Hematologic problems in pregnancy V. Obstetric transfusion therapy

A study of 37,186 admissions, from 1970 through 1974, to a large southern charity hospital obstetrics service revealed a striking 63 per cent reduction in number of patients receiving blood transfusions. Analysis showed no change in patient population, bleeding disorders, toxemia, incidence of obstetric hemorrhage, serious febrile morbidity, or incidence of antepartum anemia. In the study period cesarean section rate increased 77 per cent and anemia at delivery markedly decreased. Transfusions associated with spontaneous abortion decreased by 70 per cent, and after the third study year no patient undergoing legal abortion received blood. The study demonstrated improvement in specific hematinic therapy of antepartum anemia and avoidance of transfusion therapy in the presence of uncharacterized antepartum or puerperal anemia. Despite the remarkable decrease in blood transfusions, obstetric outcome (including perinatal mortality rate, maternal mortality rate, and serious febrile morbidity) did not suffer but, indeed, improved.     

Elective cesarean section is preferred after the completion of a minimum of 38 weeks of pregnancy

OBJECTIVE: To determine the frequency of neonatal respiratory morbidity following elective caesarean delivery at term and to identify prognostic factors for this morbidity. DESIGN: Retrospective. SETTING: Academic Hospital Utrecht/Wilhelmina Children's Hospital Neonatal Intensive Care Unit, Utrecht, the Netherlands. METHOD: All elective caesarean deliveries in the Academic Hospital Utrecht from the period 1990-1995 were studied. Also, neonates were included who were admitted for intensive neonatal care because of respiratory insufficiency following elective caesarean delivery in the region surrounding Utrecht. An elective caesarean delivery was defined as a delivery performed after 37 weeks of gestation without any complicating factor that might influence the timing of delivery. Prognostic factors for neonatal morbidity after caesarean delivery were identified by multivariate logistic regression analysis. RESULTS: During 1990-1995, 272 elective caesarean deliveries after 37 weeks of gestation were performed that fulfilled the inclusion criteria; 5.1% of the neonates were admitted to the medium care unit because of respiratory problems. The relative risk of respiratory morbidity after delivery by caesarean section with a gestational age of 39-42 weeks compared with a gestational age of 37-38 weeks, was 0.14 (95% confidence interval: 0.03-0.64; p < 0.001). Male sex was a cofactor. Nine neonates of whom 8 (90%) had a gestational age of less than 39 weeks were admitted to the intensive care unit. CONCLUSION: Most of neonatal respiratory morbidity could have been avoided by postponement of the at-term elective caesarean section until a certain gestational age of at least 38 complete weeks. An elective caesarean section should not be performed before that period.     

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.     

Acute hepatic failure by phenytoin]

Two portable battery powered pulse oximeters were tested on Joint Services expeditions to the Sahara Desert and the Andes mountains. Their ability to measure changes in pulse, oxygen saturation of arterial haemoglobin (SaO2), their durability, ease of use, power systems and ancillary equipment were therefore evaluated in two extreme conditions. Although durable, easy to use and with good monitoring equipment, the batteries failed in extreme cold and the integral printer was too fragile for field use.     

Essential hypertension: first reason for persistent hypertension after unilateral adrenalectomy for primary aldosteronism?

