Primary hyperparathyroidism, hypercalcemic crisis and subsequent seizures occurring during pregnancy: a case report.

A first-trimester primigravid patient presented with hyperemesis and malaise. Work-up was consistent with primary hyperparathryoidism. During acute treatment, she developed generalized motor seizures considered to be secondary to hypercalcemia. Evaluation and treatment of women with primary hyperparathyroidism and hypercalcemia are reviewed, and the pathogenesis of seizures associated with hypercalcemia is discussed.

Relationship between subjective grade and examination score in obstetrics and gynecology clerkships at community and university sites.

OBJECTIVE: To determine if there were differences in a medical student's subjective grade and obstetric-gynecologic (OB/GYN) test scores based upon the student's site of rotation, hospital type or presence of OB/GYN residents. STUDY DESIGN: We evaluated 521 students taking their third-year OB/GYN clerkship. The OB/GYN clerkship was eight weeks in length. The six sites (five community and one university) divided the OB/GYN rotations similarly. Five sites had OB/GYN residents; three had University of Illinois (UIC) residents. Comparisons were made between each student's subjective grade and OB/GYN final examination test score with respect to site, presence/absence of OB/GYN residents, community vs. university hospital and presence of UIC residents. Using the chi 2 test of association and regression models, we evaluated for relationships between the subjective grades, final examination scores and final grades. Significance was set at P < .05 for all evaluations. RESULTS: Examination scores lowered final grades for 9.4% of students trained at the university hospital as opposed to 11.5% of nonuniversity hospitals. Final examination scores were lower than subjective assessments more often than in the nonuniversity hospitals (27.6% vs. 16.2%, P < .001). Hospitals with OB/GYN residents had less of a reduction in grades than did those without residents (8.9% vs. 24.6%, P < .0001) as well as lower final examination scores (with respect to subjective grade) (21.5% vs. 40.3%, P < .0001). The presence of UIC residents further reduced the incidence of examination scores lower than subjective assessment (19.7% vs. 34.0%, P < .0001). A linear correlation was noted between subjective grade and final examination score (r = .243, P < .001); this was strongest at the university hospital. CONCLUSION: Students trained at a university hospital were less likely to have test scores lower than their subjective grades. Subjective assessments made in the presence of OB/GYN residents reduced the likelihood of a final grade reduction.

Relationship between normal amniotic fluid index and birth weight in term patients presenting for labor.

OBJECTIVE: To investigate whether a relationship between birth weight (BW) and amniotic fluid index (AFI) existed for term patients with intact membranes and, if so, whether it could predict macrosomia and intrauterine growth retardation. STUDY DESIGN: Two hundred thirty-one eligible women at term (37-42 weeks' gestation) had an AFI between 5.0 and 24.0 cm at the time of admission. Demographic information was collected, including BW. Statistical comparisons were made, with significance set at P < .05. RESULTS: The mean gestational age was 39.5 weeks, and the mean AFI was 11.3. There were 28 infants with BWs > 4,000 g (macrosomia). The cesarean section rate was 16.9%. Macrosomia was associated with a higher cesarean section rate (39.2% vs. 13.8%, P < .002). The mean AFI was higher for those with macrosomia (13.5 vs. 11.0, P < .001). Patients with an AFI > 15.0 had over twice the incidence of macrosomia (RR 2.72, 1.1-6.6, 32.1% vs. 14.8%, P < .027). The risk was even greater for them with an AFI > 18.0 (RR 6.4, 2.2-18.7, P < .002). A linear relationship was observed between AFI and BW (r2 .061, P < .0001). BW increased with increasing AFI. No relationship between AFI of 5-8 and BW < 2,500 g was found. CONCLUSION: Increasing AFI correlates linearly with increasing BW, and macrosomia is associated with an increased incidence of cesarean delivery. AFI > 15 carries over double the risk of birth of a macrosomic infant, while AFI > 18 has a risk of over six times. No association between low normal AFI and a growth-restricted infant was found.

Obstetrics and gynecology final examination scores at university and community hospitals. A comparison.

