Smoking, hemoglobin levels, and birth weights in normal pregnancies.

Of 811 otherwise healthy, nonanemic, pregnant Norwegian women, 43% smoked during the third trimester. No significant association existed between smoking habits and hemoglobin levels during the third trimester, but the fairly small number of heavy smokers (greater than 10 cigarettes per day) may have precluded the discovery of subtle true differences. Birth weights were transferred to a weight-for-dates percentile scale, based on the distribution of the total Norwegian birth population over an 11-year period. With a grouping in quartiles according to this scale, a strong correlation between smoking habits and low birth weights emerged, with 47% of newborn infants of heavy smokers falling in the lowest quartile. Levels of hemoglobin were inversely correlated to birth weight quartiles, equally in mothers who smoked and those who did not smoke. However, when birth weights were grouped according to maternal hemoglobin at term, the tobacco-related effect on birth weight appeared only with levels of hemoglobin above 12 gm/dl, being particularly strong for levels above 13 gm/dl. Hemoglobin levels of 9.0 to 11.9 gm/dl appeared to protect from growth retardation the fetuses of nonanemic mothers who smoked. Studying ponderal, or weight-by-length, indices, we found that growth-retarded babies of mothers who smoked tended to be thin, thus indicating that they had been deprived of nutrients.

PIP: Of 811 otherwise healthy, nonanemic, pregnant Norwegian women, 43% smoked during the 3rd trimester. No significant association existed between smoking habits and hemoglobin levels during the 3rd trimester, but the fairly small number of heavy smokers (more than 10 cigarettes per day) may have precluded the discovery of subtle true differences. Birth weights were transferred to a weight-for-dates percentile scale, based on the distribution of the total Norwegian birth population over an 11-year period. With a grouping in quartiles according to this scale, a strong correlation between smoking habits and low birth weights emerged, with 47% of newborn infants of heavy smokers falling in the lowest quartile. Levels of hemoglobin were inversely correlated to birth weight quartiles, equally in mothers who smoked and those who did not smoke. However, when birth weights were grouped according to maternal hemoglobin at term, the tobacco-related effect on birth weight appeared only with levels of hemoglobin above 12 gm/dl, being particularly strong for levels about 13 gm/dl. Hemoglobin levels of 9.0-11.9 gm/dl appeared to protect from growth retardation the fetuses of nonanemic mothers who smoked. Studying ponderal, or weight-by-length, indices, the authors found that growth-retarded babies of mothers who smoked tended to be thin, thus indicating that they had been deprived of nutrients.

Maternal hemoglobin concentration is closely related to birth weight in normal pregnancies.

Maternal Hb levels during the third trimester were studied in relation to certain maternal and fetal parameters in 877 apparently normal pregnancies. Low Hb levels at term were closely associated with increased frequency of newborns in the heavy weight-for-date group. Conversely, high maternal Hb levels were closely associated with an increased frequency of newborns in the light weight-for-date group. The maternal Hb levels both in the early third trimester and at term were significantly higher in mothers of small-for-date newborns than in those with newborns of normal weight. In both groups the maternal Hb levels increased significantly during the third trimester of pregnancy. High maternal Hb levels both early and late in the third trimester of pregnancy should be a matter of concern rather than of reassurance.

Serum urate as a predictor of fetal outcome in severe pre-eclampsia.

Maternal serum urate levels were studied in 50 normal pregnancies and 72 cases of severe pre-eclampsia. Markedly elevated levels of serum urate were found in severe pre-eclampsia, compared with normal pregnancy. In severe pre-eclampsia significantly higher levels were found prior to parturition in cases of growth retardation and perinatal distress, compared with patients whose newborns were of normal size and condition. Particularly high serum urate levels were found early in the third trimester in cases of perinatal death. A slight but significant correlation was found between the weight centile of the newborn and the last maternal urate level before parturition. A rapidly rising urate level reliably predicted perinatal distress. The last maternal serum urate before parturition was correlated with the hemoglobin and erythrocyte volume fraction values in the same blood sample.

The predictive value of total estriol; HPL and Hb on perinatal outcome in severe pre-eclampsia.

