Fetal risks due to warfarin therapy during pregnancy

Two mothers with heart valve prosthesis were treated with warfarin during pregnancy. In the first case a caesarean section was done one week after replacement of warfarin with heparin. The baby died of cerebral and pulmonary hemorrhage. The second mother had a male infant by caesarean section. The baby showed warfarin-induced embryopathy with nasal hypoplasia and stippled epiphyses (chondrodysplasia punctata). Nasal hypoplasia with or without stippled epiphyses has now been reported in 11 infants born to mothers treated with warfarin during the first trimester, and a causal association is probable. In view of the risks to both mother and fetus in women with prosthetic cardiac valves it is recommended that therapeutic abortion be advised as the first alternative.     

Prenatal diagnosis of congenital toxoplasmosis transmitted by an immunocompetent woman infected before conception. Reims Toxoplasmosis Group

OBJECTIVE: To determine the outcome of subsequent labour in primiparous women after a caesarean section for delay in descent in the second stage of labour in cephalic presentations with or without trial of instrumental vaginal delivery. DESIGN: Retrospective follow up study. SETTING: Medical Centre Leeuwarden, The Netherlands. PARTICIPANTS: All primiparous parturients who delivered after prior caesarean section during the second stage of labour in the period 19861998. METHODS: Data concerning the outcome of the first subsequent delivery were gathered from delivery notes and patients charts. The group of women was subdivided into those with or without trial of instrumental vaginal delivery during the previous labour. RESULTS: Of 132 women, 29 (22%) underwent a planned repeat caesarean section. Of the 103 women who were allowed a trial of labour, 82 (80%) were successful in having a vaginal delivery, and 21 (20%) had a second caesarean section. Of the 74 women with a failed trial of instrumental delivery during the previous labour, 19 had a planned repeat caesarean section and 41 of the remaining 55 (75%) had a successful trial of labour. CONCLUSIONS: In women with a cephalic presentation who had an arrest of descent in the second stage of labour during their first delivery, the chances of vaginal delivery in their next pregnancy are high, even after a failed instrumented vaginal delivery, and a trial of labour can usually be pursued.     

Patterns of various modes of delivery in relation to presence of different risk factors in term pregnant mothers--a case-control study

A case-control study, was carried out, which aimed to determine whether a relation exists between risk factors present in mother and the mode of delivery i.e., outcome. Cases were those mothers who had one or more risk factors present during pregnancy (namely, short stature, malpresentation, antepartum haemorrhage, pre-eclamptic toxaemia/eclampsia, anaemia-haemoglobin less than 10 g/dl, twins, bad obstetric history, prolonged pregnancy, history of previous caesarean section and instrumental delivery, pregnancy associated with general diseases, prolonged difficult labour and RH-iso-immunisation). Controls were those mothers who did not have any of the above mentioned risk factors. Total of 250 cases and 250 controls were taken. Results showed that surgical and instrumental deliveries were strongly associated with presence of risk factors (odd's ratio: 5.94; attributable risks: 72%). Out of risk factors among cases, most common indication of caesarean section, was previous caesarean section followed by malpresentation, prolonged difficult labour and short statured mothers in descending order.     

Barium granuloma of the rectum

Every child with severe or moderate haemophilia A or B, born in Sweden during the period 1970-1990, was treated in the national haemophilia register, all 117 case records being surveyed for mode of delivery and perinatal complications. Of the 117 deliveries, 13 were by caesarean section and the remaining 104 vaginal. Of the 13 caesarean sections, 2 were performed because the woman was a haemophilia carrier, the remaining 11 (5 emergency, 6 elective) for other reasons. Neonatal complications were: subgaleal or cephalic haematoma (n = 12), intracranial haemorrhage (n = 4), umbilical bleeding (n = 4), haematuria (n = 1), retro-orbital bleeding (n = 1) and abnormal bleeding after surgery, injection or venepuncture (n = 28). Of the 12 infants with subgaleal/cephalic haematoma, 10 were delivered by vacuum extraction. Seven more infants were delivered by vacuum extraction and another 11 were born without abnormal bleedings after laborious (> 24 h) delivery. Of the 4 children with intracranial haemorrhage, all were sporadic cases of haemophilia, 1 was a premature birth by caesarean section in the 27th week, I was delivered by vacuum extraction and the remaining 2 vaginally. In these 4 cases there were no sequelae or only minor ones. We conclude that the risk of serious bleeding in conjunction with normal vaginal delivery is small, but that vacuum extraction should be avoided when delivering offspring of haemophilia carriers.     

