Subcapsular hepatic hematoma in an otherwise uncomplicated pregnancy.

Subcapsular hepatic hematoma is rare in pregnancies not complicated by pre-eclampsia or the HELLP syndrome. We now report such a case.

Fetal heart rate baselines in twins. Interobserver agreement in antepartum estimation.

OBJECTIVE: To assess interobserver agreement in antepartum estimation of fetal heart rate (FHR) baselines in twins. STUDY DESIGN: Two residents and one specialist in obstetrics and gynecology, all with special interest in FHR monitoring, independently estimated baselines in 162 consecutive antepartum FHR tracings recorded in 24 twins. Tracings were obtained with a dual-channel fetal monitor for the simultaneous recording of both twins' heart rates. Baselines were estimated, as single values corresponding to the mean of the lowest stable FHR segment, in the absence of fetal movements and uterine contractions, within physiologic limits (110-150 beats per minute [bpm]). If these criteria were not met, the possibility of persistent bradycardia or tachycardia was considered, and if this was confirmed in a tracing with at least 40 minutes, a baseline < 110 or > 150 bpm was chosen. Interobserver agreement was assessed by the proportions of agreement (PA), kappa statistic (K) and intraclass correlation coefficient (ICCC), with 95% confidence intervals (CIs). RESULTS: Interobserver agreement was excellent, with a PA of 0.90 (95% CI: 0.89-0.91), K of 0.88 (95% CI: 0.84-0.92) and ICCC of 0.91 (95% CI: 0.88-0.94). CONCLUSION: Interobserver agreement in antepartum estimation of fetal heart rate baselines in twins was excellent with the baseline concept used in this study.

SisPorto 2.0: a program for automated analysis of cardiotocograms.

OBJECTIVE: To describe the latest version of SisPorto, a program for automated analysis of cardiotocograms that closely follows the FIGO guidelines, analyses ante- and intrapartum tracings, performs no signal reduction, and has the possibility of simultaneously recording twins. METHODS: A detailed description of the program's processing algorithms and operation is provided, as well as the main results of the studies performed to-date with this system. RESULTS: Considering both current and previous versions of the program, SisPorto has been tested in over 6000 pregnancies. The system's FHR baseline was compared with an average of three experts' estimates, and the difference was under 8 bpm in all cases. A fair to good agreement was found with experts' identification of accelerations, decelerations, contractions, and normal/reduced variability (proportions of agreement 0.64-0.89). In a preliminary validity study (n = 85), a sensitivity of 100% and a specificity of 99% were obtained in prediction of poor neonatal outcome. The system is currently undergoing an international multicentre validation study. CONCLUSIONS: Although still at the research level, a considerable experience has now been gathered with this system. Promising results have been achieved in studies comparing SisPorto with experts' analysis and in those evaluating the validity of the system.

Inconsistencies in classification by experts of cardiotocograms and subsequent clinical decision.

Inter-observer agreement in the interpretation according to the FIGO guidelines of 33 cardiotocographic tracings by experts and subsequent clinical decision was evaluated, using the kappa statistic (K) and the proportions of agreement (Pa). Overall agreement in the classification of tracings was fair (K = 0.48) and was better for normal (Pa = 0.62), than for suspicious (Pa = 0.42) or pathologic tracings (Pa = 0.25). Overall agreement on clinical decision was slightly higher (K = 0.59), but mostly was centred on the decision to take 'no action' (Pa = 0.79). Experts especially disagreed over the decisions to 'monitor closely' (Pa = 0.14) or to 'intervene immediately' (Pa = 0.38). These limitations should be taken into account in clinical audits and in medical jurisprudence.

Objective computerized fetal heart rate analysis.

