Fetal cardiac hypertrophy and cardiac function in diabetic pregnancies.

OBJECTIVE: Our purpose was to evaluate the relationship between fetal cardiac wall hypertrophy and ventricular function in fetuses of metabolically controlled, insulin-requiring diabetics. STUDY DESIGN: M-mode directed fetal echocardiography included measurements of left and right ventricular free wall and interventricular septal thickness and ventricular diastolic and systolic dimensions. Fetal measurements included biparietal diameter, estimation of fetal weight, and cardiac area/thoracic area. Cardiac size is expressed as a ratio of wall thickness/biparietal diameter, and function is expressed as ventricular shortening fraction (Ventricular diastolic dimension-Ventricular systolic dimension/Ventricular diastolic dimension). Fetuses of diabetics at 20 to 24, 28 to 31, and 32 to 36 weeks' gestation were compared with normal fetuses of nondiabetic mothers at similar gestational ages, which were used as a control group. RESULTS: Study and control groups were comparable in mean gestational age (22 vs 20, 29 vs 29, 35 vs 34 weeks) in each of groups 1, 2, and 3. All fetuses tested fell within these groups. Estimated fetal weight, cardiac area/thoracic area, right ventricular wall thickness/biparietal diameter, and interventricular septal thickness/biparietal diameter were greater in the study group between 32 and 36 weeks: 3227 +/- 430 versus 2235 +/- 176 gm (p < 0.05), 0.32 versus 0.29, (p < 0.05), 0.53 +/- 0.05 versus 0.44 +/- 0.05 mm (p < 0.05), and 0.50 +/- 0.3 versus 0.46 +/- 0.5 mm (p < 0.05), respectively. Right ventricular shortening fraction/left ventricular shortening fraction was significantly different from controls in this group (1.30 vs 0.89, p < 0.05). This change was a function of altered right ventricular shortening fraction in late diabetic pregnancy. Right ventricular shortening fraction in the study groups was 0.39, 0.36, and 0.52, respectively, versus 0.36, 0.41, and 0.33 in controls. Left ventricular shortening fraction in the group at 32 to 36 weeks and in controls in three groups was 0.42, 0.39, 0.40 and 0.44, 0.37. CONCLUSION: These findings reveal an increase in right ventricular shortening fraction associated with global cardiac enlargement. Myocardial hypertrophy involving right ventricular wall thickness and interventricular septal thickness in metabolically stable insulin-requiring diabetics revealed hypercontractility of the right ventricle.

Amniotic fluid analysis for antimicrobial factors.

The antimicrobial factors in amniotic fluid (AF) were analyzed in 81 women during various periods of gestation. The AF inhibited the growth of E. coli 026 when the phosphate/zinc ratio was less than 200 or iron less than or equal to 1.2 microgram/ml and unbound transferrin was greater than 40%. A heat-stable non-lysozymal phosphate insensitive cationic protein with molecular weight higher than transferrin was also found in inhibitory AF. The antimicrobial properties of AF did not correlate with absolute zinc or lysozyme levels. The AF was non-inhibitory when it contained greater than 60 +/- 5 micrograms/ml of phosphate with phosphate/zinc ratio greater than 200, iron greater than 1.2 microgram/ml and unbound transferrin was less than 40%. Amongst all criteria described, iron (P = 0.002) and unbound transferrin levels (P = 0.0005) were the most reliable and consistent all through pregnancy but others were highly reliable only during the 36th-40th week of gestation. The clinical application of these factors are being investigated.

Prenatal diagnosis and management of nonimmunologic hydrops fetalis.

As problem pregnancies are increasingly subjected to ultrasound evaluation, the prenatal diagnosis of hydrops fetalis is being made more and more frequently. The authors encountered 5 cases of this disorder in 12,830 deliveries (1:2566) and made the diagnosis prior to delivery in 4 of the 5 cases. Amniocentesis and amniotic fluid bilirubin determination have been performed in association with ultrasound scan and a battery of other diagnostic tests, and the results have been correlated with fetal outcome. In general the combination of fetal ascites and increased amniotic fluid bilirubin denotes a poor fetal prognosis. Unless there are other mitigating circumstances, a conservative course of management is recommended.

Control of perinatal infection by traditional preventive measures.

A 9-year review of nosocomial infections occurring in the department of obstetrics and gynecology of a major teaching hospital demonstrated the dramatic effect of strict asepsis and isolation on postoperative infection rates. With rigidly enforced preventive measures and without the use of prophylactic antibiotics, the rates of wound infection and endometritis and the relative prevalence of gram-negative aerobic organisms cultured from these infections could be reduced substantially. The role of anerobes in these infections was not established, since adequate techniques for the accurate diagnosis of anaerobic infection were not available at the time of this study. The relative importance of the numerous infection-control measures used is unclear. It is apparent, however, that by implementing all traditional methods of asepsis, virtually all types of nosocomial infection could be controlled, and the increased prevalence of gram-negative infections observed during the past decades could be reversed.

Reduced hepatic bilirubin uridine diphosphate glucuronyl transferase and uridine diphosphate glucose dehydrogenase activity in the human fetus.