OBJECTIVE: To evaluate the performance of two pulse oximeters in the measurement of arterial hemoglobin saturation in hypoxemic children. DESIGN: Prospective, repeated-measures observational study. SETTING: A 16-bed pediatric intensive care unit in a children's tertiary hospital. PATIENTS: Sixty-six patients with arterial saturation of <90%. INTERVENTIONS: Three arterial blood samples were taken from each subject during a 48-hr period. Pulse oximeter measurements of arterial saturation were compared with arterial saturation determined by cooximetry. MEASUREMENTS AND MAIN RESULTS: Arterial saturation was measured using one or both pulse oximeters (SpO2) and compared with the arterial hemoglobin saturation determined by cooximetry (SaO2). Sixty-two subjects were studied, using the Ohmeda pulse oximeter giving 185 data points (78 with saturations <75% [defined by the average of pulse oximeter and cooximeter]); 53 subjects were studied, using the Hewlett-Packard pulse oximeter yielding 155 data points (60 with saturations <75%). SpO2 ranged from 24% to 94%. Bias and precision of the Ohmeda pulse oximeter were -2.8% and 4.8% >75% and -0.8% and 8.0% <75%. Bias and precision of the Hewlett-Packard pulse oximeter were -0.5% and 5.1% >75% and 0.4% and 4.6% <75%. Intrapatient regression coefficient (r) for the differences between pulse oximeter and cooximeter was 0.58 for the Ohmeda and 0.59 for the Hewlett-Packard. Regression coefficients for predicting change in cooximeter value given a change in the Ohmeda pulse oximeter were 0.59 and 0.71 <75% and >75%, respectively. Similar coefficients for the Hewlett-Packard pulse oximeter were 0.50 and 0.70, respectively. CONCLUSION: The performance of the Ohmeda pulse oximeter deteriorated below an SpO2 of 75%. The Hewlett-Packard pulse oximeter performed consistently above and below an SpO2 of 75%. The ability of both pulse oximeters to reliably predict change in SaO2 based on change in pulse oximetry was limited. We recommend measurement of PaO2 or SaO2 for important clinical decisions.     

Pulse oximetry in severe carbon monoxide poisoning

STUDY OBJECTIVES: To evaluate the accuracy and quantitate the error of pulse oximetry measurements of arterial oxygenation in patients with severe carbon monoxide (CO) poisoning. DESIGN: Retrospective review of patient clinical records. SETTING: Regional referral center for hyperbaric oxygen therapy. PATIENTS: Thirty patients referred for treatment of acute severe CO poisoning who demonstrated carboxyhemoglobin (COHb) levels >25%, with simultaneous determinations of arterial hemoglobin oxygen saturation by pulse oximetry (SpO2) and arterial blood gas (ABG) techniques. MEASUREMENTS AND RESULTS: COHb levels and measurements of arterial oxygenation from pulse oximetry, ABG analysis, and laboratory CO oximetry were compared. SpO2 did not correlate with COHb levels. SpO2 consistently overestimated the fractional arterial oxygen saturation. The difference between arterial hemoglobin oxygen saturation (SaO2) calculated from ABG analysis and SpO2 increased with increasing COHb level. CONCLUSIONS: Presently available pulse oximeters overestimate arterial oxygenation in patients with severe CO poisoning. An elevated COHb level falsely elevates the SaO2 measurements from pulse oximetry, usually by an amount less than the COHb level, confirming a prior observation in an animal model. Accurate assessment of arterial oxygen content in patients with CO poisoning can currently be performed only by analysis of arterial blood with a laboratory CO-oximetry.     

Multicenter study on the clinical value of fetal pulse oximetry. II. Compared predictive values of pulse oximetry and fetal blood analysis. The French Study Group on Fetal Pulse Oximetry

OBJECTIVE: Our purpose was to compare the predictive value of intrapartum fetal pulse oximetry with that of fetal blood analysis for an abnormal neonatal outcome in case of an abnormal fetal heart rate. STUDY DESIGN: A prospective multicenter observational study was conducted from June 1994 to November 1995. Fetal oxygen saturation was continuously recorded with a Nellcor N-400 fetal pulse oximeter in case of an abnormal fetal heart rate during labor. Simultaneous readings of fetal oxygen saturation and fetal blood analysis obtained before birth (i.e., either at full dilatation or before cesarean section when indicated) were compared with the neonatal status. The criteria for an abnormal neonatal outcome were (1) an umbilical arterial blood pH < or = 7.15 and (2) a combined variable including 5-minute Apgar score < or = 7, umbilical arterial pH < or = 7.15, secondary respiratory distress, transfer in a neonatal care unit, or neonatal death. RESULTS: At a 7.20 threshold for fetal scalp pH and 30% for fetal oxygen saturation (i.e., the 10th percentile in the study population), the predictive value of fetal pulse oximetry was similar to that of fetal blood analysis for an arterial umbilical pH < or = 7.15 and for an abnormal neonatal outcome (positive predictive value 56% vs 55%, negative predictive value 81% vs 82%, sensitivity 29% vs 35%, and specificity 93% vs 91%, respectively). The receiver-operator characteristic curve showed similar performance of either technique for cutoff values < or = 7.20 for fetal blood pH and < or = 30% for fetal oxygen saturation, whereas fetal pulse oximetry became superior at higher thresholds. CONCLUSION: The predictive value of intrapartum fetal pulse oximetry can be favorably compared with that of fetal blood analysis. Randomized controlled management trials can now be performed to assess potential clinical benefits of this new tool.     