OBJECTIVE: To assess the validity of a computerized methodology for cardiotocogram analysis based on a recently described reproducible visual estimation of the baseline. METHODS: Forty-two antepartum and 43 intrapartum cardiotocograms (CTGs) acquired by a personal computer were selected. Antepartum tracings were performed in the 48 h that preceded an elective cesarean section, and intrapartum tracings were performed until delivery. FHR baselines were estimated by an expert, according to an objective and reproducible methodology. Using these baselines, automated detection of accelerations and decelerations and estimation of variability was performed by the personal computer. A quantitative adaptation of the FIGO guidelines for fetal monitoring was used to classify tracings. Perinatal outcome was classified according to the Apgar score and umbilical arterial pH. Validity was then assessed by the proportions of agreement (PA), kappa statistic (K), sensitivity and specificity, with 95% confidence intervals (95% CI). Cases showing a disagreement between CTG and perinatal classification were reviewed and an adjustment in baseline definition was tested. RESULTS: The initial overall PA and kappa between CTG and perinatal classification were, respectively, 0.79 (95% CI: 0.69-0.87) and 0.62 (95% CI: 0.41-0.83). The overall PA and K, after baseline adjustment were, respectively, 0.89 (95% CI: 0.81-0.95) and 0.78 (95% CI: 0.58-0.98). Sensitivities and specificities ranged between 79% (95% CI: 60-92%) and 100% (95% CI: 95-100%). CONCLUSIONS: Good clinical prediction may be possible with an objective methodology for cardiotocogram analysis based on a recently described reproducible baseline estimation.

Non-Hodgkin lymphoma during pregnancy.

The authors report a case of a pregnancy with a Non-Hodgkin lymphoma. A histological association of high-grade B-cell and a MALT type lymphoma was found which, to their best knowledge, is described for the first time in pregnancy.

Evaluation of interobserver agreement of cardiotocograms.

OBJECTIVE: To evaluate interobserver agreement in visual analysis of each cardiotocographic event. METHODS: Three experts independently divided 16 antepartum and 17 intrapartum cardiotocograms into baseline segments, accelerations and decelerations, according to the FIGO guidelines. Baseline segments were further classified as having normal, reduced or increased variability and decelerations as early, late and variable. Uterine activity was divided into tonus and contractions. Agreement was assessed by the proportions of agreement (pa) with 95% confidence intervals. RESULTS: Reproducibility in assessment of baseline segments with normal variability, accelerations and uterine activity was acceptable (pa = 0.56-0.71) whereas that of other segments was not (pa = 0.14-0.45). CONCLUSIONS: Analysis of most cardiotocographic events is poorly reproducible, even when experts use the FIGO guidelines. This may be explained by some still ambiguous guidelines, by eyeball limitations in evaluation of subtle events, and by the incapacity of busy clinicians to assess complex and multiple cardiotocographic events in a systematic and disciplined fashion.

Comparative study of lactoferrin and other blood markers of inflammatory stress between preeclamptic and normal pregnancies.

OBJECTIVE: To test lactoferrin as a blood discriminator of neutrophil activation between normal and preeclamptic pregnancy. DESIGN: Comparative study between normal (n = 40) and preeclamptic women receiving treatment (n = 42) in the third trimester of pregnancy and in the post partum period (30 women with normal pregnancy and 22 with preeclampsia). METHODS: Blood, serum or plasma measurements of neutrophils, lactoferrin, vitamin C, vitamin E, lipid peroxidation products, elastase, C-reactive protein (CRP), gamma-glutamyltranspeptidase (gamma GT), haptoglobin, osmotic fragility, urea, creatinine, uric acid, transaminases (ASAT, ALAT), lactic dehydrogenase (LDH), platelets, red and white blood cells. RESULTS: In preeclamptic women the ratios of lactoferrin per neutrophil or per erythrocyte are higher before delivery than in normal women but decrease after delivery. Delivery induces a greater inflammatory response in normal pregnancy as detected by blood concentrations of inflammatory markers and hepatic and renal parameters. CONCLUSION: Whereas in normal pregnant women neutrophil activation increases with delivery, in preeclamptic women the opposite occurs.

Lactoferrin as a sensitive blood marker of neutrophil activation in normal pregnancies.