OBJECTIVE: To determine if there were differences in standard obstetrics and gynecology final examination scores for students whose clerkships were at either the university or one of five community hospitals. STUDY DESIGN: All students taking their obstetrics and gynecology clerkship from July 1995 to June 1998 were included in the analysis. The clerkship was eight weeks in length. All sites had four weeks of obstetrics and four of gynecology. Six sites were utilized--five community and one university. University of Illinois at Chicago (UIC) residents rotated to two of the community hospitals. Two of the remaining three hospitals had freestanding obstetrics and gynecology residency programs. Core lectures were provided for five of six sites at the university; one site gave its own series of similar topics. Comparisons were made with respect to obstetrics and gynecology final examination scores (National Board type). United States Medical Licensure Examination (USMLE) scores were evaluated to determine whether a control with respect to test performance was needed. Only the first attempt for either examination was evaluated. Student's t test and one-way analysis of variance were used as indicated. Significance was set at P < .05. RESULTS: Five hundred twenty-two students were included in the analysis. There was no difference with respect to obstetrics and gynecology examination scores between the combined community and university hospitals. There were no significant differences between sites for obstetrics/gynecologic scores when evaluated using USMLE step I scores as a control. The presence of UIC residents and higher final examination scores was significant (3.6 points, P < .024). The presence of obstetrics and gynecology residents and higher final examination scores was also significant (2.5 points, P < .035). CONCLUSION: The type of hospital (community vs. university) does not appear to affect obstetrics and gynecology final examination performance, but the presence of obstetrics and gynecology residents may positively affect student performance on final examinations, with a greater benefit noted in facilities with university-based residents.

Caffeine-induced hypokalemic paralysis in pregnancy.

BACKGROUND: Excessive ingestion of caffeine can induce hypokalemia, which affects the neuromuscular system and can lead to paralysis. CASE: A 24-year-old woman, gravida 3, para 2-0-0-2 at 33 weeks' gestation presented with muscular paralysis and hypokalemia secondary to drinking 6 to 7 L of cola per day with little other oral intake. After potassium replacement and stopping caffeine ingestion, the symptoms resolved quickly. CONCLUSION: The physiologic changes of pregnancy might potentiate the effect of caffeine on serum potassium concentration.

United States Medical Licensure Examination step 1 scores and obstetrics-gynecology clerkship final examination.

OBJECTIVE: To determine if scores from first attempts at the United States Medical Licensure Examination step 1 correlated with obstetrics-gynecology examination scores and identified students at risk of failure. METHODS: All students in obstetrics-gynecology clerkships at the University of Illinois at Chicago from July 1995 through June 1998 were studied. The clerkship length was 8 weeks. Six clerkship sites were used, each of which assigned students to obstetrics-gynecology for the same length. Only first attempts at the obstetrics-gynecology clerkship examination and United States Medical Licensure Examination step 1 were evaluated. RESULTS: Among 522 students the mean (+/- standard deviation [SD]) United States Medical Licensure Examination step 1 score was 205 (+/-24.4). The mean score (+/-SD) for the standard obstetrics-gynecology examination was 69.5 (+/-8.1). The obstetrics-gynecology examination score correlated significantly with the United States Medical Licensure Examination step 1 score (r = .662, P<.001). Sixty-five students failed their first attempts at the United States Medical Licensure Examination step 1 examination, and ten failed their first attempts at the clerkship examination. Students who failed their first attempts at the United States Medical Licensure Examination step 1 were more likely to fail their first attempts at the clerkship examination (relative risk 18.6; 4.6, 72.6; P<.001). More than half the students who failed their initial United States Medical Licensure Examination step 1 examinations failed or finished in the lower 25th percentile on their obstetrics-gynecology finals. CONCLUSION: United States Medical Licensure Examination step 1 scores correlated with obstetric-gynecology clerkship examination scores. Failure on the first attempts of the United States Medical Licensure Examination step 1 examination predicted students at risk of failures of the obstetrics-gynecology final examination and those who finished in the lower 25th percentile.

The Jarisch-Herxheimer reaction and fetal monitoring changes in pregnant women treated for syphilis.