Androgen-dependent beard dermal papilla cells secrete autocrine growth factor(s) in response to testosterone unlike scalp cells

The serum levels of choline decreased by approximately 50% in patients having a surgery under general as well as epidural anesthesia. The decrease is lasts for two days after surgery. Intravenous administration of succinylcholine, either by a single bolus injection or by a slow continuous infusion, increased the serum choline levels several folds during surgery. In these patients, a significant decrease in the serum choline levels was observed one and two days after surgery. In 16 pregnant women at the term, serum choline levels were higher than the value observed in 19 nonpregnant women. The serum choline levels decreased by about 40% or 60% after having a childbirth either by vaginal delivery or caesarean section, respectively. Serum choline levels in blood obtained from 9 patients with traumatic head injury were significantly lower than the observed levels in blood samples obtained from healthy volunteers. These observations show that serum choline levels increase during pregnancy and decrease during stressful situations in humans.     

Obstetric implications of burns in pregnancy

Analysis of 50 patients with burns in pregnancy has allowed the objective consideration of obstetric implications. Patients in the second and third trimester of pregnancy with burns of greater than or equal to 50% should be delivered immediately as maternal death is otherwise certain and fetal survival rate is not improved by waiting. Vaginal delivery has always proved possible, even in the presence of perineal burns but caesarean section should be considered and may be preferred. Patients in the first trimester may survive with more extensive burns and possible reasons for this are discussed. Pregnancy testing on admission should be mandatory in burns of women of reproductive age. In patients with burns of less than 40% in the second and third trimesters, spasmolytics should be used to suppress spontaneous labour and to cover operations. Greater fetal maturity without worsening maternal prognosis can thus be achieved. Insufficient data exist to recommend this for burns of between 40 and 50%.     

Successful twin pregnancy and delivery following free rectus abdominis muscle flap at 15 weeks gestational age

Although a vertical rectus abdominis flap would not have been selected for reconstruction of the patient's defect had her pregnancy been detected preoperatively, the present case does demonstrate the remarkable resiliency and integrity of the anterior abdominal wall after rectus abdominis muscle flap surgery. Meticulous closure of the abdominal wall is of utmost importance in maintaining abdominal wall competence. Although the merits of muscle splitting techniques and the use of mesh are beyond the scope of this report, there is no evidence that modification of technique should be performed in the patient considering future pregnancy. Our case supports other reports that rectus abdominis flap surgery is not a contraindication to future pregnancy. Intuitively waiting at least 1 year, as recommended by Chen et al., seems reasonable, although the present case demonstrated a successful pregnancy and delivery of twins after a vertical rectus abdominis flap was harvested during pregnancy.     

Regulation of progesterone biosynthesis in the human placenta by estradiol 17 beta and progesterone

The information available concerning the effects of chemotherapy administered during pregnancy is limited and consists of case reports and small series. A registry has been established at the National Cancer Institute, but there are currently only several hundred cases of neonates exposed to chemotherapy registered. All clinicians who care for women receiving chemotherapy during pregnancy should report those experiences to the National Cancer Institute to increase the data base. When chemotherapy is used during the embryogenesis period in the first trimester there is an increased rate of spontaneous abortion and major birth defects. The most toxic chemotherapeutic agents administered during pregnancy are methotrexate and aminopterin and should be avoided when possible, particularly during the first trimester. Pregnancy-related physiologic changes should be kept in mind when dosing and administering cytotoxic chemotherapy. The risk of fetal malformation when chemotherapy is administered during the second and third trimesters is probably not greater than background rate, but there may be a greater risk of stillbirth, fetal growth restriction, premature birth, and maternal and fetal myelosuppression. Breastfeeding should be avoided in women receiving chemotherapy.     