The prognostic value of total maternal plasma estriol, human placental lactogen (HPL) and hemoglobin (Hb) with regard to perinatal outcome was compared in 74 cases of severe pre-eclampsia. No combination of the tests predicted all cases of fetal and newborn pathology. HPL was the most reliable single test in cases of intra-uterine growth retardation, while Hb was the best predictor of severe fetal pathology and perinatal distress. In cases of severe fetal and neonatal pathology, the prognostic value of the combination of HPL and Hb was more reliable than the combination of all the three tests.

Iron requirement in normal pregnancy as assessed by serum ferritin, serum transferrin saturation and erythrocyte protoporphyrin determinations.

Serum iron, serum iron-binding capacity, serum ferritin and erythrocyte protoporphyrin were determined during uncomplicated pregnancy in 45 healthy women; 22 were given oral iron while the others were given a placebo. When iron was not given, 15 out of 23 women had exhausted iron stores and iron deficiency at term, as judged from low serum ferritin, low serum transferrin saturation and high erythrocyte protoporphyrin values. Only seven of them had a haemoglobin concentration between 10 and 11 g/dl at term but none had values less than 10 g/dl. In the iron-treated group (n = 22) none of the women developed iron deficiency. Serum ferritin was the most sensitive and specific test of iron deficiency. A practical procedure to detect iron deficiency and to control iron supplementation in pregnancy is suggested.

PIP: Serum iron, serum iron-binding capacity, serum ferritin, and erythrocyte protoporphyrin were determined during uncomplicated pregnancy in 45 healthy women; 22 were given oral iron while the others were given a placebo. When iron was not given, 15 of 23 women had exhausted iron stores, and irondeficiency at term as judged from low serum ferritin, low serum transferrin saturation, and high erythrocyte protoporlphyrin values. Only 7 of them had a hemoglobin concentration between 10 and 11 g/dl at term but none had values 10 g/dl. In the iron treated group (n=22), none of the women developed iron deficiency. Serum ferritin was the most sensitive and specific test of iron deficiency. A practical procedure to detect iron deficiency and to control iron supplementation in pregnancy is suggested.

Haemoconcentration in severe pre-eclampsia.

The last maternal haemoglobin (Hb) concentration before delivery was related to the perinatal outcome in 87 non-anaemic women suffering from severe pre-eclampsia. Abnormally high Hb concentrations were found in most women with evidence of placental dysfunction. An inverse correlation was found between the centile weight of the newborn and the maternal Hb. Significantly higher Hb levels were found in pregnancies complicated by fetal growth retardation and perinatal distress compared with those in pregnancies with good outcomes. Particularly high levels were found in pregnancies that ended in perinatal deaths. The hypothesis is put forward that raised haemoconcentration during severe pre-eclampsia causes increased blood viscosity which predisposes to placental pathology and initiates a vicious circle.

Comparison of thiopentone and diazepam as induction agents of anaesthesia for Caesarean section.

Clinical effects of thiopentone (3 mg/kg body weight) and diazepam (0.3 mg/kg) were compared for elective caesarean sections in two groups of 43 and 39 women, respectively. They were given general anaesthesia in left lateral tilt. The systolic, diastolic and mean arterial pressures were moderately elevated at onset of surgery in both groups, probably indicating light anaesthesia. Later, a gradual decrease to the preinduction levels was observed. The mean injection-delivery (I-D) interval was 344 s in the thiopentone group and 339 s in the diazepam group. The I-D intervals were shorter than 10 min in 39 of the cases in the thiopentone group and 38 cases in the diazepam group. Low Apgar scores at 1 min (6 or less) occurred in five of the neonates in each group, while all had normal Apgar scores at 5 min ( 7 or mor) As judged by the Apgar scores and the acid-base status of umbilical cord blood, the effects of the induction agents on the neonatal condition were indistinguishable in the two groups. In the thiopentone group, unpleasant recollections were reported in 5 out of 40 patients (12.5%) compared to none in the diazepam group. Diazepam-nitrous oxide anaesthesia is well accepted by the mothers and is alternative to supplementing thiopentone induction with a volatile gas for patients who have previous experienced wakefulness or express fear of awareness. The main drawback with diazepam induction, however, is the slow induction of sleep. Harmful drug effects on the neonates must be expected if the dose has to be increased in order to ensure sleep.

High hemoglobin levels during pregnancy and fetal risk.