OBJECTIVE: To estimate the incidence of the Jarisch-Herxheimer reaction in pregnant women undergoing treatment of syphilis and the incidence of changes in uterine activity or fetal heart rate (FHR). METHODS: Pregnant women of at least 24 weeks' gestation diagnosed as needing treatment of syphilis were reviewed retrospectively. Patients were admitted for their first dose of benzathine penicillin, and the FHR was recorded continuously before and for 24 hours after injection. The occurrence of the Jarisch-Herxheimer reaction was noted, and all available FHR records for this admission were reviewed. Evaluations for changes in the FHR pattern and uterine activity were made. Statistical comparisons used Student t, Fischer exact, and chi2 tests, when applicable (significance P < .05). RESULTS: We reviewed 50 charts and 31 available FHR records. The average gestational age was 30.8 weeks. We found 20 cases of probable Jarisch-Herxheimer reaction (40%). Thirteen of 31 patients (41.9%) developed regular uterine contractions, median onset, 10 hours. All resolved within 24 hours of treatment. Patients with uterine contractions had a greater mean increase in temperature (1.15F versus 0.68F, P < .008). Twelve of 31 women (38.7%) developed recurrent variable decelerations, median onset, 8 hours. All patients but one had their contractions resolve within 24 hours of treatment. Lower gestational age was associated with the occurrence of recurrent variable decelerations (29.6 weeks versus 32.3 weeks, P < .05). No patients required delivery at the time of treatment. CONCLUSION: The incidence of Jarisch-Herxheimer reaction in treated syphilitic pregnancies is about 40%; similar proportions of patients develop regular uterine contractions and recurrent variable decelerations.

Detection of group B streptococcus: comparison of an optical immunoassay with direct plating and broth-enhanced culture methods.

The aim of this study was to compare the diagnostic accuracy of an optical immunoassay (STREP B OIA, Biostar) to direct plating and broth-enhanced culture for the detection of group B streptococcus (GBS) colonization of the lower genital tract in pregnant women. GBS cultures from the lower genital tract were obtained in a prospective fashion using a dual swab transport system from patients with risk factors for perinatal GBS infection. One swab was used to inoculate a trypticase soy agar plate with 5% sheep blood (TSA) and then placed in Lim broth. The other swab was used to perform the Strep B OIA. Growth of GBS by either direct plating or broth-enhanced culture was used as the gold standard for determining GBS colonization. Of the 524 women in the study, 90 women had positive cultures (either TSA or Lim broth). The sensitivity, specificity, positive predictive value, and negative predictive value of the Strep B OIA were 47% (42/90), 96% (416/434), 70% (42/60), 90% (416/464). The sensitivity, specificity, positive predictive value, and negative predictive value of the TSA were 61% (55/90), 100% (434/434), 100% (55/55), 93% (434/469). The sensitivity, specificity, positive predictive value, and negative predictive value of Lim broth were 97% (87/90), 100% (434/434), 100% (87/87), and 97% (434/437). The sensitivity of the Strep B OIA to detect light GBS colonization and heavy GBS colonization, as determined by the TSA, was 53% (19/36) and 90% (17/19), respectively. The Strep B OIA and direct agar plate culture appear to be of limited clinical value due to their poor sensitivities. This study also demonstrates the need to use a selective medium such as Lim broth when assessing for GBS colonization of the lower genital tract.

Effects of smoking, alcohol, and drugs of abuse on the outcome of "expectantly" managed cases of preterm premature rupture of membranes.

We evaluated the outcome of pregnancies complicated by preterm premature rupture of membrane (PROM) in order to determine if tobacco, alcohol, or illicit drug usage were associated with alterations in pregnancy or neonatal outcome. Comparisons in outcome were made with respect to tobacco, alcohol, and/or illicit drug usage. Comparisons were made with gestational age (GA) of PROM, GA of delivery, latency period (LP), maternal age, initial cervical exam (by speculum), age, race, tocolytic use, chorioamnionitis, and birthweight. Student's t-test, Mann-Whitney test, and Chi-square analysis were used to evaluate for significant differences (significance set at P < 0.05). A total of 119 charts were evaluated. Differences were noted with respect to smokers vs. nonsmokers for latency period (6.0 days vs. 9.4 days, P < 0.03), age (29.1 years vs. 24.8, P < 0.001), and gravidity (4.2 vs. 2.8, P < 0.005). Differences were noted for use of alcohol and age (29.9 vs. 25.2, P < 0.006). Differences were also noted for the use of illicit drugs and the following variables: age (30.0 vs. 24.9, P < 0.001), gravidity (4.7 vs. 2.5, P < 0.006), latency (6.2 vs. 9.0, P < 0.009), and parity (2.6 vs. 1.2, P < 0.01). A difference was noted with respect to cocaine and latency period (5.8 vs. 9.0, P < 0.01), age (31.2 vs. 24.8, P < 0.001), gravidity (4.8 vs. 2.9, P < 0.01), and parity (2.6 vs. 1.2, P < 0.03), and the use of tocolytics (22% vs. 55.4%, P < 0.02). These relationships held after multivariate analysis was performed. There were no associations among use of tobacco, alcohol, drugs of abuse, or cocaine and respiratory distress syndrome, intraventricular hemorrhage, or necrotizing enterocolitis. The use of tobacco during pregnancy appears to shorten the latency period in pregnancies complicated by PROM. Cocaine abuse also appears to shorten the latency period. These shortened latency periods could potentially contribute to increased neonatal morbidity. Larger studies evaluating this are needed.

