Prediction of neonatal outcome in women with gestational hypertension or mild preeclampsia after 36 weeks of gestation.

BACKGROUND: There is little knowledge about neonatal complications in GH and PE and induction at term, we aim to assess whether they can be predicted from clinical data. METHODS: We used data of the HYPITAT trial and evaluated whether adverse neonatal outcome (Apgar score < 7, pH < 7.05, NICU admission) could be predicted from clinical data. Logistic regression, ROC analysis and calibration were used to identify predictors and evaluate the predictive capacity in an antepartum and intrapartum model. RESULTS: We included 1153 pregnancies, of whom 76 (6.6%) had adverse neonatal outcome. Parity (primipara OR 2.75), BMI (OR 1.06), proteinuria (dipstick +++ OR 2.5), uric acid (OR 1.4) and creatinine (OR 1.02) were independent antepartum predictors; In the intrapartum model, meconium stained amniotic fluid (OR 2.2), temperature (OR 1.8), duration of first stage of labour (OR 1.15), proteinuria (dipstick +++ OR 2.7), creatinine (OR 1.02) and uric acid (OR 1.5) were predictors of adverse neonatal outcome. Both models showed good discrimination (AUC 0.75 and 0.78), but calibration was limited (Hosmer-Lemeshow p = 0.41, and p = 0.20). CONCLUSIONS: In women with GH or PE at term, it is difficult to predict neonatal complications, possibly since they are rare in the term pregnancy. However, the identified individual predictors may guide physicians to anticipate requirements for neonatal care.

[Perineal infiltration anaesthesia for episiotomy: a needle which is bent manually may break off and migrate through the body]. / Perineale infiltratieanesthesie voor een episiotomie: een met de hand voorgebogen naald kan afbreken en gaan zwerven.

A 28-year-old pregnant woman was given local anaesthesia in the perineum with a Monoject disposable needle in preparation for an episiotomy. The needle was bent manually in order to facilitate infiltration. During infiltration the needle broke off and disappeared. The delivery was uneventful. Radio diagnostic examination located the needle deep in the patient's left buttock. It was removed a week later via a small incision. Breakage of the needle was probably caused by the bending in combination with a sudden movement by the patient at the moment of infiltration. In obstetrics episiotomy is a common surgical procedure. For infiltration anaesthesia of the perineum a long, flexible, reusable Unimed needle is recommended instead of a short, inflexible, disposable Monoject needle.

Different pharmacokinetics of tramadol in mothers treated for labour pain and in their neonates.

OBJECTIVE: The aim of the present study was to investigate the pharmacokinetic profile of tramadol hydrochloride in neonates, born from mothers who underwent analgesia with tramadol for the relief of labour pain. METHODS: Intramuscular tramadol (100--250 mg) was administered to 22 mothers giving birth who requested pain relief. At the time of birth (1.5--6.0 h after last tramadol dose), maternal and umbilical blood samples were taken. Another venous blood sample was drawn from each neonate, and at the same time from its mother, at 1, 2, 3, 6 or 12 h post-partum, providing the data for a population pharmacokinetic evaluation of tramadol and its metabolite M1. Routine APGAR scores and a standard neurological and adaptive capacity test were considered for evaluation of the effect of tramadol on the neonates. RESULTS: Serum tramadol concentrations at the time of birth (t(0)) were 243+/-102 ng/ml (mean+/-SD, umbilical vein), 258+/-103 ng/ml (umbilical artery) and 250+/-113 ng/ml (maternal vein). Serum M1 concentrations were 52+/-27 ng/ml (umbilical vein), 47+/-24 ng/ml (umbilical artery) and 56+/-21 ng/ml (maternal vein). The two-compartment type elimination profiles during the first 12 h post-partum for neonates (and mothers, respectively) were characterised by terminal t(1/2) (tramadol)=7.0 (7.2) h and t(1/2) (metabolite M1)=85.0 (5.5) h. CONCLUSION: The intramuscular application of tramadol in birth-giving mothers almost freely reaches the neonate, confirming a high degree of placental permeability. The neonates already possess the complete hepatic capacity for the metabolism of tramadol into its active metabolite. However, the renal elimination of the active tramadol metabolite M1 is delayed, in line with the slow maturation process of renal function in neonates. Despite this difference in pharmacokinetics between neonates and adults, the intramuscular application of tramadol at the recommended dosage range during delivery appears to effective in the relief of labour pain.

[Malacoplakia of the female genital tract in a woman with postmenopausal bleeding]. / Malacoplakie van de tractus genitalis bij een vrouw met postmenopauzaal bloedverlies.

A 74-year-old woman had vaginal bleeding for 6 months with no other complaints. A suspected tumour was visible on the cervix and the endometrium was slightly thickened. Histological examination revealed Michaelis-Gutmann bodies. Following antibiotic treatment, the tumour and the bleeding disappeared. Malacoplakia is a chronic inflammation which usually arises in the urinary tract of older women and, rarely, in the female genital tract. The abnormality often appears to be a malignancy, although histologically it is an inflammatory condition. Histological examination is necessary to establish the diagnosis. Treatment usually consists of antibiotics and surgical excision.

Ascending dose tolerance study of intramuscular carbetocin administered after normal vaginal birth.

