Cervical dysplasia in pregnancy: progression versus regression post-partum.

OBJECTIVE: To assess the natural history of cervical dysplasia during pregnancy and determine the rates for progression or regression post-partum by the severity of the lesion. METHOD: This was a retrospective study of 100 patients screened by PAP smear. Lesions were graded by colposcopy and biopsy, and followed post-partum. RESULTS: Lesions were graded as ASCUS, LGSIL, and HGSIL. The majority of lesions showed a tendency to regress post-partum (approximately 64%), a trend that was statistically significant (P < .003). A substantial minority (approximately 34%) showed no change in severity of the lesion. The tendency for lesions to progress in severity was very low (approximately 3%). No patient had microinvasive disease. Of patients who had CIS, persistence of this lesion post-partum was present in 67%. CONCLUSION: Patients with cervical dysplasia in pregnancy may be followed conservatively with colposcopy and biopsy.

Cesarean section for the second twin.

OBJECTIVE: To determine the reasons for cesarean section (C/S) for the second twin following vaginal delivery of twin A, and causes of neonatal death (NND). STUDY DESIGN: Five hundred forty-one twin deliveries were studied retrospectively from 1987 to 1995. Deliveries were fractionated by fetal presentation for twin A and twin B (i.e., vertex A/vertex B, vertex A/breech B, vertex A/transverse lie B, breech A/vertex B, ... transverse lie A/transverse lie B, yielding nine groups). The variation in C/S rate was noted with respect to fetal presentation for twin A and twin B. The indications for C/S of twin B following successful delivery of twin A were noted, as were sources of NND. RESULTS: The C/S rate rose as the presentation of twin A changed from vertex to breech to transverse lie (13.8%, 67.4% and 100%, respectively, for twin B vertex). A similar trend was found for twin B as breech or transverse lie. The overall C/S rate was 34.6%, and of these, 27 were solely to deliver twin B, for 5.0% of all twins and 14.4% of all C/S. The risk for C/S for the second twin was increased 7.6x if twin A was vertex rather than breech. The prime reasons for C/S of twin B varied with the presentation of twin B. Cord prolapse of twin B was most common for vertex A/vertex B (7/8), whereas inability to turn and extract twin B was most common for vertex A/transverse lie B (back down) (9/14). The other two reasons for C/S were fetal distress of twin B (two) and abruption (two). Two cases of neonatal demise resulted from asphyxia: one due to cord prolapse (vertex A/vertex B), and one due to traumatic internal version and extraction (vertex A/transverse lie B). CONCLUSION: C/S delivery for the second twin is most common in vertex twin A pairs since it is these that are generally allowed to be delivered vaginally until an untoward event complicates the delivery of twin B. Hence, 96% of these C/S deliveries occur when twin A is vertex. The "safest" configuration (vertex A/vertex B) results in 26% of cases delivered by C/S for cord prolapse of twin B, while 52% of C/S deliveries are for change in presentation of twin B, with inability to perform internal podalic version and extraction. These two indications accounted for 81.5% of C/S and all the neonatal deaths.

Cocaine-associated rhabdomyolysis causing renal failure in pregnancy.

BACKGROUND: Cocaine use is known to have multisystemic effects. Recently, acute renal failure as a result of rhabdomyolysis has been described as a complication of cocaine use. During pregnancy, cocaine is associated with abruptio placentae. A patient presenting with both complications is described. CASE: A 25-year-old multiparous woman at 34 weeks' gestation developed abruptio placentae approximately 18 hours after using cocaine alkaloid. Six hours later, a cesarean delivery was performed after she presented with vaginal bleeding and fetal bradycardia. Oliguria was present from admission and persisted despite aggressive fluid hydration, dopamine infusion, and intravenous administration of furosemide. Serum creatinine phosphokinase and urine myoglobin were both elevated at 558 IU/L and 432 ng/mL. Hemodialysis was required for presumed cortical necrosis. CONCLUSION: Rhabdomyolysis, as indicated by elevated creatinine phosphokinase and the presence of myoglobin in the urine, suggests that nephrotoxicity from myoglobinuria may contribute to acute renal failure in cases of cocaine mediated abruptio placentae.

Neuroprotective effect of phenytoin against in utero hypoxic brain injury in fetal guinea pigs.

The present study tests the hypothesis that phenytoin, an antiepileptic agent known to block Na+ and Ca2+ channels, will prevent hypoxic brain injury in the fetus by preventing lipid peroxidation and preserving Na+,K(+)-ATPase activity. Studies were performed in 37 fetuses obtained from pregnant guinea pigs at 58-60 days gestation (term). The pregnant guinea pigs were divided into four groups: a normoxic group, a hypoxic group, a normoxic group treated with phenytoin, and a phenytoin treated hypoxic group. There were eight to ten fetal guinea pigs in each group. The treatment groups were given phenytoin 30 mg/kg (50 mg phenytoin/ml solvent) intraperitoneally. Hypoxia was induced by exposing the guinea pigs to 7% oxygen for 60 min. This level of hypoxia has been shown to decrease ATP and phosphocreatine levels by 90%. The fetal brains were harvested and the brain cell membranes were prepared from each group of fetuses. Na+,K(+)-ATPase activity and lipid peroxidation products, measured as relative fluorescent intensity, were determined. The mean Na+,K(+)-ATPase activity in the control, hypoxic, phenytoin-normoxic and phenytoin-hypoxic groups was 56.4 +/- 9.7, 37.9 +/- 10.6, 47.0 +/- 8.4 and 52.0 +/- 9.7 mumol inorganic phosphate/mg protein per h, respectively. The hypoxic group had significantly less Na+,K(+)-ATPase activity than both the normoxic group (P < 0.01), and the phenytoin treated hypoxic group (P < 0.05). There was no significant difference between the normoxic group and either of the phenytoin-treated groups (P = ns).(ABSTRACT TRUNCATED AT 250 WORDS)