Plastic reorganization of neural systems for perception of others in the congenitally blind.

Recent evidence suggests that the function of the core system for face perception might extend beyond visual face-perception to a broader role in person perception. To critically test the broader role of core face-system in person perception, we examined the role of the core system during the perception of others in 7 congenitally blind individuals and 15 sighted subjects by measuring their neural responses using fMRI while they listened to voices and performed identity and emotion recognition tasks. We hypothesised that in people who have had no visual experience of faces, core face-system areas may assume a role in the perception of others via voices. Results showed that emotions conveyed by voices can be decoded in homologues of the core face system only in the blind. Moreover, there was a specific enhancement of response to verbal as compared to non-verbal stimuli in bilateral fusiform face areas and the right posterior superior temporal sulcus showing that the core system also assumes some language-related functions in the blind. These results indicate that, in individuals with no history of visual experience, areas of the core system for face perception may assume a role in aspects of voice perception that are relevant to social cognition and perception of others' emotions.

Human uterine leiomyomata express higher levels of peroxisome proliferator-activated receptor gamma, retinoid X receptor alpha, and all-trans retinoic acid than myometrium.

Uterine leiomyomata are the main indication for a hysterectomy in the United States and occur in 25% of women >35 years. Because uterine leiomyomata can form when ovariectomized guinea pigs are exposed to estradiol and retinoic acids, we tested whether human leiomyomata had high levels of retinoic acids and related nuclear receptors. Compared with normal human myometrium, leiomyomata had 3- to 5-fold higher levels of peroxisome proliferator-activated receptor gamma (PPARgamma), retinoid X receptor alpha proteins, and all-trans retinoic acid, but only during the follicular phase of the menstrual cycle. 9-cis Retinoic acid was undetectable in either leiomyomata or myometrium. PPARgamma mRNA levels were lower in leiomyomata than myometrium, but only during the luteal phase of the cycle. A PPARgamma agonist, troglitazone, was given to guinea pigs along with estradiol and all-trans retinoic acid and produced the largest leiomyomata seen to date in this model. By contrast, no tumors formed when troglitazone was given alone or with estradiol or when troglitazone was given with estradiol and 9-cis retinoic acid. New therapies for human leiomyomata may emerge by combining antagonists for PPARgamma and retinoid X receptor alpha with selective estrogen receptor modulators.

Helicobacter pylori infection and persistent hyperemesis gravidarum.

Hyperemesis gravidarum is the most severe spectrum of gastrointestinal complaints in pregnant women. Our purpose is to describe an association of Helicobacter pylori with hyperemesis gravidarum. Three pregnant women are described with the working diagnoses of hyperemesis gravidarum unresponsive to standard therapy. The medical management used to treat Helicobacter pylori in these women are elaborated. The persistence of the symptomatology and/or hematemesis resulted in Helicobacter pylori testing of these women. A 2-week course of antibiotics and a proton pump inhibitor or H2 receptor antagonist resulted in resolution of the hyperemesis. A discussion of the incidence, diagnosis, and management of Helicobacter pylori in pregnancy is described. When the symptoms of hyperemesis gravidarum are persistent into the second trimester, active peptic ulcer disease from Helicobacter pylori should be included in the differential diagnoses.

Effects of raloxifene in a guinea pig model for leiomyomas.

OBJECTIVE: Chronic exposure of oophorectomized guinea pigs to 17beta-estradiol causes leiomyoma formation. Our aims were to determine whether these leiomyomas can become estradiol independent after exposure to estradiol and if raloxifene inhibits leiomyoma growth when given concomitantly with estradiol. STUDY DESIGN: To induce leiomyoma development, 6 oophorectomized animals received two estradiol implants for 140 days. Next, the estradiol implants were replaced with empty implants in 3 animals, whereas the other 3 received 2 new estradiol implants and raloxifene given per os 10 mg/kg per day for 60 days. Tumor size was monitored biweekly by ultrasonography. RESULTS: On estradiol removal, abdominal wall leiomyomas regressed within 15 to 30 days; when estradiol implants were reintroduced, leiomyomas redeveloped. Within 30 days on raloxifene, all abdominal leiomyomas (n = 9) regressed as determined by ultrasonography and verified at laparotomy. Serum raloxifene and estradiol levels were 432 +/- 46 pg/mL and 78 +/- 13 pg/mL (mean +/- SEM, n = 3), respectively, after 60 days of treatment. CONCLUSIONS: Leiomyomas did not become estradiol independent, even after long exposure to estradiol; ultrasonography allowed frequent, noninvasive assessment of leiomyoma size, and raloxifene rapidly regressed leiomyomas in this animal model.

