The Indiana University School of Dentistry archives: back to the future

OBJECTIVE: To report our experience with high doses (0.1-0.2 mg per 10 kg pregnant weight) of intravenous (IV) nitroglycerin as a uterine relaxing agent for managing internal podalic version of the second twin in transverse lie with unruptured membranes. METHODS: Between August 1994 and December 1997, we managed 22 cases of internal podalic version of the second twin with the administration of high doses of IV nitroglycerin. RESULTS: Twenty internal podalic versions were completed successfully, and two cases failed. One failure was considered not related to IV nitroglycerin because the patient had a panic attack, requiring general anesthesia for sedation. The internal podalic version then succeeded. The patient with true failure of IV nitroglycerin required emergency cesarean because of acute fetal bradycardia and a nonrelaxed uterus. This was the only nontransverse lie, but with a very high face presentation. One internal podalic version was complicated by hemorrhage (2000 mL). CONCLUSION: Intravenous nitroglycerin to induce uterine atonia, with epidural analgesia, avoids general anesthesia and makes internal podalic version easier. In 22 cases (with success in 20) of internal podalic version of the second twin in transverse lie with unruptured membranes, IV nitroglycerin induced transient and prompt uterine relaxation without affecting maternal and fetal outcomes.     

Amnioinfusion with Hartmann's solution: a safe distention medium for endoscopic fetal surgery in the ovine model

In this study, we have investigated the maternal effects of distending the uterine cavity with Hartmann's solution in 2nd trimester equivalent pregnant sheep. In 7 pregnant ewes, double endoscopic cannulation of the amniotic cavity was performed under general anesthesia, and 1 liter of Hartmann's solution at 38 degrees C, radiolabeled with 99mTc-red blood cells, was infused. Maternal central venous pressure, hematocrit, serum and amniotic fluid osmolarity, and amniotic fluid volume were measured at nine time points within a 2-hour period. Over this time interval, no significant fluid shift to the maternal compartment was observed. We detected no adsorption of radioactivity to the fetus or membranes, and no diffusion of radioactivity to maternal or fetal tissues was noticed. We conclude from these experiments that following double cannulation and intra-amniotic infusion of Hartmann's solution into the 2nd-trimester pregnant ovine uterus, no significant shift of fluid to the maternal compartment was observed over a 2-hour time period.     

Fetal survival in abdominal pregnancy: a review of 11 cases

PURPOSE: Little has been written regarding the ultrasound imaging features that might allow prediction of fetal viability in abdominal pregnancies. Toward this goal, we present our experience with a series of 11 abdominal pregnancies. MATERIALS AND METHODS: From 1981 to 1993, 11 patients presented to Universidad Catolica, Santiago, and Universidad de Austral, Valdivia, Chile, with third trimester abdominal pregnancies. Five had complete ultrasound examinations, and these five patients were managed expectantly. The other six women presented as acute abdominal emergencies and underwent emergent surgery. RESULTS: Four of five fetuses that survived had a complete placental attachment to the uterus, and one surviving neonate had a partial attachment of the placenta to the uterus. Three fetuses died prior to delivery, and all three had a complete mesenteric placental attachment. Two died in the early neonatal period. One had a complete uterine placental attachment, and the other had a partial attachment. CONCLUSIONS: The survival rate of abdominal pregnancies may be better than is generally believed. Placental attachment to the uterus appears to be a factor related to fetal survival and maternal morbidity. More cases are necessary to determine the feasibility of managing women with abdominal pregnancies expectantly.     

Shortcut of the photosynthetic electron transfer in a mutant lacking the reaction center-bound cytochrome subunit by gene disruption in a purple bacterium, Rubrivivax gelatinosus

OBJECTIVE: The purpose of our study was to determine the aetiological factors of uterine rupture during labour, and propose preventive measures. METHODS: This retrospective study was performed between February 1989 and July 1994, to analyze the cases of rupture uterus in relation to causes, age, parity, maternal and fetal mortality and morbidity. RESULTS: There were 37 cases of uterine rupture at our institutions. Obstructed labour by malpresentation and disproportion was the main cause. The presence of previous caesarean section scar, dysfunctional labour, injudicious use of uterine stimulant, were the other causes. There was no maternal death and the fetal loss was 17 (46%). CONCLUSIONS: The high incidence of uterine rupture is attributed to lack of prenatal care, labour in high risk patients outside the hospital because of declining economy, and more patients with 2 or more previously scarred uterus with many of them labouring more than 14 hours. Maternal and neonatal complications have remained very high in the developing countries.     