Laparoscopically assisted vaginal hysterectomy

OBJECTIVE: To report our experience with laparoscopically assisted vaginal hysterectomy (LAVH) and evaluate the advantages of LAVH. STUDY DESIGN: From January 1991 to August 1992, 176 LAVHs were performed at the Department of Obstetrics and Gynecology, College of Medicine, Chung-Ang University, Seoul, Korea. The indications for LAVH, based on the preoperative diagnosis, were uterine myomas, dysmenorrhea, chronic pelvic inflammatory disease or pelvic pain, dysfunctional uterine bleeding and cervical intraepithelial neoplasia (in order of frequency). RESULTS: Patients had concomitant procedures, including incidental appendectomy, posterior wall repair, pelvic adhesiolysis and salpingo-oophorectomy. Bipolar forceps were used to compress and desiccate vessels. The Nd-YAG laser, scissors and/or unipolar electrode were used for tissue division, excision of adhesions and cutting. The intraoperative complications were bladder perforation, massive hemorrhage and inferior epigastric vessel injury (one case each). The postoperative complications were infection, voiding difficulty, febrile morbidity, pelvic abscess, incisional hernia, vaginal vault bleeding and peroneal nerve palsy (one case each). CONCLUSION: Hysterectomy can be safely performed vaginally assisted by operative laparoscopy by well-trained laparoscopists, resulting in reduced surgical morbidity, blood loss, postoperative discomfort, recovery time and hospitalization.     

An experience with trial of scar in 66 Ethiopian women

The purpose of this study was to determine the circumstances in which trial of scar is conducted in the obstetric unit of Tikur Anbessa Hospital, Addis Ababa, Ethiopia, and evaluate the safety of the undertaking in terms of maternal and perinatal morbidity and mortality. Between 11 September, 1991 to 10 September, 1992, 66 women with previous caesarean section were given a trial of scar. The main pre-requests to allow a trial of scar were: only one previous lower uterine segment section, a cephalic presentation with no disproportion in the current labour and, the presence of a functional operating theatre. Labour was being monitored by checking the uterine contractions by fundal palpation and counting the Foetal heart rate (FHR) using the Pinnard Stethoscope. Compatible blood was prior prepared in only 7 (10.6%) labours. Forty seven (71.2%) parturients delivered vaginally. In 19 (28.2%) an emergency repeat section was done for failure of progress in labour. In one (1.5%) patient, a uterine scar dehiscence was detected. The 5th minute APGAR score was 7/10 or more in 64 (94.1%) and 6/10 in 3 (4.5%) of 68 neonates. There was one prepartum intra-uterine foetal death and one neonatal death of a preterm baby making the perinatal mortality rate (PNMR) of 29.4 per thousand. There was no maternal death. In conclusion, this study demonstrates that a trial of scar was a safe procedure.     