Cesarean delivery of twins during maternal cardiopulmonary arrest.

BACKGROUND: In modern times, maternal death is rare. Timely cesarean delivery in the setting of maternal cardiopulmonary arrest may save both the infant and the mother. CASE: A 36-year-old white woman with a twin pregnancy suffered cardiopulmonary arrest at 28 weeks' gestation. Advanced cardiopulmonary resuscitative measures were unsuccessful, and the twins were delivered by cesarean at the bedside. Immediately after delivery, a maternal pulse was noted; both the mother and her infants are alive 15 months later. CONCLUSION: Relieving vena caval occlusion by perimortem cesarean delivery in a term gravida allows chest compressions to provide sufficient cardiac output in the unfortunate event of maternal cardiopulmonary arrest. When delivery occurs within 5 minutes of maternal insult, the neonatal outcome is favorable.

Urine protein dipstick measurements. A screen for a standard, 24-hour urine collection.

OBJECTIVE: To determine if the sum of urine protein dipstick values recorded during every void can be used to screen for patients who need a standard, 24-hour urine collection for determination of protein excretion. STUDY DESIGN: Thirty inpatient and 17 outpatient pregnant women undergoing 24-hour urine collection for protein concentration were enrolled. The volume, dipstick protein values and time of void were recorded. The 24-hour quantitative analysis of protein excretion performed by the laboratory was compared to the 24-hour sum of the products of each voided volume and dipstick value (dipstick factor). RESULTS: The dipstick factor significantly correlated with the total 24-hour protein excretion (correlation coefficient 0.84, P < 1 x 10(-7)). A dipstick factor of > or = 300 mg, indicated proteinuria with a sensitivity of 96%, specificity of 90%, positive predictive value of 92% and negative predictive value of 95%. Separately, we found differences in the amount of protein excretion when the 24-hour period was divided into six 4-hour periods, using analysis of variance. Paired t test analysis of the mean protein excretion from 16:00 to 04:00 showed significantly higher results than did the protein excretion from 04:01 to 16:00 (1,197 +/- 356 mg vs. 674 +/- 158 mg, P < .0001). CONCLUSION: The sum of dipstick factors in a 24-hour period is a reliable screening test for identifying patients who need the standard laboratory test for proteinuria.

Maternal weight gain patterns and birth weight outcome in twin gestation.

OBJECTIVE: To evaluate the association between maternal weight gain patterns, based on pregravid body mass index (BMI) and birth weight outcome in twins, and to make specific recommendations for maternal weight gain during twin gestation. METHODS: One hundred eighty-nine twin pregnancies were reviewed retrospectively. Weekly rates of maternal weight gain before 20 weeks, from 20 weeks to delivery, and for total gestation were calculated. Thresholds of weekly maternal weight gain were determined for underweight and normal-weight women. RESULTS: In underweight women, a higher weekly rate of gain before 20 weeks was associated with the birth of both twins weighing at least 2500 g (1.13 versus 0.70 lb/week, P = .017), when compared with mothers of at least one twin weighing less than 2500 g. A higher rate of weight gain from 20 weeks to delivery was associated with the delivery of twins weighing at least 2500 g in both underweight (1.92 versus 1.29 lb/week, P = .031) and normal weight (1.63 versus 1.29 lb/week, P = .046) women. No significant differences in weight gain patterns were found between overweight women delivering twins weighing less than 2500 g or at least 2500 g. A weekly rate of gain from 20 weeks' gestation to delivery of at least 1.75 lb/week in underweight women and at least 1.50 lb/week in normal-weight women was associated with the birth of both twins weighing at least 2500 g. After controlling for other potential determinants of birth weight, the threshold of 1.75 lb/week in underweight women showed a trend toward significance as an independent predictor of both twins weighing at least 2500 g (P = .06). CONCLUSION: Certain maternal weight gain patterns during twin pregnancy are associated with the birth of each twin weighing at least 2500 g. As with singletons, recommendations for maternal weight gain during twin pregnancy can be based on pregravid BMI.