Operative hysteroscopy: minimally invasive surgery to control of menorrhagia

Diagnostic hysteroscopy is a valuable method for evaluation of intrauterine disorders. After diagnosing, the endoscopic treatment of these pathologies is the major question of past decade. Possibility of solving cause of infertility or abnormal uterine bleeding without laparotomy or hysterotomy/hysterectomy is the great advantage of operative hysteroscopic methods. In Department of Obstetrics and Gynaecology of University Medical School of Debrecen more than 1400 hysteroscopic interventions were performed from 1 September 1989 to 31 December 1996. In treatment of intractable uterine bleeding 347 operative hysteroscopy (targeted biopsy, polypectomy, transcervical endometrial ablation, fibroid resection etc.) were performed. The rate of complications was low, only 2% (4 perforations and 2 bleedings). The high success rate and low rate of complications offers a modern, safe, minimally invasive method for treatment of menorrhagia.     

Chorioamnionitis

Chorioamnionitis is an inflammatory reaction occurring in the fetal membranes of the placenta. It is usually associated with premature rupture of the membranes, whether spontaneous or artificial. Rupture of the fetal membranes sets off a time bomb that threatens both maternal and fetal welfare. The seriousness of this threat is dependent upon several variables: the length of gestation, economic status of the patient and the duration of the rupture. There is a controversy about the relative importance of these variables and about the proper degree of aggressiveness necessary to achieve optimum fetal salvage. When chorioamnionitis occurs, most obstetricians agree that the uterus should be evacuated by the most expeditious route. Usually oxytocic induction will accomplish delivery without difficulty, but should it fail to effect cervical ripening and dilatation within a reasonable time, cesarean section should be performed without further delay. If cesarean section is necessary in the presence of gross infection, hysterectomy is advocated by some.     

Clinical study on painless labor under drugs combined with acupuncture analgesia

To study the analgesia efficacy of drugs combined with acupuncture analgesia for painless labor, 462 normal pregnancy women were observed. During the latent phase in labor, several analgesia methods: acupuncture analgesia, analgesics, magnetotherapy and auricular acupressure, TENS combined with dihydroetorphine were used respectively. While the intrauterine pressure and the peripheral content of beta-EP were measured during labor, the experiments of SEPS were also performed on healthy adults to demonstrate the analgesia efficacy of those analgesia methods. The combination of drugs with acupuncture is an excellent method for painless labor without any complications and all the mothers and babies are safety. The effectiveness is 97.5%. The results demonstrate that the mechanism of analgesia efficacy should be regulated the incoordinate uterine action and improve the hypertonic status of uterus, but also can decrease the pain threshold and elevate the tolerance of uterine contractions during labor.     

Progesterone levels in amniotic fluid and maternal plasma in prostaglandin F2alpha-induced midtrimester abortion

Progesterone concentrations in amniotic fluid and maternal plasma were determined in 11 midtrimester pregnant patients following the intraamniotic administration of prostaglandin F2alpha. Samples were obtained at 3-hour intervals until abortion or spontaneous rupture of membranes occurred or fetal heart tones disappeared. In amniotic fluid, the mean progesterone concentrations increased throughout the sampling period. The plasma progesterone levels declined by about one-third of basal values in the first 3 hours after prostaglandin administration. The paradoxic increase in amniotic fluid progesterone is probably secondary to alterations in uterine blood flow and intrauterine pressure.     

Surveyed use of fetal and uterine monitoring during maternal surgery

The goal of this study was to determine the frequency and methods of intraoperative fetal and uterine monitoring during maternal surgery in the United States. Maternal surgery was defined as nonobstetric surgery during pregnancy that required general or regional anesthesia. We mailed a 21-item questionnaire to the perioperative nurse managers of US hospitals at which more than 2,000 babies are delivered annually (n = 579). Nearly 60% of responding hospitals routinely used some form of fetal monitoring during maternal surgery; more than 40% of responding hospitals did not use intraoperative fetal and uterine monitoring routinely during maternal surgery.     

