Placental transfer of essential fatty acids in humans: venous-arterial difference for docosahexaenoic acid in fetal umbilical erythrocytes.

Docosahexaenoic acid [22:6(n-3); 22:6(4,-7,10,13,16,19) (DHA)] is required in quantity by the developing nervous system of the fetus. This need could be met through synthesis of DHA from linolenic acid in the fetus or through placental transfer of DHA directly. To study the placental transfer of n-3 fatty acids, we obtained umbilical and maternal blood samples from 26 healthy women and infants at parturition and measured the fatty acid composition and content of both plasma and erythrocytes. A striking finding was a considerable venous-arterial difference for DHA in the umbilical erythrocytes as a proportion of total fatty acids and in absolute concentration. This difference of 2.2 micrograms per billion erythrocytes was 6 times larger than the difference in fetal plasma, when the plasma and erythrocyte concentrations were normalized to whole blood. Most other erythrocyte fatty acids showed a similar trend. In umbilical plasma, significant venous-arterial differences were found for 16:0, 16:1, 18:2, and total saturated fatty acids. There was a similar trend for most other plasma fatty acids. Compared with maternal blood, fetal plasma and erythrocytes had higher levels of 20:4 and DHA and lower levels of 18:2 and 18:3(n - 3) fatty acids as a proportion of total fatty acids. These results suggest that erythrocytes play a major role in the necessary transport of the essential fatty acid DHA into the fetus.

Enlarged cisterna magna in trisomy 18: prenatal ultrasonographic diagnosis.

Ultrasonographic visualization of an enlarged cisterna magna was the initial clue that led to the prenatal diagnosis of trisomy 18 in five patients. Prenatal diagnosis of trisomy 18, a lethal defect, is important for proper patient counseling and management.

Heart rate variability in neurosurgical patients.

Cardiac monitors determine heart rate by counting the number of beats in a given time interval. The normal heart, however, does not beat at a constant rate. Instead, there is a continuous change in heart rate on a beat-by-beat basis. This is termed the instantaneous heart rate and it represents the projected rate per minute that the heart would beat if only one R-R interval (the time between sequential R waves) was repeated throughout a 60-second period. Calculation of the instantaneous heart rate for each heart beat (R-R interval) produces a pattern that demonstrates the variability in heart rate. This instantaneous heart rate pattern was prospectively studied in 102 patients admitted to a neurosurgical intensive care unit. Short-term (STV) and long-term (LTV) heart rate variability were compared to the Glasgow coma scale as a method for patient assessment. LTV seems to be the most useful heart rate parameter in the clinical setting, and both STV and LTV performed better in the serial evaluation of patients. Two postulations found in the heart rate literature were not borne out in this study. First, we did not find a strong correlation between elevated intracranial pressure and decreases in heart rate or variability, as previously reported by Lowensohn et al. Second, the morphological classification of heart rate patterns described by Evans in his study of head-injured patients did not carry the same prognostic value when applied to this broad spectrum of patients with a variety of acute neurological disorders. Heart rate and its variability is a simple parameter to monitor.(ABSTRACT TRUNCATED AT 250 WORDS)

The significance of C-reactive protein levels in women with premature rupture of membranes.

In a prospective study of 100 patients with preterm premature rupture of membranes, clinical chorioamnionitis was present in 18 and histologic chorioamnionitis was present in 63. Patients who were managed conservatively for premature rupture of membranes were monitored by C-reactive protein determination, white blood cell and differential counts, maternal temperature, and fetal heart tone. C-reactive protein was measured nephelometrically (Immuno-chemistry Analyzer II, Beckman). Elevated C-reactive protein levels correlated well with both the pathologic and the clinical diagnosis of chorioamnionitis. Elevated C-reactive protein levels (at least 12 to 24 hours before delivery) were more sensitive than other standard laboratory or clinical tests in predicting chorioamnionitis both by clinical and pathologic criteria. When C-reactive protein values were normal, clinical chorioamnionitis was rarely found, whereas pathologically diagnosed chorioamnionitis was found half of the time. We conclude that although the C-reactive protein level is a very sensitive predictor of infectious morbidity in premature rupture of membranes, its specificity is not high.

Prenatal assessment of fetal outcome by amniotic fluid C-peptide levels in pregnant diabetic women.