Young people with spina bifida: transfer from paediatric to adult health care

INTRODUCTION: The method used to terminate pregnancy on medical grounds during the second trimester must be safe, rapid, psychologically feasible and associated with a minimal risk of long-term sequelae. The objective of the present work was a critical analysis of the author's standard protocol of termination of pregnancy during the second trimester. MATERIAL AND METHODS: For induction of abortion during the second trimester the authors used a synthetic prostaglandin analogue (PG) F2 alpha-Dinoprost which was administered in a single dose of 30 mg by the intraamniotic route. At the time of onset of uterine contractions the authors administered peridural anaesthesia. The authors investigated indications, mean period of induction, correlation between the period of induction of abortion and the indications for termination of pregnancy, the week of pregnancy and parity of the mother. They recorded also the type and number of complications. RESULTS: From January 1991 till June 1997 179 pregnancies were terminated by intraamniotic PG administration. After a single intraamniotic PG administration 72% women aborted within 24 hours. In 26% women the intraamniotic administration was repeated twice and in 2% women three times. The mean induction period, i.e. the interval between the administration and abortion of the foetus was 22.6 hours. The interval was significantly longer (28 hours) in foetuses where pregnancy was terminated because of a neural tube defect (p < 0.01). The authors did not detect a correlation between the period of induction and the indication, week of gestation and parity of the mother. COMPLICATIONS: once a general reaction to intraamniotic administration, in three patients a major blood loss replaced by transfusion of erythrocyte mass, no uterine rupture. CONCLUSION: In all instances the therapeutic effect was achieved and there was no need to perform section minor. The disadvantage of the method is the high price of the preparation and need of repeated intraamniotic administration of PG in 29% of the patients.     

Assignment1 of human putative tumor suppressor genes ST13 (alias SNC6) and ST14 (alias SNC19) to human chromosome bands 22q13 and 11q24-->q25 by in situ hybridization

OBJECTIVE: Our aim was to describe the indications of repeat caesarean delivery and to determine modifiable practice patterns that might lead to fewer repeat caesarean deliveries. METHOD: Hospital records of all women with previous caesarean sections who delivered between 15 April, 1994-31 December, 1994 at the Princess Badeea Teaching Hospital in North Jordan were reviewed. Three groups were identified: 1) elective repeat caesarean 2) vaginal birth after caesarean 3) failed vaginal birth after caesarean. RESULTS: In this study there were 388 patients. Of these, 208 had a repeat caesarean delivery for the following reasons: failed vaginal birth after caesarean (39, 10.1%) and repeat elective caesarean section (169, 43.5%). The remaining (180, 46.4%) patients had a vaginal birth after caesarean. CONCLUSIONS: Our vaginal birth rate after one previous caesarean section was 82.2%. If this rate can be maintained in patients with 2 or 3 previous caesarean deliveries, we can reduce repeat caesarean rates by at least 14% by allowing more patients with 2 or even 3 previous caesarean deliveries to have a trial of labour under appropriate conditions and also proper management of dystocia.     

Spontaneous hemoperitoneum due to rupture of a regenerating nodule as primary manifestation of hepatic cirrhosis

Therapy of thyroid dysfunction needs a close cooperation between endocrinologist and gynecologist. In addition to a number of metabolic changes during pregnancy, the diaplacentar transfer of different substances (thionamides, antibodies) has to be considered. Pregnant women with overt and subclinical hypothyroidism should be treated using L-Thyroxine with the bTSH between 1 and 2 mU/l. Many of the women need an increase of the L-Thyroxine dose during pregnancy. Overt hyperthyroidism (mostly due to Graves' disease) has to be treated immediately after diagnosis using thionamides. Because thionamides cross the placenta, the dose should be as low as possible with the fT4 in upper level and bTSH in the lower level of normal range. Most studies show, that both methimazole (MI) and propylthiouracil (PTU) can be used in pregnancy. Although PTU is preferred especially in the USA, an advantage of PTU over MI is not proven. Surgery is necessary in only few cases of hyperthyroidism during pregnancy with the optimal time for surgery during the second trimester. In case of subclinical hyperthyroidism and HCG induced hyperthyroidism several controls of thyroid function should be performed to decide whether treatment is necessary.     