OBJECTIVE: To determine the maximum tolerated dose (MTD) of carbetocin (a long-acting synthetic analogue of oxytocin), when administered immediately after vaginal delivery at term. MATERIALS AND METHODS: Carbetocin was given as an intramuscular injection immediately after the birth of the infant in 45 healthy women with normal singleton pregnancies who delivered vaginally at term. Dosage groups of 15, 30, 50, 75, 100, 125, 150, 175 or 200 microg carbetocin were assigned to blocks of three women according to the continual reassessment method (CRM). RESULTS: All dosage groups consisted of three women, except those with 100 microg (n=6) and 200 microg (n=18). Recorded were dose-limiting adverse events: hyper- or hypotension (three), severe abdominal pain (0), vomiting (0) and retained placenta (four). Serious adverse events occurred in seven women: six cases with blood loss > or = 1000 ml, four cases of manual placenta removal, five cases of additional oxytocics administration and five cases of blood transfusion. Maximum blood loss was greatest at the upper and lower dose levels, and lowest in the 70-125 microg dose range. Four out of six cases with blood loss > or = 1000 ml occurred in the 200 microg group. The majority of additional administration of oxytocics (4/5) and blood transfusion (3/5) occurred in the dose groups of 200 microg. All retained placentae were found in the group of 200 microg. CONCLUSION: The MTD was calculated to be at 200 microg carbetocin.

[Puerperal toxic shock syndrome caused by Group A beta-hemolytic streptococci]. / Toxische-shocksyndroom in het kraambed door beta-hemolytische streptokokken uit groep A.

This case report describes the history of a young female with a streptococcal toxic shock syndrome secondary to a puerperal sepsis. The syndrome was complicated by severe hypotension, reversible kidney dysfunction, adult respiratory distress syndrome, coagulation disturbances, myositis and rhabdomyolysis. This latter complication required amputation of both lower legs.

Lethal lung hypoplasia in infants after prolonged rupture of membranes.

A retrospective study to detect the frequency of lethal lung hypoplasia in 48 cases with prolonged rupture of membranes (greater than 7 days) before 34 weeks' gestation was made. Fourteen infants died (29%), but only four deaths (8.3%) were due to lung hypoplasia. Three infants with lung hypoplasia had their membranes ruptured before 20 weeks' gestation and showed echoscopically a persistent oligohydramnios, as did the one with rupture at 26 weeks. Neither the duration of rupture of membranes nor the gestational age at the time of rupture showed any influence on the occurrence of lung hypoplasia. The rupture of membranes before 20 weeks' gestational age with resulting persistent oligohydramnios will certainly lead to lung hypoplasia.

First experiences with Swan-Ganz measurements in patients with severe hypertension during pregnancy from an unselected population.

In 10 patients with severe hypertension during pregnancy (6 patients with preexisting hypertension and 4 with severe preeclampsia) Swan-Ganz measurements were done in order to detect and correct a reduced circulating volume and lower the blood pressure. It appeared that 6 patients had a reduced circulating volume (group I) and 4 patients a normal circulating volume (group II). In both groups there were 2 patients with severe preeclampsia; most patients were referred and had antihypertensive medication before and most infants had a birthweight less than the 10th centile. A difference was found in prolongation of pregnancy if counted from the first hemodynamic measurement (and start of therapy): on average 25 days in group I (despite careful volume correction and vasodilatation) versus on average 25 days in group II (vasodilatation only). Moreover, all infants but one were delivered by cesarean section, but fetal distress as indication for delivery was only noted in group I. Although Swan-Ganz measurements are very useful to determine filling state and effect of therapy it is concluded that once a reduced circulating volume is present one is too late to be able to prolong pregnancy considerably despite proper therapy of volume correction and vasodilatation. This makes Swan-Ganz measurements on "fetal indication" questionable.

One-year morbidity in very premature infants: prognostic value of duration of pregnancy, birthweight and neonatal morbidity.

Morbidity in the first year of life of 120 infants, born before the 34th wk of pregnancy, was studied in relationship to both duration of pregnancy and birthweight. Moreover, the interrelationships of morbidity in three time-periods (first-hour, first 28 days and first year after delivery) were studied. The major handicap rate at one year was 5%, without major handicaps in infants born before 29 wk or weighing less than 1250 g. This finding seems to justify intensive treatment of even the youngest and smallest infants. Significantly more morbidity in the first 28 days of life was found when intervention within the first hour after delivery was necessary, indicating that morbidity in the first hour after delivery may be a prognostic bad sign for morbidity in the first 28 days of life. However, no significant differences in handicap rates at one year of age were found in infants with and without morbidity in the first hour or in the first 28 days. This indicates that early morbidity will not necessarily be followed by morbidity in later life, but, on the other hand, absence of early morbidity does not preclude handicaps later on.

Survival probabilities of infants delivered prior to the 34th week of pregnancy as estimated by means of a logistic model.

Survival of 188 infants born alive before the 34th wk of pregnancy is assessed in relation both to birthweight and duration of pregnancy. A logistic model is used which describes, based on these parameters, probabilities of 1-yr survival of relatively small populations in a continuous way. Although there may be differences between measured and estimated birthweight, this method might enable the perinatologist to estimate before birth the survival probabilities if he knows the duration of pregnancy and estimated birthweight.