Amniotic fluid C-peptide (AFCP), insulin, and glucose levels were measured in 33 diabetic and 126 nondiabetic pregnant women at greater than or equal to 36 weeks' gestation. Levels of AFCP distinguished diabetic from nondiabetic patients more reliably than amniotic fluid (AF) insulin or glucose. Levels of AFCP in diabetic patients correlated well with infant birth weight adjusted for gestational age (large for gestational age greater than adequate for gestational age), degree of diabetic control (fair to poor control greater than good control), or diabetogenic infant morbidity, but did not correlate with classes of diabetes within the limits of the population studied. We conclude that AFCP is a useful prognostic index for predicting fetal outcome in diabetic pregnancies. A level of AFCP of greater than or equal to 1.0 pmoles/ml is associated with an increased risk of macrosomia in infants of diabetic mothers.

Face presentation at term.

A retrospective study was conducted of 50,300 consecutive deliveries between July of 1973 and January of 1978. There were 40 instances of face presentation with gestational age greater than 36 weeks and fetal weight greater than 2500 g for an incidence of 1 per 1250 deliveries. Cesarean section was performed in 50% of cases. Spontaneous vaginal delivery occurred with mentum anterior presentation 88% of the time, with mentum transverse presentation 45% of the time, and with mentum posterior presentation 25% of the time. Fetal heart rate (FHR) monitoring was available for review in 29 of the 38 (76%) live births. Internal techniques were used in 79% and external techniques in 21% of the cases. The FHR patterns were classified according to the predominant pattern seen in the first stage of labor. In 59% (17 of 29), variable decelerations were noted, and severe variable decelerations were present in 29% (8 of 29). Late decelerations were noted in 24% (7 of 29) of cases. Only 4 patients completed labor without variable or late decelerations. There were 38 live births and 2 stillbirths. Both of the stillborns were noted to have tight nuchal cords which were believed to be the cause of death. One death occurred intrapartum. Of the 38 live births, there were 14 (37%) with 1-minute Apgar scores of 6 or less and 5 (13%) with 5-minute Apgar scores less than 7. Four of the 5 low 5-minute Apgar scores occurred in babies with mentum posterior position. Of the 23 patients monitored by internal electrodes, no serious trauma was noted as a result of the electrode placement.

Current patterns of neonatal morbidity and mortality in infants of diabetic mothers.

Recent advances in antepartum fetal evaluation have contributed to a marked reduction in fetal deaths in pregnancies complicated by overt diabetes mellitus. To determine the effect of these changes on neonatal morbidity and mortality, a retrospective analysis of complications in 322 infants of diabetic mothers (IDM) in White classes B--R was undertaken. The majority (89 per cent) of the IDM were delivered at term with a mean gestational age of 38 weeks. Neonatal morbidity correlated significantly with gestational age, occurring in 80 per cent of the preterm and 40 per cent of the term infants. The overall incidence of complications was: hyperbilirubinemia 37 per cent, hypoglycemia 31 per cent, hypocalcemia 13 per cent, polycythemia 8 per cent, and necrotizing enterocolitis 2 per cent. Respiratory distress syndrome (RDS) occurred in 9 per cent and congenital malformations in 6 per cent of the infants. Nine infants died, and four of these deaths were due to anomalies. These data indicate that (1) a reduction in fetal mortality has been accompanied by a reduction in neonatal mortality; (2) neonatal morbidity has been decreased but remains significant in the IDM; and (3) congenital anomalies have replaced RDS as a major cause of neonatal death for the IDM.

Management and outcome of pregnancy in diabetes mellitus, classes B to R.

During the period 1971 to 1975, 260 women with diabetes mellitus, Classes B through R, were delivered of their infants at Los Angeles County Women's Hospital. The plan of patient management included frequent clinic visits and hospitalization to assure good control. A program of intensive antepartum fetal surveillance was begun at 34 weeks' gestation, with the use of daily 24 hour urinary estriol determinations and a weekly contraction stress test (CST). A lecithin/sphingomyelin ratio was evaluated for all patients before elective delivery. The perinatal mortality rate in these diabetic pregnant women was 46 per 1,000 as compared to 24 per 1,000 in the general population. Only three stillbirths occurred in the diabetic group, none within one week of a negative CST. Congenital malformations were responsible for almost half of the neonatal deaths. There were no deaths due to iatrogenic prematurity or trauma. Mean gestational age at delivery was 37.9 weeks and vaginal delivery was the mode for approximately half of the women. Two thirds of the infants did experience some morbidity.

A fever index evaluation of chloramphenicol or clindamycin in patients with serious pelvic infections.