Preterm premature rupture of membranes: comparison between twin and singleton gestations.

The purpose of this study was to evaluate the clinical characteristics and pregnancy outcomes of twin and singleton pregnancies complicated by preterm premature rupture of membranes (PROM) and to compare the groups to evaluate for differences in these areas. In this retrospective study, patients with a gestational age of < 36 weeks admitted between 1993 and 1996 with PROM were evaluated for their clinical characteristics and pregnancy outcomes. Twin and singleton pregnancies were compared and the results were evaluated for significant differences. Patients with lethal fetal anomalies, clinical chorioamnionitis at presentation, or fetal distress at presentation were excluded from analysis. Liberal use of tocolysis was provided to both groups of patients, as were serial doses of betamethasone and vitamin K. Twenty-eight sets of twins and 119 singleton pregnancies were included in the analysis. Differences were noted with respect to twin and singleton pregnancies for both latency period (4.26 days vs 8.6 days, P < 0.001) and birthweight (1,464 vs 1,698 g, P < 0.03). The birthweight for twins was an average of the pair. No differences were noted with respect to gestational age at time of rupture, maternal age, gravidity, parity, race, tocolytic use, steroid use, prophylactic antibiotics, or sexually transmitted diseases. The incidence of chorioamnionitis showed a trend for a higher occurrence in singleton pregnancies. The latency period for twin pregnancies complicated by preterm PROM is shorter than for singleton pregnancies. The incidence of chorioamnionitis may be higher in singleton pregnancies, but this may be related to their longer latency period. A knowledge of these differences may be of benefit when counseling these patients.

Amniotic fluid distribution in predicting perinatal outcome in patients with ruptured membranes.

OBJECTIVE: To determine if amniotic fluid distribution predicts perinatal outcome in women with spontaneously ruptured membranes. METHODS: Patients presenting for labor and delivery with spontaneously ruptured membranes had amniotic fluid indices determined upon admission. Those with greater than 50% of their amniotic fluid in the upper quadrants were placed in the upper-greater group and those with greater than 50% in the lower quadrants were placed in the lower-greater group. The groups were compared with respect to meconium staining, 1- or 5-minute Apgar scores below 7, persistent variable or late decelerations, umbilical arterial or venous pH below 7.20, cesarean for non-reassuring fetal heart rate monitoring, and neonatal intensive care unit admissions. RESULTS: One hundred women were studied, 60 in the upper-greater group and 40 in the lower-greater group. Significant differences between upper-greater and lower-greater distributions were noted in meconium staining (28.3% compared with 0%, P < .001), 1-minute Apgar score below 7 (16.7% compared with 2.5%, P < .027), variable decelerations (63.3% compared with 25.0%, P < .001), late decelerations (23.3% compared with 0%, P < .001), and cesarean for non-reassuring fetal heart tracing (11.6% compared with 0%, P < .025). The negative predictive values for all of the variables studied were in the range 92.5-100%, with the exception of variable decelerations (75%). CONCLUSION: Amniotic fluid distribution predicts perinatal outcome in patients with ruptured membranes. This test's high negative predictive value indicates its potential as a valuable screening tool. These results may provide additional guidance in defining the intrapartum management of patients presenting with ruptured membranes.

Dandy-Walker malformation in a fetus with pentasomy X (49,XXXXX) prenatally diagnosed by fluorescence in situ hybridization technique.

We present the case of a pentasomy X (49,XXXXX) prenatally diagnosed. The fluorescent in situ hybridization technique assisted in making the diagnosis. The problems identified in this fetus include a Dandy-Walker malformation, hydrocephaly, ventricular septal defect, hypertelorism and polyhydramnios.

Catalase activity as a predictor of amniotic fluid culture results in preterm labor or premature rupture of membranes.