In a series of 24 apparently uncomplicated pregnancies with small-for-dates newborn at or below the tenth percentile, 15 women had hemoglobin (Hb) levels 2 SD above the mean value of normal distribution in late pregnancy. Among these 15 was the only case with intrauterine death of unknown cause. In a series of 15 cases intrauterine fetal death of unknown cause, before start of labor 10 had Hb levels 2 SD above the mean, while in a series of 16 cases of late abortion where the fetus was alive until labor started, only one had a Hb level 2 SD above the mean. In three cases with serial Hb estimations, the levels were 2 SD above the mean one week or more before intrauterine fetal death. Two of these cases also had been observed during a successful pregnancy in which the Hb levels were within normal limits. It is concluded that high Hb levels during pregnancy may indicate a fetus at risk. High viscosity of the mother's blood may impede the uteroplacental circulation, casing placental infarction, growth retardation and ultimately fetal death.

A comparative study of labor induced by oral prostaglandin E2 and buccal tablets of demoxytocin.

A comparative study of the efficacy of oral prostaglandin E2 and buccal tablets of demoxytocin for induction of labor in overdue pregnancies was made in groups of randomly selected patients. Labor was successfully induced in 95.7% of the women in the prostaglandin group and 92.1% of the women in the demoxytocin group. Although the operative delivery rate was low in both groups, it was significantly higher for the demoxytocin group. A low rate of perinatal distress was recorded and there were no serious side effects in either group. The time from start of induction until delivery, as well as the time from amniotomy until delivery, were compared for primiparae and multiparae separately. No significant differences were found. The blood loss during the third stage of labor was lower in the prostaglandin group. We find oral induction of labor in overdue pregnancies effective, safe and convenient.

Plasma estriol, progesterone, cortisol, placental lactogen and alpha-fetoprotein in a pregnancy with an anencephalic fetus followed from the seventh week till term.

Concentrations of total estriol, progesterone, cortisol, human placental lactogen and alpha-fetoprotein were measured in maternal venous plasma at regular intervals from the seventh week of pregnancy until term in a woman with an anencephalic fetus. Except for the first trimester, during which the values were in the lower normal range, the concentration of estriol was constantly subnormal. The "physiological" rise in cortisol levels was absent. Progesterone and HPL were both within the low normal range. The levels of alpha-fetoprotein were transiently raised during the 13th--25th weeks of pregnancy.

Fetal growth retardation associated with inadequate haemodilution in otherwise uncomplicated pregnancy.

The Hb level during pregnancy was followed in 113 non-anaemic women with uncomplicated pregnancy and birth weight of the baby above the 2.5th percentile. There was an inverse correlation close to statistical significance between the birth weight of the baby and the lowest Hb level reached during pregnancy as well as the Hb level in late pregnancy (38th week). A group of seven non-anaemic women with birth weight of the baby below the 2.5th percentile had a significantly higher (p less than 0.001) Hb level in late pregnancy than the normal group. Four of these cases had a statistically significant higher Hb level already in the second trimester. Trends in the reproductive history, complaints in the present pregnancy as well as results of hormone assays and the condition of the baby indicated that the seven cases represented a pathological group with fetal growth retardation. None of the women in the two groups were treated with diuretics. All had iron supplementation in high doses.

Transplacental passage of ketamine after intravenous administration.

This study was designed to measure how fast and at what concentrations ketamine would enter the foeto-placental circulation, when administered intravenously to 10 healthy mothers immediately before forceps delivery, which was indicated by a delayed second stage of labour. It is shown that ketamine very rapidly passes the placenta, and that ketamine levels in cord blood exceed the levels in the maternal venous blood as early as 1 min 37 s after the injection. The ketamine levels in cord blood reach a maximum in the period 1 min 37 s to 2 min 5 s after the injection. Later they show a tendency to decline. A short-lasting, marked elevation of blood pressure was produced by the ketamine anaesthesia. Two of the newborn showed low Apgar scores at 1 min. In one of them this was probably attributable to the anaesthesia.

Epidural block in twin labour and delivery.