The effect of magnesium sulfate on bleeding time in pregnancy.

OBJECTIVE: The bleeding time is one of the most commonly used diagnostic tests to evaluate platelet-related hemorrhagic disorders. Magnesium has been shown in vitro to be a platelet antiaggregant. This study was conducted to evaluate the hypothesis that magnesium sulfate has no effect on the template bleeding time. STUDY DESIGN: The study group consisted of 24 women who required magnesium sulfate in pregnancy. A blood cell count, platelet count, magnesium level, bleeding time, and mean arterial pressure were obtained before and 2 hours after magnesium sulfate infusion. Magnesium sulfate was infused beginning with a 6 gm intravenous bolus followed by 2 gm/hr. A template bleeding time was performed with a Simplate-II (Organon Teknika, Durham, N.C.) device. Two of the authors performed all the bleeding times. Data were analyzed with a paired t test and Wilcoxon rank test. RESULTS: Fifteen (63%) patients received magnesium sulfate for tocolysis or before external cephalic version and nine (37%) for preeclampsia prophylaxis. No differences were found between the normotensive and hypertensive groups regarding maternal age, gestational age, initial bleeding time, or platelet count. Analysis of the entire study group revealed a prolongation of the bleeding time after magnesium sulfate (5.7 +/- 1.8 vs 6.6 +/- 1.9 minutes, p < 0.05); a lowering of the mean arterial pressure (p < 0.05), and a rise in the magnesium level (p < 0.05). Four patients (16.7%) had a postmagnesium bleeding time > 9 minutes. CONCLUSION: Magnesium sulfate appears to prolong the bleeding time in pregnancy. The clinical significance remains to be determined.

Estrogen-induced guinea pig model for uterine leiomyomas: do the ovaries protect?

A guinea pig model was used to study the hormonal control of uterine leiomyomas. Twenty female guinea pigs were divided into four groups--young, old, ovariectomized (OVX), and non-OVX animals--and were given two estradiol-17 beta (E2) silastic implants each for 3-10 mo; another four older OVX animals served as controls and received empty implants. After 3 mo, 100% (8 of 8) of the OVX animals, but none of the OVX controls, developed tumors, mainly on the uterine serosa and the abdominal wall. Electron microscopy and desmin immunostaining demonstrated that the tumors were leiomyomas. In E2-treated animals, E2 levels in serum, leiomyomas, or leiomyoma-free uterine segments rose significantly while serum progesterone (P4) was negligible. Surprisingly, only 8% (1 of 12) of the non-OVX animals developed a tumor. This apparent "ovarian protection" was transient: after 6-9 mo, 50% of the remaining non-OVX animals developed leiomyomas, but these were smaller and fewer than in OVX animals. On the basis of this model, we propose the hypothesis that some factors from the ovaries suppress leiomyoma growth in response to estrogen but that as the ovaries age this protection is diminished, allowing the clinical development of leiomyomas.

Blunt versus sharp expansion of the uterine incision in low-segment transverse cesarean section.

OBJECTIVE: Both blunt and sharp expansion of the initial incision at transverse cervical cesarean birth have advocates, on the basis of theoretic concerns. We sought to study the incidence of complications, including unintended extension, associated with each of these methods by comparison by means of a prospective, randomized study. STUDY DESIGN: Women scheduled to undergo nonemergency cesarean birth were assigned to blunt and sharp expansion groups. Other than expansion of the incision, standard technique was used throughout surgery. Data, including length and number of unintended extensions, vessel laceration, and length of surgery, were recorded immediately. RESULTS: The blunt (n = 139) and sharp (n = 147) expansion groups were similar with regard to indication and duration of labor. No difference in the incidence of unintended extension, postoperative endometritis, duration of surgery, or estimated blood loss was noted. The frequency of unintended extension (1.4%, 15.5%, and 35.0% for no labor and first and second stages, respectively) correlated with the stage of labor. CONCLUSION: Blunt and sharp expansions of the uterine incision are equivalent in ease and safety.