Fetal and maternal endocrine responses to experimental intrauterine infection in rhesus monkeys

OBJECTIVE: Our purpose was to describe the temporal and quantitative relationships among intrauterine infection, fetal-placental steroid biosynthesis, and preterm labor in a nonhuman primate model. STUDY DESIGN: On approximately day 130 of gestation (term 167 days) chronically instrumented rhesus monkeys (Macaca mulatta) were infected with 10(6) colony-forming units of group B streptococci either by intraamniotic (n = 4) or choriodecidual (n = 2) inoculation. As controls, four additionally chronically instrumented noninfected monkeys were followed up to spontaneous parturition. Amniotic fluid and maternal and fetal arterial blood were serially sampled in all monkeys (both before and after infection) for progesterone, estrone, estradiol, dehydroepiandrosterone, dehydroepiandrosterone sulfate, androstenedione, and cortisol by specific radioimmunoassays, and uterine activity was continuously recorded. RESULTS: Spontaneous parturition was preceded by gradual and significant increases in the plasma concentrations of fetal dehydroepiandrosterone, dehydroepiandrosterone sulfate, and androstenedione and fetal and maternal levels of estrone, estradiol, and progesterone but not by changes in cortisol. In contrast, infection-associated parturition (either intraamniotic or choriodecidual) was characterized by abrupt increases in fetal dehydroepiandrosterone, dehydroepiandrosterone sulfate, androstenedione, progesterone, and cortisol but not by increases in maternal or fetal estrone or estradiol. Infection-associated steroid changes occurred concurrently with or after increases in uterine activity. CONCLUSION: Infection-associated preterm parturition is associated with dramatic increases in fetal adrenal steroid biosynthesis but not by corresponding increases in placental estrogen biosynthesis. This suggests that fetal stress in accompanied by placental dysfunction and that infection-associated parturition is not dependent on the increased estrogen biosynthesis observed in spontaneous parturition.     

Partner notification and focused intervention as a means of identifying HIV-positive patients

PURPOSE: A procedure using transvaginal sonohysterography (SHG) to perform operative intrauterine biopsies and resections is described. METHODS: Seven women, six with intrauterine pathology noted on diagnostic SHG and one with a thickened endometrium noted on transvaginal ultrasonography, underwent attempted operative SHG. The indications were peri- and postmenopausal bleeding (n = 4) and infertility requiring assisted reproduction (n = 3). Access to the uterine cavity was accomplished with a 9-F cervical access catheter (CAC) with a 3-ml balloon (BEI Medical Systems, ZSI Gynecology Products Division, Chatsworth, CA), which was placed in the cervical canal or lower uterine segment. Depending on the position of the noted uterine pathology, a 6-F uterine ostial access catheter (UOAC) (BEI Medical Systems, ZSI Gynecology Products Division) was placed through the CAC. The uterine cavity was distended with 5-10 ml of 1% Lidocaine and a 3-F loop grasper or finger-like biopsy grasper was then passed through the UOAC or a 5-F operative instrument directly within the CAC with attempted resection under ultrasound guidance. Biopsied samples were sent to pathology for definitive diagnosis. Office hysteroscopy was then performed to confirm adequate resection. RESULTS: Three of six patients had adequate resection or biopsy of intrauterine pathology, while the seventh patient successfully had a directed biopsy of the fundal cavity under ultrasound guidance. In one case, the visualized lesion could not be grasped. In the other two cases, each patient had severe cervical stenosis and declined in-office cervical dilation precluding the procedure. Each procedure was well tolerated, with an average time from start to finish of about 25 min (range, 18-43 min) without complications. CONCLUSIONS: Operative SHG makes it possible to resect and biopsy intrauterine pathology often missed on Pipelle sampling. If found to be as effective as hysteroscopy, operative SHG would provide a cost-effective alternative. Further study is ongoing to perfect the existing instruments to allow removal of larger lesions both safe and possible.     

A new technique applicable to pediatric laparoscopic surgery: abdominal wall 'area lifting' with subcutaneous wiring

BACKGROUND: Recently, the authors developed a unique method of laparoscopic surgery without pneumoperitoneum: "area lifting of the abdominal wall with subcutaneous wiring." METHODS: In this gasless procedure, the anterior abdominal wall is pulled upward by a pair of wires placed subcutaneously and held by thick sutures for "hanger lifting." Simultaneous lifting of a pair of subcutaneous wires across the abdomen, produces a wide, roof-shaped intraabdominal space sufficient for laparoscopic surgical procedures. The practical aspects of this gasless technique, as well as the authors' limited experience with this method in 24 children, ranging from 8 days to 15 years of age is presented. These children have had various pathologies including splenomegaly, rectal prolapse, ovarian cyst, gall stone, adrenal neuroblastoma, and abdominal wall abscess. CONCLUSIONS: Gasless laparoscopic surgery with double subcutaneous wiring is safe for children including neonates and those with respiratory compromise because all operative procedures are performed under normal abdominal pressure. Because of the highly elastic abdominal wall musculature inherent in children, this selective area lifting of abdominal wall creates a relatively larger peritoneal volume than in adults.     

