Successful management of severe idiopathic thrombocytopenia in the second trimester of pregnancy.

This paper describes a case of severe idiopathic thrombocytopenia in a primigravida. The disorder became symptomatic at 22 weeks gestation with a platelet count of 20,000/microliter. The existence of chronic idiopathic thrombocytopenia under remission was strongly suspected, but could not be documented. The patient was treated with oral corticosteroids over a period of 7 weeks. During this period, she also had three cycles of high-dose intravenous globulin. This treatment produced a transient improvement, but the platelet count fell to 4,000/ microl by the 29th gestational week. Caesarean section was carried out for maternal indication a week later, following a fourth intensified course of gamma-globulin, coupled with platelet transfusions and low-dose vinblastine. Splenectomy was not performed. Potentially life-threatening thrombocytopenia persisted for 6 weeks post partum. Despite the presence of circulating antiplatelet globulin in the maternal blood and the antenatal use of vinblastine, the infant was entirely unaffected and thrived.

Comparison of patient-controlled analgesia and epidural morphine for postcesarean pain and recovery.

A greater awareness of the advantages and limitations of new methods of administering postcesarean analgesia would help the obstetrician care for the recovering patient. Patient-controlled analgesia and epidural morphine are two new modalities for postoperative pain relief. The purpose of this prospective investigation was to compare their effectiveness, safety, side effects, patient satisfaction and cost. During an eight-month period, 161 women undergoing cesarean delivery were assigned to receive narcotics by either epidural morphine (76 patients) or patient-controlled analgesia (85 patients) using a combined continuous infusion and demand dosing of meperidine. The demographic characteristics of the two groups were similar. Mild or no pain was reported with similar frequencies in both groups. No reduced respiration or undesired sedation was seen in either group. The postoperative times before sitting at the bedside, ambulating, tolerating clear liquids and leaving the hospital were also comparable. No complications were encountered with patient-controlled analgesia, but pruritus and alarms from apnea monitors occurred commonly in the epidural morphine group. The costs to the patient were similar for the two groups. Patient-controlled analgesia using a combined continuous infusion and demand dosing is an acceptable alternative to epidural morphine after cesarean delivery.

Failed induction of labor despite sequential prostaglandin E2 therapy.

Preinduction cervical ripening with prostaglandin E2 (PGE2) is useful in minimizing the chances for a failed induction of labor. The lack of sufficient cervical dilation despite PGE2 and oxytocin therapy is uncommon. This investigation was undertaken to determine reasons for any failed inductions in pregnancies with pregel Bishop scores 4 or lower and requiring delivery within 24 hours. Fifteen (12.1%) of 124 eligible patients had failed inductions despite two 2.5 mg intravaginal doses. A finding in all the failures was a very unfavorable cervix (pregel Bishop score 0 to 2). The need for preterm delivery (33 to 37 weeks) was a common finding in the presence of a very unfavorable cervix. The data suggest that complicated pregnancies requiring delivery within 24 hours and failing to respond to sequential PGE2 therapy in the presence of a very unfavorable cervix may benefit from cesarean section without a prolonged induction.