Vulvar application of lidocaine for pain relief in spontaneous vaginal delivery.

OBJECTIVE: To evaluate the effect of topical perineal lidocaine on immediate postpartum perineal pain. METHODS: Two hundred three volunteers randomly received either 2% lidocaine jelly or chlorhexidine gluconate topically to the perineum during the second stage of labor in a double-blind study. A four-point analogue pain scale was used to rate perineal pain 30 minutes after delivery. Parametric data were evaluated with the unpaired Student t test. Nonparametric data were analyzed using Mann-Whitney, Pearson chi 2, and Mantel-haenzel tests, and forward stepwise logistic regression. RESULTS: Women receiving topical lidocaine reported less overall perceived pain (48%, P < .05) and less moderate to severe pain (52%, odds ratio 1.83, P < .04) at delivery than those receiving placebo (33 and 67%, respectively). The incidence of perineal lacerations was similar in the two groups. A logistic regression found topical lidocaine and multiparity as significant correlates of diminished peripartum pain (P < .007). CONCLUSIONS: Topical application of 2% lidocaine gel was associated with decreased pain perception in the immediate postpartum interval. If confirmed by other investigators, this technique may offer improved analgesia while minimizing the injection route with local analgesia.

Pregnancy complicated by Gorham disease.

BACKGROUND: A pregnancy with Gorham disease (massive osteolysis syndrome) is described. To our knowledge, this is the first reported case of a pregnancy associated with this disease. CASE: A 25-year-old woman was seen for pre-conception counseling with the diagnosis of Gorham disease. Before pregnancy, magnetic resonance imaging confirmed a stable disease process. The woman and fetus were followed during pregnancy with ultrasound and consultations. Severe preeclampsia developed at delivery, with a significant thrombocytopenia. We delivered the infant by low forceps, with a good outcome. Subsequently, the mother and child were doing well at 18 months postpartum. CONCLUSION: We briefly review this rare bone disease as it relates to pregnancy and provide information for preconception counseling.

Evaluation of oxygen desaturation events in singleton pregnancies.

Previous investigators have demonstrated that oxygen desaturation may occur in laboring women. The purposes of this study were to identify groups at risk for desaturation and to seek correlation with newborn outcome. Volunteers in labor were evaluated for oxygen desaturation, analgesic exposure, magnesium sulfate administration, and various medical illnesses. Desaturations were noted more frequently in women exposed to narcotic analgesics, sedatives, and magnesium sulfate. A trend toward more desaturations in the women with preeclampsia was noted. Although desaturations related to narcotic analgesics and sedatives are most likely due to hypoventilation, the mechanism in women treated with magnesium sulfate is uncertain. Maternal peripartum desaturations did not result in unfavorable neonatal Apgar scores, cord blood gas measurements, or neonatal oxygen desaturation values, but the staff was aware of the events and prompt treatment was instituted.

Comparison of cord purine metabolites to maternal and neonatal variables of hypoxia.

Umbilical arterial concentrations of purine metabolites were evaluated prospectively as markers of hypoxia. The results suggest that hypoxanthine accumulates in association with fetal acidosis and reduced levels of buffer base (P less than .01). Acute hypoxemia defined by umbilical arterial oxygen pressure was accompanied by elevation of uric acid concentrations (P less than .01). Fetal heart rate tracings with characteristics classically associated with fetal stress correlated with increased concentrations of hypoxanthine and xanthine (P less than .01). Therefore, intrapartum events may occur that are not documented by standard markers of perinatal hypoxia at delivery.

Fetal abdominal hyperechoic mass: diagnosis and management.

In the last 2 years, we have had the opportunity to follow 12 cases diagnosed with hyperechoic abdominal masses. Four of the cases ended with a fetal demise, while 7 resulted in the birth of an anomalous or medically ill neonate. Only 1 case has shown spontaneous resolution of the hyperechoic mass with the birth of a normal neonate. The in utero diagnosis of a hyperechoic abdominal mass should encourage the clinician to further investigation since the differential diagnosis is quite diverse. Appropriate counselling for the patient is a necessary part of prenatal care.