In a clinical study, 28 twin mothers were provided with epidural block during labour and delivery. This group was compared to 24 twin mothers who received conventional analgesics throughout labour. General anaesthesia was administered when operative delivery was indicated in the control group. In the epidural group, duration of labour was significantly prolonged. A delayed second stage of labour caused an increased number of operative vaginal deliveries. Intra-uterine asphyxia was not more frequent in the epidural group. Judged by the Apgar score and the neonatal course, there was no difference between the newborn in the two groups. Neither clinical evaluation, nor acid-base investigations showed any difference between the condition of Twin I and Twin II in the epidural group.

Ketamine and diazepam as anaesthesia for forceps delivery. A comparative study.

In a clinically controlled trial in forceps delivery, a comparison was made between the general anaesthesia induced by ketamine and that by a combination of diazepam and N2O. Local anaesthesia was added in the diazepam group for episiotomy and suturation. The indication for operative delivery was in all cases a prolonged second stage of labour. In the katamine group, awareness was noted in four cases out of 13, even if the analgesic effect was found to be good. Four patients showed marked, short-lasting elevation of blood pressure and seven had unpleasant dreams. All thirteen mothers in the diazepam group found the anesthesia effective and the recovery pleasant. The blood pressure was stable. One mother in each group required ventilation with oxygen due to respiratory depression of short duration. Three of the children in the ketamine group and two in the diazepam group had subnormal Apgar score with slight acidosis. This was probably not attributable to the anaesthesia.

Transplacental passage of diazepam following intravenous injection immediately prior to operative vaginal delivery.

The early phase of diaplacental transfer of diazepam was studied in 39 women given the drug as a basic anaesthetic for operative vaginal delivery indicated by prolonged second stage of labour (9 cases), breech delivery (19 cases) and intrauterine hypoxia (11 cases). A total dose of 30 mg diazepam (Valium Roche) was injected intravenously over a period of 15 sec umbilical cord blood was collected immediately after delivery. Diazepam was extracted with diethyl ether and determined by gas chromatography. The concentration of diazepam in cord blood increased from greater than 5-250 ng/ml at 57-60 seconds to 48-1861 ng/ml at 90-100 seconds after completion of the intravenous injection. Thereafter a plateau seemed to be reached but the interindividual variation was still great with values ranging from 45-3034 ng/ml up to 360 seconds. Judged by Apgar score and the clinical course the neonates seemed to be unaffected by the medication administered to the mother.

Serum alkaline phosphatase in pregnancy. II. Serial HSAP65degreesC estimations in pregnancy complicated with hypertension and pre-eclampsia.

This is a study of heat-stable alkaline phosphatase (HSAP65degreesC) concentrations in the serum of pregnant women with hypertension (42 cases), mild preeclampsia (40 cases) and severe pre-eclampsia (22 cases). The results are seen in relationship to the occurrence of intrauterine fetal death, growth retardation, intrauterine and neonatal asphyxia as well as the respiratory distress syndrome (RDS) in the newborn. The importance of a precise clinical classification of the patients is stressed. Pathological HSAP values are those which lie either over or under the normal range for HSAP activity. In addition "zig-zag" curves with values within the normal range are characterized as abnormal. Thus, serial estimations give the most reliable results. Serial estimations of HSAP are especially valuable in severe pre-eclampsia. Abnormal HSAP values in the 28th-38th week of pregnancy are a serious prognostic sign. False abnormal HSAP results were found in all 3 patient groups. One possible false normal HSAP curve also occurred.

Serum alkaline phosphatase in pregnancy. I. A comparative study of total, L-phenylanine-sensitive and heat-stable alkaline phosphatase at 56 degrees C and 65 degrees C in normal pregnancy.

312 paired, serial estimations of total, L-phenylalanine-sensitive and heat-stable alkaline phosphatase (at two temperatures, 56 degrees C and 65 degrees C) were performed on sera from 31 pregnant healthy women from 18 weeks to term. Heat-stable alkaline phosphatase, determined at 65 degrees C, enriched the serum in a smooth exponential course throughout the second and third trimester, whereas the other enzymic activities investigated showed more irregular increments. There was a slight, but significant correlation between total alkaline phosphatase activity of the placenta and serum heat-stable alkaline phosphatase at term, whereas there was no correlation between the weight of the child at birth and heat-stable alkaline phosphatase in the serum of the mother. It is concluded that to test the feto-maternal unit, determination of serum alkaline phosphatase should be performed at 65 degrees C with due regard to appropriate sampling and experimental design.