less than 0.001) and the umbilical artery blood pH (r = 0.92, P less than 0.01). These findings confirm the accuracy of the tissue pH instrumentation in reflecting fetal acid-base status and support the potential usefulness of the instrumentation in perinatal medicine for continuous fetal acid-base monitoring.