Oxygen desaturation during sedation for colonoscopy in elderly patients

BACKGROUND/AIMS: Conscious sedation increases the tolerance of patients to endoscopic examination, but arterial oxygen desaturation during endoscopy has often been reported. Elderly patients are considered to be at special risk. However, sedation-induced changes in cardiovascular function in the elderly have not been well investigated. Therefore, this study examined the effects of sedation on pulse rate, systolic blood pressure, and arterial oxygen saturation in elderly patients. METHODOLOGY: Twenty patients aged less than 60 years and 20 patients aged 60 years or more, scheduled to undergo colonoscopic removal of colorectal polyps, received 0.05 or 0.025 mg/kg body weight, respectively, of midazolam intravenously. Before, during, and after endoscopy, pulse rate, systolic blood pressure, and arterial oxygen saturation were recorded every 5 min with a pulse oximeter. RESULTS: Administration of midazolam had no significant effect on pulse and arterial systolic blood pressure in either group. In contrast, midazolam significantly reduced the levels of arterial oxygen saturation during and after endoscopy in both age groups. However, although patients aged 60 years or more received midazolam at half dosage, arterial oxygen saturation during endoscopy was significantly lower and the incidence of 5% or more oxygen desaturation was significantly higher than in the patients aged less than 60 years. CONCLUSIONS: Midazolam increases the tolerance of elderly patients to endoscopy, but it significantly lowers the level of arterial oxygen saturation and increases the incidence of desaturation. Continuous monitoring is especially valuable during endoscopy in the elderly.     

Effectiveness of obstetric epidural analgesia. II. Caesarean section

A questionnaire was sent to 260 women who in 1979 had undergone a caesarean section under either epidural or general anaesthesia. Those women who had an epidural for their caesarean section were on average very well informed about the procedure. In contrast, those who had been given a general anaesthetic felt that they had been badly or inadequately informed. Over 90% of the patients of both the epidural and the general anaesthetic groups described the type of anaesthesia which they had received as "very good" to "adequate". In the epidural group, 80% of the patients described the experience of the birth as very intense. Headache, back pain and other complaints such as abdominal pain and wound pain were significantly more frequent in the general anaesthetic as compared to the epidural group. 85.8% of the women given an epidural said that they would choose the same again for a future caesarean, 12.1% would not. Of the group given a general anaesthetic, 29.9% said that in the future they would choose an epidural, and 62.3% that they would prefer to have a general anaesthetic again. The Apgar score at one minute, and the umbilical artery pH values of the newborn of the epidural group were significantly better than those of the general anaesthetic group, whereas at 5 and 10 min the Apgar scores of the babies of both groups showed no differences.     

Treatment with a gonadotrophin releasing hormone agonist before hysterectomy for leiomyomas: results of a multicentre, randomised controlled trial

OBJECTIVES: To ascertain whether uterine shrinkage induced by a gonadotrophin releasing hormone agonist before hysterectomy for fibroids increases the possibility of a vaginal procedure. DESIGN: A multicentre, prospective, randomised, controlled study. PARTICIPANTS: One hundred and twenty-seven premenopausal women with a uterine volume of 12 to 16 gestational weeks. INTERVENTIONS: Twelve weeks of triptorelin depot treatment before hysterectomy or immediate surgery. MAIN OUTCOME MEASURES: Number of vaginal and abdominal hysterectomies, operating time, blood loss, degree of difficulty of the procedure, perioperative serum haemoglobin and haematocrit levels, hospital stay, and patients' overall satisfaction with treatment. RESULTS: After randomisation, four women withdrew from the study, leaving 60 women in the triptorelin arm and 63 in the immediate surgery arm. At baseline evaluation a vaginal hysterectomy was indicated in seven women allocated to pre-operative medical therapy (12%), and in 10 of those allocated to immediate surgery (16%). Clinical assessment after the 12-week GnRH agonist course showed that abdominal hysterectomy was no longer indicated in 25/53 women (47%) as a vaginal procedure appeared appropriate. Thus the overall rate of indication for a vaginal procedure in the pre-operative medical treatment arm was 32/60 cases (53%), with a between-group difference of 37% (95% CI, 26% to 51%; chi2(1) = 19.18, P < 0.0001; OR 6.06; 95% CI, 2.60 to 14.10). Pre- and post-operative serum haemoglobin and haematocrit levels were significantly higher in the GnRH agonist than in the immediate surgery arm. No appreciable difference was observed between the groups in the other intra- and post-operative variables, including patients' satisfaction. CONCLUSIONS: Pre-operative GnRH agonist therapy increased the rate of vaginal hysterectomy in selected women with fibroids and uterine volume of 12 to 16 gestational weeks.     