Hepatic bilirubin uridine diphosphate glucuronyl transferase (UDPG-T) activity was 0.14 and 0.22 units in two fetuses aged 17 and 22 weeks, respectively, and less than 0.1 unit in 15 fetuses, aged 8--19 weeks compared to 0.68--1.99 units in 21 normal adults. Hepatic uridine diphosphate glucose dehydrogenase (UDPG-D) activity in 14 fetuses, aged 8--18 weeks, ranged from 6.2--15.0 units (mean = 11.3 +/- 0.7) compared to 28.8--49.2 units (mean = 39.6 +/- 2.5) in eight normal adults (P less than 0.001). There was no correlation between UDPG-D activity and gestational age. The hepatic UDPG-D activity was 16.5 units in a 33-day-old full term, female infant, 42.4 and 24.3 units in two 2-year-old infants, respectively, and 24.3 units in a 5.5-year-old child. In three human fetuses, the apparent Km UDPG was 0.54 x 10(-4) M. Thus, both hepatic bilirubin UDPG-T and UDPG-D activity are markedly reduced in the human fetus during the second trimester of gestation. Retarded development of hepatic UDPG-D may extend beyond the first month of life.

Microflora of the cervix during normal labor and the puerperium.

The normal flora of the cervix was studied in 50 healthy women in labor and on the third day postpartum. Aerobic bacteria were the exclusvie isolates in 25% of these women, and 75% had anaerobic bacteria in addition to aerobes. Anaerobes were always found in association with aerobes. The most frequent isolate of Bacteroides was Bacteroides melaninogenicus, found in 20% of the women during labor and 14% during the puerperium. Bacteroides fragilis was distinctly absent during labor but was found in 6.8% of the women during the puerperium. Clostridia were found in 1% but histotoxic clostridia were not found. None had gram-negative diplococci (Neisseria or Veillonella). Gram-negative diplococci and spore-bearing bacilli visible by gram strain and B. fragilis demonstrated by culture, if present in the cervical specimens obtaineduring labor, should be considered abnormal.

The management of severe preeclampsia and eclampsia with intravenous diazoxide.

Twelve patients with either severe preeclampsia (9) or eclampsia (3) were treated with intravenous diazoxide, 300-mg bolus, for the reduction of diastolic blood pressure (less than or equal 110 torr) after the usual and customary measures had been initiated to include parenteral MgSO4 and diazepam. Diazoxide precipitously decreased both systolic and diastolic blood pressure proportionately (35-50%); the nadir was invariably reached in 5-15 minutes. Diastolic pressure never fell below 50 torr, and mean arterial pressure always exceeded 70 torr. Oliguria was not apparent. The vasodepressor response was fairly persistent for 4 hours in all but 3 patients; 2 of these received a second 300-mg dose. Significant changes in fetal heart activity (bradycardia, dysrhythmia) were observed in only 1 patient. Labor was immediately ablated in all patients, but could be restimulated with oxytocin. All pregnancies were terminated within 7 hours (mean, 3.7 hours), seven of them by cesarean section. Eleven newborns did well. We conclude that the immediate reduction in maternal arterial blood pressure is without apparent hazard to the mother as well as the fetus.

Sampling the fetoplacental circulation. II. Combined laparoscopy-fetoscopy in the pregnant ovine.

Induction of pneumoperitoneum, laparoscopy, and intrauterine endoscopy (fetoscopy) were successfully accompished in 23 pregnant sheep at 45 to 60 days' gestational age. The fetoscope, a conventional 2.7 mm. Hopkins straightforward wide-angle telescope (Stortz 27018A) encased in a prototype 3.1 mm. eccentric cannula, incorporates a 25 gauge needle channel. Multiple pregnancy was encountered in 11 animals. Forty-two separate fetoscopic trials were accomplished; a fetoplacental blood sample was obtained in 52 per cent of the trials. A mean interval of 19 +/- 9 days (+/- S.D., range 6 to 37 days) was allowed between fetoscopy trials. Fetal deaths occurred in nine animals (39 per cent). We believe that laparoscopy permits preselection of the proposed fetoscopy puncture site and will permit the operator to thereby avoid the placenta and/or uterine vessels.

Antimicrobial effect of amniotic fluid against anaerobic bacteria.

Amniotic fluid samples were obtained at term and tested for their antimicrobial effect on anaerobes, Peptostreptococcus (Ps.) anaerobius, Peptococcus (Pc.) prevotii, Bacteroides (B.) fragilis, and B. coagulans with facultative Escherichia (E.) coli serving as control. Amniotic fluid had only temporary bacteriostatic effect on Pc. prevotii and B. fragilis for 8 to 16 hours. This effect lasted for only 8 hours on Ps. anaerobius. On the contrary, the bacteriostatic effect of amniotic fluid was well sustained on E. coli and B. coagulans, lasting for the entire test periods of 20 and 32 hours, respectively. At the end of the time intervals mentioned, Ps. anaerobius, Pc. prevotii, and B. fragilis exhibited logarithmic growth, confirming the earlier reports that it is not nutritionally deficient. Amniotic fluid exhibited temporary bacteriostatic effect on Ps. anaerobius, P. prevotii, and B. fragilis, but this effect was well sustained against B. coagulans.