The fever index measured the responses of 102 women with serious pelvic infections who had received either chloramphenicol or clindamycin, in combination with other antibiotics. There was no statistical difference in the number of degree hours in the two populations. Patients with salpingo-oophoritis had significantly more fever than those with a septic abortion. Bacteremia did not delineate a group of women with a markedly elevated febrile response. Within the populaton with salpingo-oophoritis, neither black women nor women with an intrauterine device in place had significantly more fever, but patients requiring operation had more fever while those with an endocervical culture positive for the gonococcus at the time of admission had the most favorable clinical response. The significance of these findings is discussed.

Lecithin/sphingomyelin ratio in pregnancies complicated by diabetes mellitus.

The amniotic fluid lecithin/sphingomyelin (L/S) ratio was determined in 182 pregnancies complicated by Classes B and C diabetes and in 28 patients with Classes D, F, and R diabetes. These data were retrospectively correlated with the occurrence of the respiratory distress syndrome (RDS) or hyaline membrane disease (HMD). Only four cases of RDS and two cases of HMD were observed in 200 patients with an L/S ratio of 2.0 or greater prior to delivery. This 3 per cent incidence of complications is no higher than that of the nondiabetic population in our institution. Seven of 10 neonates with an antenatal L/S ratio of 1.5 to 1.9 developed RDS. An L/S ratio of 2.0 or more appears to be reliable predictor of fetal pulmonary maturity even in pregnancies complicated by diabetes mellitus.

Heart-rate variability in brain-damaged adults.

To test whether or not the characteristics of the adult heart-rate reflect the condition of the central nervous system (as they seem to do in the fetus), ten patients with neurological deficits of acute onset were studied. No patients had received drugs and none was hypoxic. The findings indicate that the normal cyclic changes in heart-rate are reduced in the presence of severe brain damage. Variability decreases rapidly if intracranial pressure rises, and the rate of return of variability reflects the subsequent state of neuronal function, even when intracranial pressure has been restored to normal. In this limited setting, then, it appears that heart-rate variability may reflect the functional state of the central nervous system.

Management and outcome of class A diabetes mellitus.

Patients who have a normal fasting serum glucose (FSG) and an abnormal glucose tolerance test, and who require little dietary regulation, have been designated as Class A diabetics by White. During the period 1970 through 1972, 261 Class A women were delivered at Los Angeles County (LAC) Women's Hospital. These patients were managed by a uniform protocol which included dietary supervision and continued surveillance for the onset of overt diabetes. Elective intervention prior to 40 weeks' gestation was to be avoided. Twenty-five per cent of the Class A patients--those who had had a previous stillbirth or who developed pre-clampsia--were considered at greater risk for perinatal death and were managed as if they had overt diabetes. The perinatal death rate for the entire Class A group was 19/1,000 as compared to 32/1,000 in the general population. Five perinatal deaths occurred, three associated with congenital malformations. There were no unexplained stillbirths or deaths due to trauma or iatrogenic prematurity. Our data thus indicate that as long as the FSG remains normal, an unexplained intrauterine death is a rare event. Twenty-five per cent of the infants did experience some morbidity.

A study of the relationship between Goodwin's high-risk score and fetal outcome.

Correlation between Goodwin's high-risk score and Apgar score was studied in 266 pregnancies managed with the use of the information from clinical monitoring. The correlation coefficients between Goodwin's score and Apgar scores were -0.3178 for one-minute Apgar scores and -0.2668 for five-minute Apgar scores. Both are significant at the level of p less than 0.001. When the patients were divided into two groups by Goodwin's score, fetuses of the group with the higher score (greater than or equal to 4) were significantly more acidotic than those of the group with the lower score. Therefore, Goodwin's high-risk scoring system is simple and useful in the selection of potential risk patients.

Computer assessed fetal heart rate patterns and fetal scalp pH. A preliminary study.

From the beginning of biophysical and biochemical monitoring of the fetus during labor, a continuing attempt has been made to determine if a reliable correlation exists between these measurements and the well-being of the fetus. If such a correlation did indeed exist, the combined use of the two approaches would permit efficient, relatively simple fetal monitoring. This preliminary report describes the use of computer processed fetal heart rate patterns to predict fetal scalp blood pH. Initial results show a 90% overall accuracy in predictions; when corrected for some of the bias of retrospective predictions, the accuracy is 91% for high pH and 72% for low pH.