Minor morbidity after day-case surgery

The number of patients and procedures considered suitable for day-case anaesthesia and surgery continues to grow and it is hoped that 50-60% of all operations in the UK will eventually be performed on a day-patient basis. However, minor but troublesome post-operative side effects remain common. We have examined the incidence of the most common causes of minor morbidity, namely headache, nausea/vomiting and pain occurring after a wide variety of day-case surgical and diagnostic procedures. Patient satisfaction with treatment and the impact of day case surgery on the workload of the general practitioner was also assessed. The anaesthetic records of the patients involved were reviewed in an attempt to determine if there was any association between the anaesthetic technique and an adverse outcome. A simple postal questionnaire completed on the morning after surgery was returned by 553 patients (response rate over 87%). More than 50% of respondents complained of some morbidity, with 40% complaining of pain, 19% of headache and 9% of nausea and vomiting. One third self-medicated to modify their symptoms, and in most cases (81%) this was effective. However, 6% of patients called their GP for advice and 2% received a home visit. No patient required readmission. A total of 92 patients (17%) would have preferred treatment as an in-patient. Analysis of the anaesthetic drugs and techniques suggested that the commonly used anti-emetics droperidol and metoclopramide had little effect on the incidence of postoperative nausea and vomiting. Intubation was associated with a significantly higher incidence of minor morbidity although this may be related to surgical factors.     

Value of combined spinal and epidural anesthesia in the management of peroperative analgesia in prosthetic surgery of the lower limb. Prospective study of 68 cases

PURPOSE OF THE STUDY: Efficient peri-operative analgesia is more comfortable, allows earlier mobilisation and better functional results for lower limb arthroplasties. We report our 60 cases prospective study of combined spinal and epidural anesthesia, and expose interests of this technique to control peri-operative pain. MATERIALS: From 1994 to 1995, 60 patients ASA class 1 were operated: 45 total hip replacement (THR), 15 total knee replacement (TKR). The average age was sixty five years (range thirty nine to eighty five years). Combined spinal and epidural anesthesia was performed in every case. METHODS: In lateral decubitus position, a translucent 25 Gauge needle was introduced in L2-L3 interspace. In a first time spinal anesthesia was made with 20 mg Bupivacaine. In a second time, a lumbar epidural catheter was inserted. All patients received an epidural post-operative analgesia with 4 mg Morphine once a day during two days and intravenous Paracetamol. Visual analogue scale (0 to 10) (VAS) were recorded after the third post operative hour and every twelve hours. During this period satisfaction mark was also recorded (1 to 3). RESULTS: We didn't observe any case of respiratory depression or infection with the epidural catheter. We observed 10 cases of pruritus (one needed to stop protocol) and 18 urinary retentions. Six uretral catheters were necessary; we had one case of pyelonephritis (escherichia coli). The first micturition was obtained 13.5 hours after the end of surgery. For the fifty nine remaining patients, visual analogue scale was always inferior or equal to 2/10 and the satisfaction mark to 1/3. DISCUSSION: Different techniques allow peri-operative analgesia, but a few are efficient during the first two days. Plexus nerve blocks are simple and reliable but post-operative anesthesia is short (inferior to 15 hours). Intravenous morphine controlled by patients themselves with programmed display needs expensive and sophisticated material. The principal risk is respiratory depression. Epidural morphine has a lower respiratory depression risk, but needs a heavier technique. The principal problems is higher incidence of urinary side effects. Epidural anesthesia might tend to show a greater efficacity with the best visual analogue scale and satisfaction mark. CONCLUSION: The results indicate that combined spinal and epidural anesthesia for the management of peri-operative pain provide an excellent pain control with a daily morphine injection. For lower limb arthroplasties, visual analogue scale is always inferior or equal to 2 and satisfaction mark equal to 1.     