Project management, Part II

OBJECTIVE: Our purpose was to determine the relationship between previous caesarean section and subsequent development of placenta praevia and placenta praevia with accreta. METHOD: A retrospective review of the case records of all women delivered with the diagnosis of placenta praevia during the 2-year period from January 1, 1995, to December 31, 1996, at the tertiary referral centre, Princess Badeea Teaching Hospital, in north Jordan. RESULTS: There were 18, 651 deliveries in the study period. 65 (0.35%) had placenta praevia, 21 (32.3%) of whom had a history of previous caesarean section. The incidence of placenta praevia was significantly increased in those with a previous caesarean section (1.87%) compared with those with an unscarred uterus (0.25%); p < 0.0001). This risk increased as the number of previous caesarean sections increased: 1.78% for one previous section; 2.4% for two, and 2.8% for three or more. The incidence of anterior placenta praevia and placenta accreta was significantly increased in those with previous caesarean scars. In the group without antecedent of caesarean section, accretism risk was 9%, with one section or more 40.8% (p < 0.005). CONCLUSION: There is a high association between anterior placenta praevia, placenta accreta and previous caesarean section. This was enhanced with the increasing number of previous caesarean sections. Patients with an antepartum diagnosis of placenta praevia who have had a previous caesarean section should be considered at high risk of developing placenta praevia and accreta.     

A comparison of two different systems for CD34+ selection of autologous or allogeneic PBSC collections

Narghile smoking, a common habit among women in many non-Western societies, is assumed by the public to be minimally harmful. This study aims at identifying the effect of smoking narghiles during pregnancy on the weight of the newborn and other pregnancy outcomes. Three groups of pregnant women were interviewed in several hospitals in Lebanon between 1993 and 1995: 106 who smoked narghiles during their pregnancy, 277 who smoked cigarettes, and 512 who did not smoke. The adjusted mean birth weight of babies born to women who smoked one or more narghiles a day during pregnancy and to women who started smoking in the first trimester was more than 100 g less than that of babies born to nonsmokers (p < 0.1). The adjusted odds ratio of having babies with low birth weight (<2,500 g) among the narghile smokers was 1.89 (95% confidence interval (CI) 0.67-5.38). The risk increased to 2.62 (95% CI 0.90-7.66) among those who started smoking narghiles in the first trimester. A stronger association and a dose-response relation were found among cigarette smokers. The association between narghile smoking and other pregnancy outcomes, especially Apgar score and respiratory distress, was also noticeable. Further research and a policy action to fight the misperception that narghile smoking is safe are both recommended.     

Increased xanthine oxidase during labour--implications for oxidative stress

Xanthine dehydrogenase/oxidase (XDH/XO) produces uric acid. When in the oxidase form, this production is coupled with the generation of free radicals. Hypoxia-reperfusion enhances conversion of XDH to XO. Since the placenta is exposed to short periods of hypoxia reperfusion during labour, 17 placentae of pregnancy terminated by elective caesarean section and five placentae of pregnancies terminated by caesarean section during labour were examined for XDH/XO activity. It was found that XO activity was higher in the placentae of labouring women (P = 0.003), which suggests that labour enhances conversion of XDH to XO, facilitating free radical production.     

Morphological characteristics of lungs in embryos and fetuses in women living in regions contaminated with radionuclides after accident at the Chernobyl power plant

The possibility of transplacental passage of Cr-90 and Cs-137 as well as their traces appearance in descendants muscles and bones beginning from the 2nd pregnancy trimester (and this was sometimes associated with teratogenic effects) was demonstrated on the abortion material (human embryos and fetuses) from the controlled zones of the Bryansk region. Statistically significant inhibition of the bronchial branching (according to the morphometry of the lung histological section) this indicating the disturbance of the lung prenatal morphogenesis during the "pseudoglandular" developmental stage was observed in the 1st trimester of the pregnancy in the descendants of the irradiated mothers. Lung hypoplasia was observed in some cases in the 2nd and 3rd trimesters of the pregnancy. Activation of lymphoid cells in the fetal lungs and the tendency to the enhancement in them of the ectopic erythroid hemopoiesis was revealed. These processes are considered as a reflection of the compensatory adaptive cellular reaction in the descendants respiratory organs in response to the tissue hypoxia and antigenic stimuli from the organism of the pregnant woman irradiated after the Chernobyl accident.     