OBJECTIVE: To test lactoferrin as a marker of neutrophil activation during pregnancy. DESIGN: Cross-sectional study in normal pregnant (n = 100), nonpregnant (n = 11) and post partum women (n = 30). METHODS: Serum or plasma measurements of neutrophils, lactoferrin, vitamin C, vitamin E, lipid peroxide, elastase, C-reactive protein gamma-glutamyltranspeptidase, haptoglobin and osmotic fragility. RESULTS: During normal pregnancy all markers of neutrophil-activation increase. CONCLUSION: Neutrophil-activation compromises the antioxidant defense mechanism during normal pregnancy.

Inter-observer agreement in analysis of basal body temperature graphs from infertile women.

In this study, we evaluated the reproducibility of analysis of basal body temperature graphs under optimized conditions for agreement. A total of 160 recordings were selected from spontaneous cycles of infertile women and analysed by three experienced clinicians using uniform criteria. Agreement at the various stages of analysis was assessed by the 'proportions of agreement' with 95% confidence intervals. Agreement in identification of the thermal nadir was clearly superior to that reported in previous publications. Reproducibility of 'ovulatory' graph features (i.e. biphasic graphs and adequate thermal shifts) was excellent. Agreement in classification of monophasic graphs and inadequate thermal shifts, although lower, was still good. Thus, with experienced observers and uniform criteria, a good agreement can be achieved in analysis of the most important parameters of the basal body temperature graph. We believe that an effort should be made to generalize the use of uniform analysis criteria, because only then can results from different institutions be compared and the remaining clinical evaluation of the method be performed.

Loss of dopamine D1-like receptors in the umbilical artery of pre-eclamptic subjects.

1. The influence of pre-eclampsia on the density and pattern of dopamine D1-like receptors was studied in frozen samples of the placental end of the umbilical artery by using radioligand binding and autoradiographic techniques in combination. 2. Analysis was performed on normotensive (n = 10) and pre-eclamptic subjects (n = 9) undergoing caesarean delivery, using [3H]-SCH 23390 as a ligand. Pre-eclamptic patients received a low salt diet and were treated with magnesium sulphate and hydralazine. The possibility that this treatment may cause changes in the density of dopamine D1-like receptors was evaluated by treating male Wistar rats in the same way and by determining [3H]-SCH 23390 binding in sections of the kidney which represents an organ containing dopamine D1-like receptors. 3. The density of dopamine D1-like receptors of the umbilical artery, which are probably vasodilatory, was decreased in pre-eclamptic compared with normotensive subjects. In contrast, the affinity of the radioligand for dopamine D1-like receptors was not statistically different between normotensive and pre-eclamptic subjects. Low salt diet, magnesium sulphate and hydralazine treatment did not affect [3H]-SCH 23390 binding to sections of rat kidney. This suggests that changes in the density of dopamine D1-like receptors in pre-eclamptic patients are a specific phenomenon not dependent upon antihypertensive measures. 4. Analysis of the pharmacological profile of [3H]-SCH 23390 binding to sections of the umbilical artery both in normotensive and pre-eclamptic subjects indicates the labelling of dopamine D5 receptors. 5. These findings collectively suggest that the dopaminergic vasodilatory tone in the umbilical artery is impaired in pre-eclampsia. The possible significance of these data should be clarified in future studies.

Pharmacological characterization and autoradiographic localization of dopamine D1 receptors in the human umbilical artery.

Combined in vitro radioreceptor binding and autoradiographic techniques with [3H]SCH 23390 as a ligand were used to analyze the pharmacological profile and anatomical localization of dopamine D1 receptor sites in sections of human umbilical artery. The ligand was bound to sections of the artery in a manner consistent with the labelling of D1 receptors. These receptors, which show a fetal-to-maternal gradient with the highest concentration near the placenta, are located within the smooth muscle layer of the umbilical artery. The above findings suggest that endogenous dopamine may be involved in the control of the tone of the umbilical artery through the interaction with D1 receptors.