Comparison of tramadol and tramadol/droperidol mixture for patient-controlled analgesia

PURPOSE: To compare the analgesic efficacy and side effects of tramadol vs tramadol and droperidol for post-operative patient-controlled analgesia (PCA). METHODS: Randomised, double-blind study. Thirty-four patients undergoing elective colorectal or head and neck surgery were allocated to Group 1 (n = 18, PCA bolus 10 mg tramadol) or Group 2 (n = 16, PCA bolus 10 mg tramadol + 0.1 mg droperidol). Anaesthesia was induced with fentanyl and thiopentone and maintained with O2, N2O plus enflurane or isoflurane with iv morphine at doses decided by the attending anaesthetists. Muscle relaxation was achieved with atracurium or vecuronium. Patients were observed four-hourly for pain using an 11-point verbal rating scale (VRS). Nausea and vomiting, and sedation were assessed using four-point scales post-operatively. Vital signs, request for rescue anti-emetic and analgesic, and overall satisfaction were recorded. RESULTS: The mean nausea scores were lower in Group 2 (1.00 +/- 1.33 vs 0.06 +/- 0.25 at 0-8 hr, 1.22 +/- 1.93 vs 0.06 +/- 0.25 at 8-16 hr, P < 0.01; 0.81 +/- 1.68 vs 0 at 32-40 hr, P < 0.05; Group 1 vs Group 2). The vomiting scores were also lower (0.50 +/- 1.04 vs 0 at 0-8 hr, 0.67 +/- 1.50 vs 0, at 8-16 hr, P < 0.05; Group 1 vs Group 2). Seven (39%) patients in Group 1, but none in Group 2 requested rescue anti-emetic (P < 0.01). There were no differences in VRS, sedation score, overall satisfaction or vital signs. CONCLUSION: Tramadol and droperidol combination is superior to tramadol alone for post-operative PCA. It provides a similar quality of analgesia with less nausea and vomiting and without an increase in sedation.     

Evaluation of post-operative analgesia following laparoscopic application of Filshie clips

OBJECTIVE: To evaluate the efficacy of injecting 1% lignocaine into the subserosal aspect of the cornual end of the fallopian tubes to control post-operative pain after laparoscopic Filshie clip application. DESIGN: A double blind, randomised controlled trial. SETTING: The day surgery unit of the Dunedin Public Hospital, Otago, New Zealand. PARTICIPANTS: Fifty-nine women attending the public hospital requesting sterilisation. INTERVENTIONS: The experimental group received an infiltration of 1% lignocaine into the subserosal aspect of the cornual end of the fallopian tubes. The control group received an infiltration of normal saline in the same site. MAIN OUTCOME MEASURES: The use of post-operative pethidine and the scores obtained on a modification of the McGill present pain intensity score, a visual analogue scale of present pain, a pain relief score and comparisons of time to first analgesia use. RESULTS: The use of pethidine in the experimental group was significantly reduced [P = 0.001] Pain relief scores indicated significant benefit from the intervention. The time to first analgesic use was significantly greater in the experimental group. CONCLUSION: Lignocaine infiltration at the cornual end of the fallopian tubes during laparoscopic Filshie clip application is highly effective in producing post-operative pain relief.     