Delivery of extremely large infants

The purpose of this retrospective study was to find out if more effort should be applied to the diagnosis of extremely large infants, with a birth weight of 5,000 grams or more, and if elective caesarean section can be recommended. In the Department of Obstetrics, Herning Central Hospital, Denmark, 67 mothers delivered an infant with a birth weight of 5000 g or more over a ten year period. This index group was compared with a matched group with infants of normal weight. The result showed significantly more caesarean sections in the index group (24% versus 5%, p = 0.002). Shoulder dystocia and Duchenne-Erb's palsy were more frequent as well. Sixteen percent in the index group were admitted to the paediatric department, but the Apgar scores were not significantly lower. Except for one, all the infants showed complete recovery. In conclusion, elective caesarean section can not be generally recommended for an estimated birthweight exceeding 5,000 g, if a trained obstetrician is present at delivery.     

Changes in urinary excretions of C-telopeptide and cross-linked N-telopeptide of type I collagen during pregnancy and puerperium

Previously we reported an increase in bone resorption during pregnancy and lactation by measuring pyridinoline (Pyr) and deoxypyridinoline (D-Pyr). To further assess bone metabolism during peripuerperal periods, we measured the urinary excretions of C-telopeptide (CTX) and cross-linked N-telopeptide (NTX) of type I collagen, new markers of bone resorption. In addition to Pyr and D-Pyr, urinary CTX and NTX were measured by two ELISAs which recognize the corresponding peptide of type I collagen after urine samples were collected cross-sectionally from 230 women who consisted of 187 pregnants, 25 puerperants, and 18 age-matched nonpregnant women. Urinary CTX was also measured longitudinally from 10 pregnants at 5-9, 28-31 and 36-39 weeks of gestation and 1, 3, 6 months after parturition. Similar to the changes in Pyr and D-Pyr, the mean CTX and NTX values significantly increased in the 3rd trimester of pregnancy and remained high during puerperium compared with nonpregnant or early pregnant women (P<0.05). In a longitudinal study, the mean CTX value significantly increased in the 3rd trimester of pregnancy and at 1 month of puerperium compared with that in the early stage of pregnancy (P<0.05). These results further confirm our previous evidence that bone resorption is enhanced during the 3rd trimester of gestation and puerperium and suggest that urinary CTX and NTX measured by ELISA, which is more convenient than HPLC, are useful markers to assess bone resorption during peripuerperal periods.     

Epidemiologic studies of childhood leukemia: where do we go from here?

BACKGROUND: Hepatocellular carcinoma presenting in pregnancy is very rare, and experience treating this condition is limited. Past reports have emphasized the need for pregnancy termination as part of treatment. CASE: A young, otherwise healthy woman was diagnosed with hepatocellular carcinoma in the second trimester. Her only risk factor was a six-year history of oral contraceptive use. She opted to maintain the pregnancy and was treated with surgical resection in the form of a right hepatectomy. Both she and her child were alive and well 24 months following surgery. CONCLUSION: Hepatocellular carcinoma in pregnancy can be successfully treated by surgical resection without adjuvant therapy; pregnancy termination is not mandatory.     

Renal transplantation in secondary systemic amyloidosis

It has been recommended that women with Eisenmenger's syndrome (ES) are better not to become pregnant and pregnancy may justifiably be terminated by artificial abortion to avoid high maternal mortality and coherent fetal mortality. We present a case report about a parturient with ventricular septal defect (VSD) and ES who received general anesthesia for Cesarean section (C/S) because of preeclampsia, as a result of which she finally succumbed to an episode of intraoperative hypotension in spite of vigorous cardiopulmonary resuscitation. The death was thought to be precipitated by continuous deterioration of maternal health during the 3rd trimester of gestation. The anesthetic management of pregnant ES patients in confinement was reviewed and discussed, and the possible etiological factors relevant to the tragic outcome were also explored.