Effects of intravenous meperidine and meperidine with promethazine on uterine activity and fetal heart rate during labor

A prospective study of the effects of the i.v. injection of 75 mg meperidine, alone or combined with 25 mg promethazine, was conducted by continuous and direct monitoring of the fetus and of intrauterine pressure. The study was carried out in 16 primiparas and 24 multiparas in active spontaneous labor with cervical dilatation of 3 to 4 cm. Administration of meperidine and of meperidine with promethazine was associated with an increase in uterine activity of 31 to 45% (Montevideo units), respectively. The most marked effects were on the amplitude of the uterine contractions. There was no significant change in uterine tone. A tetanic response was recorded in two patients who vomited after the administration of meperidine with promethazine and was followed by slowing of the fetal heart rate. In no other cases were there significant changes in fetal heart rate. Except for the latter two patients, no adverse effect of meperidine or of meperidine with promethazine on the fetal heart rate was noted. The condition of the newborns at birth was excellent in all but three cases, in two of which maternal amniotic infection and high fever were present.     

Laparoscopic management of rudimentary horn pregnancy

A unicornuate uterus with rudimentary horn is a rare Müllerian abnormality. This uterine anomaly may cause many gynaecological and obstetric complications, including infertility, recurrent abortions, preterm deliveries and rupture of the uterus, especially when the pregnancy implants in the rudimentary horn. To date, laparotomy has been the treatment of choice when resection of a rudimentary horn was indicated. We report on the case of a woman who benefited from laparoscopic surgery of a rudimentary horn pregnancy. Laparoscopy, in these exceptional cases, is the most accurate diagnostic tool that carries significant advantages in effective surgical management, thereby avoiding laparotomy.     

The effects of ovariectomy and stretch on the regulatory profile and activity of the uterus

Following ovariectomy of five New Zealand white rabbits at day 25 of pregnancy, the intrauterine pressure (IUP) and uterine progesterone (P) and prostaglandin (PG) levels were measured sequentially at days 25, 26 and 27. At day 25, when the uterine P and PGE and PGF were high, massive intrauterine treatment with 500 microng PGF2alpha provoked only a sustained contracture on which only low level oscillation in IUP was superimposed. At day 26, when the P levels had decreased significantly (P less than 0.001) and the PG levels had not changed significantly, 50 microng PGF2alpha significantly increased cyclic IUP as compared with the day 25 value (P less than 0.001). At day 27, when the P levels decreased further, as little as 5 microng PGF2alpha provoked still higher cyclic IUP, in spite of a significant reduction in PG levels (P less than o.05). Stretching the uterus of six post partum and six 26 days pregnant rabbits (after removing the uterine contents) significantly increased the uterine PGF levels (P less than o.001). However, stretch increased only cyclic IUP of the post partum uterus and was without effect on the pregnant uterus, which still had high P levels. These results indicate that the myometrium is activated by exogenous PG or stretch, regardless of whether the uterine PG levels increase, remain unchanged or even moderately decrease, provided that the uterine P levels are reduced to a critical value.     

Uterine allergy: a cause of preterm birth?

OBJECTIVE: To identify the origin of eosinophils in cases of eosinophil-associated preterm delivery. METHODS: From an established set of 465 consecutive non-anomalous singleton infants delivered at 22-32 weeks' gestation, we retrieved 161 cases of preterm delivery following spontaneous onset of preterm labor, 78 cases with maternal preeclampsia, 33 cases of abruption, and 193 cases of premature rupture of membranes (PROM). Charts were reviewed, and the placenta, umbilical cord, and membranes were examined histologically. In cases with extravascular eosinophils showing evident gradient toward the amniotic cavity, the origin of the eosinophils (fetal or maternal) was determined by the proximity to fetal or maternal vessels. RESULTS: Histologic evidence of an eosinophilic gradient toward the amniotic cavity was present only in the fetal (including umbilical cord and chorion) compartments. This eosinophilic gradient was present in 19% (90 of 465) of preterm delivery cases and was significantly more common in cases of PROM (54 of 193, 28%) and preterm labor (34 of 161, 21%) than abruption (two of 33, 6%) and preeclampsia (none of 78) (P < .001). In 84 of 90 cases (93%), the eosinophilic gradient was present along with multiple histologic indicators of acute intrauterine inflammation. CONCLUSION: An eosinophilic gradient toward the amniotic cavity, present in nearly a fifth of cases of preterm delivery, is probably of fetal origin, making it unlikely that a maternal "allergy-like" mechanism is a cause of preterm delivery.     