Better maternal outcomes are achieved with dexamethasone therapy for postpartum HELLP (hemolysis, elevated liver enzymes, and thrombocytopenia) syndrome

OBJECTIVE: Our purpose was to determine whether the routine initiation of dexamethasone therapy in patients with postpartum HELLP (hemolysis, elevated liver enzymes, and thrombocytopenia) syndrome produces specific and general therapeutic benefits. STUDY DESIGN: In this retrospective, analytic study the puerperal courses of 43 women with postpartum HELLP syndrome who were treated with dexamethasone were compared with those of 237 similar patients who did not receive corticosteroids. Dexamethasone 10 mg intravenously at 12-hour intervals was given until disease remission was noted in treated patients, at which time up to two additional 5 mg intravenous doses were given at 12-hour intervals. RESULTS: The two patient groups were similar in regard to mode of delivery, gestational age, parity, and frequency of eclampsia. Compared with control subjects, dexamethasone-treated postpartum patients were more ill with significantly higher (p < 0.05) admission mean arterial blood pressure, higher serum uric acid level, and severe proteinuria. Dexamethasone administration was associated with a more rapid normalization of platelet counts and lactic dehydrogenase values. Most impressive was a clinically significant reduction of indicated transfusion and respiratory therapy, invasive hemodynamic monitoring, infectious or bleeding-related morbidity, and length of postpartum hospital course. CONCLUSIONS: Patients who received dexamethasone for postpartum-onset HELLP syndrome experienced a shorter disease course, faster recovery, less morbidity, and less need for other interventionist therapy compared with patients with HELLP syndrome who did not receive dexamethasone.     

Congenital infection by human parvovirus B19 ascites-anaemia

A case of intrauterine infection by human parvovirus B19 (HPV B19) manifested as ascites during pregnancy is presented. Ascites was diagnosed by ultrasound at 27 weeks' gestation. A caesarean section was performed at 37 weeks'. owing to affected mobility of the fetus. A pale, female infant with low haemoglobin and bradycardia was delivered. Polymerace Chain Reaction (PCR) lab tests revealed that the mother and the fetus were infected by HPV B19. The neonate was born with low haemoglobin (Hb = 10 g/dl) and with ascites; it was discharged in good general condition 50 days after delivery.     

Trial of labor in patients with a previous lower uterine vertical cesarean section

OBJECTIVE: Our purpose was to determine the efficacy and safety of a trial of labor in patients previously delivered at least once by a lower uterine vertical cesarean section. STUDY DESIGN: A retrospective review was performed at a single tertiary perinatal center, The University of Florida Health Science Center, Jacksonville. The medical records of all patients with a previous low vertical cesarean section who underwent a trial of labor during a 72-month period from January 1988 until December 1993 were reviewed. The medical records of the next two patients who did not have a prior uterine incision admitted to labor and delivery after the index case served as the controls. The duration and outcome of labor, including mode of delivery, maternal and perinatal morbidity, and birth trauma were evaluated. RESULTS: Of 77 patients with a previous low vertical cesarean incision, 11 (14.3%) had a repeat operation compared with 14 of 154 patients (9.0%) in the no previous cesarean section group (not significant). No differences were noted in the incidences of operative vaginal deliveries or prolonged duration of the first or second stages of labor, or in the rate or maximum dose of oxytocin infusion between the two groups. One patient in the previous cesarean section group had uterine rupture. The incidence of umbilical artery pH < or = 7.20 was similar. No difference in the number of infants with 1- or 5-minute Apgar scores < or = 7 was noted. CONCLUSION: A trial of labor in women with previous low vertical cesarean sections results in an acceptable rate of vaginal delivery and appears safe for both mother and fetus.     

The effects of Entonox and epidural analgesia on arterial oxygen saturation of women in labour

The arterial oxygen saturation of 40 mothers in the first stage of labour was monitored using pulse oximetry. Half the mothers received epidural analgesia and the rest inhaled Entonox for pain relief. Eight mothers in the Entonox group and six in the epidural group had at least one episode of significant hypoxia (saturation < 90%). There was little difference in the number of hypoxic episodes experienced by either group (29 in the Entonox and 21 in the epidural) although their mean duration and severity was greater in the Entonox group. Women in labour who inhale Entonox have an appreciable incidence of arterial desaturation. Epidural analgesia reduces the severity of hypoxic episodes although it does not eliminate them.