OBJECTIVE: To evaluate catalase activity as a rapid predictor of microbial invasion of amniotic fluid (AF). METHODS: The study population consisted of 74 patients before 36 weeks' gestation with preterm labor or premature rupture of membranes (PROM). Subjects were excluded if there was evidence of clinical chorioamnionitis or fetal distress at admission. Amniocentesis was done within 24 hours of admission, and the AF was cultured for aerobic and anaerobic bacteria and for Mycoplasma species. All AF samples were Gram stained, and slides were examined by microbiology technologists. Amniotic fluid catalase activity was measured immediately after amniocentesis using a commercially available kit. The sensitivity of the Gram stain and catalase activity were compared using McNemar exact test. RESULTS: Amniotic fluid cultures were positive in 12 of 37 (32%) patients presenting with preterm labor and in 21 of 37 (56%) patients with PROM. Catalase activity was significantly more sensitive than Gram stain in detecting positive AF cultures in cases of PROM (P < .001) and preterm labor (P < .04). CONCLUSION: Catalase activity is a simple, rapid test that is useful in identifying subclinical intra-amniotic infection in patients with preterm labor or PROM.

Effect of amniotic fluid volume on ultrasonic fetal weight estimation.

We evaluated the relationship between the amniotic fluid index and the accuracy of fetal weight estimation using ultrasonography. Six hundred and sixty-four patients, between 20 and 42 weeks' gestational age, who were delivered within 1 week of a sonographic examination were studied. Five formulas for estimating fetal weight also were studied. Systematic and random errors in predicting birth weight were analyzed relative to birth weight and amniotic fluid index. The accuracy of sonographic fetal weight estimation was independent of amniotic fluid index across all gestational ages and birth weights. Each of the five formulas had similar error percentages, and no significant differences were detected. Predicted fetal weight was significantly underestimated with each of the formulas studied, a finding that was also independent of birth weight and amniotic fluid index. We conclude that ultrasonography can be used reliably to estimate fetal weight in patients with altered amniotic fluid volumes.

Pregnancy after treatment of epithelioid hemangioendothelioma. A case report.

Pregnancy occurred in a woman who had undergone hepatic, cerebral and myocardial resection of epithelioid hemangioendotheliomas (EHEs). The overall course of her pregnancy did not seem to be affected by the prior EHEs, though the pregnancy was complicated by preterm delivery. The patient was observed to have elevated maternal serum alpha-fetoprotein (MSAFP); a complete workup found no abnormalities in the fetus, and a relationship between the EHEs and elevated MSAFP was not apparent. Because of the unknown contribution of EHE to MSAFP, inclusion of targeted (level II) ultrasound and possibly amniocentesis seem appropriate to prenatally diagnose structural anomalies and ensure a normal karyotype.

Four-quadrant assessment of amniotic fluid volume: distribution's role in predicting fetal outcome.

OBJECTIVE: The amniotic fluid (AF) index has been shown to be a useful tool in the area of antepartum surveillance. An intrapartum AF index less than or equal to 5.0 has been shown to have predictive value with respect to increased perinatal morbidity. This study was designed to determine whether the distribution of the AF within the AF index is related to perinatal outcome. METHODS: Patients presenting for labor and delivery had an AF index determined and were divided into two groups. Patients with greater than 50% of their AF distributed in the upper quadrants were placed in the "upper-greater" group. The remaining patients were placed in the "lower-greater" group. The distribution data were compared with the following variables: meconium staining, 1- or 5-minute Apgar score of less than 7, persistent variable decelerations in the first stage of labor, late decelerations, neonatal intensive care unit admission, cesarean delivery for fetal distress, and umbilical arterial and venous pH less than 7.20. RESULTS: A total of 218 patients were evaluated, 125 in the upper-greater group and 93 in the lower-greater group. The upper-greater group had a greater incidence of meconium staining (32.8 versus 9.7%; P < .0001), 1-minute Apgar score of less than 7 (12.0 versus 2.2%; P < .007), variable decelerations (53.6 versus 19.4%; P < .00001), late decelerations (16.0 versus 0%; P < .0001), cesarean delivery for fetal distress (7.2 versus 0%; P < .008), umbilical arterial pH less than 7.20 (29.6 versus 8.9%; P < .0105), and umbilical venous pH less than 7.20 (8.9 versus 0%; P < .0398). These results were maintained regardless of the overall AF index. CONCLUSIONS: The distribution of the fluid within the AF index is predictive of perinatal outcome. In addition, the presence of a high negative predictive value for all of the perinatal indices studied enhances the value of this technique as a potential screening tool. Application of these results could provide additional guidelines in defining the intrapartum management and therapy of patients presenting for labor and delivery.