Embryo transfer--can we learn anything new from the observation of junctional zone contractions?

To assess whether embryo transfer can alter junctional zone contractility, we studied the effect of easy and difficult mock transfers in 14 oocyte donors during in-vitro fertilization (IVF) cycles. An Echovist bolus (30 microl) was used to represent embryos and transfer medium. An 'easy' transfer was judged to be an atraumatic insertion of the catheter without touching the uterine fundus. A 'difficult' embryo transfer was mimicked by deliberately touching the uterine fundus twice with the soft end of the cannula. Transvaginal scan images were recorded, digitized and converted into five times normal speed to allow us to evaluate junctional zone contractility. Easy mock embryo transfers did not change endometrial mechanical activity. Echovist remained in the upper part of the uterine cavity and was not dispersed after 45 min. A difficult procedure generated strong random waves in the fundal area and waves from fundus to cervix which relocated the Echovist in six out of seven cases. We observed movements of the transfer bolus from the upper part of the uterus towards the cervix (four cases) and into Fallopian tubes (two patients). Our study confirms that the mechanical activity of the uterus is capable of relocating intrauterine embryos and that this activity depends on physical stimulation. Junctional zone contractions can be implicated in cases of IVF/embryo transfer failure or ectopic gestation.     

Fetal surgery in the head-neck area. Current status and new possibilities with the endoscope

Fetal surgery is defined as the intrauterine surgical correction of malformations that endanger the unborn child's life in prenatal stages of development or lead to death or severe damage of the child postnatally. Such surgery is a clinical reality now. Indications for intrataurine surgical procedures also exist for head and neck abnormalities, especially in the upper respiratory tract. These include exposure and temporary obstruction of the fetal trachea for correction of pulmonary hypoplasia in cases with congenital diaphragmatic hernias, prenatal tracheotomy in cases of laryngeal atresia for the correction of lethal pulmonary overdistension, and resection of embryonic tumors that obstruct the respiratory tract. The relatively high surgical risk resulting in particular from preterm labor occurring postoperatively may be reduced by employing minimally invasive techniques. Endoscopic procedures render opening of the uterus unnecessary and are of particular importance. In part of the procedures, only endoscopic surgery has led to therapeutic success rates justifying its clinical use. Further reduction of the operative risk suggests prenatal interventions, even in cases with non-lethal conditions. More diseases of the head and neck may thus be included in the spectrum of indications. One example is prenatal correction of a cleft lip and palate, which until now has only been performed in animal experiments. The particular characteristics of fetal wound healing allow this to take place without scarring up to a certain stage in pregnancy. This offers the prospect of a surgical correction that is invisible externally and avoids growth-impeding scars. The particular ethical and legal aspects of fetal surgery are discussed.     

Single-port tracheoscopic surgery in the fetal lamb

BACKGROUND/PURPOSE: Endoscopic fetal surgery could help avoid many of the problems associated with open fetal surgery, but the use of multiple ports may be too traumatic to the membranes. The authors describe a single-port technique of tracheoscopic surgery in the fetus. METHODS: Time-dated pregnant ewes (95 to 105 days; term, 145 days) underwent midline laparotomy under general halothane anesthesia. A 5-mm-diameter balloon-tipped cannula was introduced in the uterus by Seldinger technique. A 1.2-mm semirigid mini-endoscope, fitted inside a 9F, 20 degrees curved sheath, was introduced under continuous, low-pressure irrigation, inside the fetus' mouth, and advanced into the trachea. RESULTS: Endotracheal procedures, including temporary (n = 11) and permanent balloon tracheal occlusion (n = 30) and placement of a barbed guide wire for endotracheal occlusion device insertion (n = 12), were performed by introducing a 1-mm diameter instrument alongside the telescope. These were successfully performed in 52 of the 53 fetuses. The rigidity of the telescope allowed controlled access to the pharynx; its curve allowed full tracheobronchial endoscopy with the fetus in utero. CONCLUSIONS: The present technique marries the control and optical quality of a rigid endoscope with the physiological curve only a flexible instrument could offer until now. The types of procedures performed with this technique illustrate its potential as a research tool; the size (1.2-mm diameter), shape, and optical qualities of the telescope should make clinical applications possible.