A. Schoenfeld

Fetal response to periodic sleep apnea: a new syndrome in obstetrics.

Periodic sleep apnea, a chronic sleep deprivation state, in which marked changes in the arterial PO2 and PCO2 tensions have been recorded, is a relatively new syndrome not previously reported in pregnancy. It is characterized by episodes of apnea, prevalently obstructive, during sleep. The majority of patients with this syndrome have snored heavily for years, suggesting a causal relationship between snoring and periodic sleep apnea. The effects of prolonged snoring on alveolar ventilation and systemic pressure(s) suggest that this snoring has physiopathological implications on maternal cardio-respiratory reserve and indirectly upon the fetus, especially as there are recordable changes in fetal heart rate and also a change in the acid-base status of the fetus. The possibility that this syndrome may have an adverse effect upon the fetus is stressed.

Obstructive sleep apnea (OSA)-implications in maternal-fetal medicine. A hypothesis

During the past fifteen years the obstructive sleep apnea syndrome (OSAS) has become widely recognized as a quite common disorder with a wide range of serious clinical complications (1, 2, 3). This syndrome arises as a result of sleep related changes in upper airway muscle function and progressive narrowing of the oropharyngeal lumen. The resulting hypoxia (or asphyxia) leads to an arousal response that terminates the initial obstructive event. The exact incidence and prevalence of OSAS is currently unknown. Lavie (4) concluded its prevalence to be 1.26 percent. Others (5, 6) found that the prevalence of heavy regular snoring (taken as an index of at least a partially obstructed airway) increased with age including 40 percent of women and 50 percent of men over 60 years of age. Polygraphically documented OSAS showed incidence of 0.99 percent in an unselected population. Postmenopausal women have frequent episodes. of OSA in contrast with their premenopausal counterparts, who very rarely have any apnea. Since we could not find in the literature any documented OSAS studies in pregnancy, we would like to base our hypothesis on our previously published clinical observations and our recent findings. In the present paper we would like to suggest that pathophysiologic changes of OSAS prolonged throughout many weeks of pregnancy may have an adverse effect upon the feto-placental unit.

Antagonism of antihypertensive drug therapy in pregnancy by indomethacin

Two women with preeclampsia treated with pindolol and propranolol became profoundly hypertensive when indomethacin was added because of premature contractions. The interaction of nonsteroidal antiinflammatory agents and beta-blockers and their role in the control of blood pressure in obstetrics are discussed. Indomethacin should not be given to pregnant patients with hypertension treated with beta-blockers.

Prevalence of minor congenital anomalies in newborns of diabetic mothers

Minor congenital anomalies (MCA) were assessed in the offspring of 802 gestational diabetic mothers, 117 pre-gestational diabetic mothers, and 380 offspring born to normal mothers. The prevalence of infants with MCA ranged between 19.4% and 20.5% in the three groups without any significant difference between them. There was no correlation between the prevalence and type of MCA and the severity of the diabetic state. Neither was there any correlation between the prevalence or type of MCA and the appearance or type of major congenital anomalies.

Carcinoma of the colon associated with high extragenital production of beta-hCG : a case report

Human chorionic gonadotropin (hCG) is a pregnancy-associated glycoprotein hormone that consists of two different and independently synthesized alpha and beta subunits. It is normally secreted by the syncytiotrophoblast of the placenta, but its levels are also elevated in trophoblastic tumors. Extragenital hCG production has been reported in carcinomas of various organs, including the pancreas, stomach, liver, breast and bladder, as well as in lymphomas and melanomas ( I , 2). Slightly elevated blood levels of beta-hCG have also been reported in connection with nonmalignant diseases, such as inflammatory bowel disease, liver cirrhosis and peptic ulcers (3). The appearance of hCG in a colonic carcinoma is an infrequent occurrence. In most of the reported cases there were only slightly elevated serum hCG levels and positive immunostaining. We present a case of colon carcinoma with unusually high serum levels of beta-hCG and strong immunohistochemical staining.

Roll-over test — errors in interpretation, due to inaccurate blood pressure measurements

In order to make the earliest possible prediction of the type of woman likely to develop pregnancy-induced hypertension (PIH), one hundred and ninety-six primigravidas underwent a roll-over test (ROT) during wk 28-32 of their pregnancy. Blood pressure (BP) readings were taken with a standard 12 cm cuff as well as with cuffs adapted to various arm circumferences. We found that the prediction rate of ROT readings with a standard 12 cm cuff was relatively low (38.5%) as compared with Gants study (94%) (Amer. J. Obstet. Gynec., 120 (1974) 1). When a suitably sized cuff was used, the prediction rate dropped (to 14.7%). Data analysis at term for the whole population of this study shows that, by measuring with a standard 12 cm cuff, 10.2% of the women were found to have PIH, whereas measuring with a suitable cuff showed PIH in only 2.55% of the cases (1:4 ratio). We suggest that the low prediction rates in this and other studies demonstrate that the ROT test is not sufficiently reliable as a tool for predicting which women are liable to develop PIH, but there is definitely enough in it to predict which group will not develop PIH (in this study 89-93%). It has been recommended that ROT be considered only as a test of possible reliability. It should be done according to proper criteria for BP measuring, and a repeat ROT should be considered after several days before starting any kind of treatment.

The importance of cuff width in measurement of blood pressure in pregnancy

Blood pressure was measured indirectly in 218 normotensive primigravidas with arm circumferences ranging from 21.7 to 36.1 cm using three standard blood pressure cuffs. It was found that the medical professions lack of awareness as to the proper use of cuffs in prenatal care may involve 40% of the patients--20% of these have a small arm circumference, will not show a true blood pressure reading, and may fail to get the proper treatment. On the other hand, 20% of these patients who have a rather large arm circumference, may be grouped among those who need special care and attention, and may be given unnecessary treatment--a fact which may bring about clinical complications, unnecessary expense, incorrect statistical data and a misleading demographic impact.

Nonimmune hydrops fetalis — a rational attitude of management

A rational attitude of management of the nonimmune hydrops fetalis (NIHF) is stressed in order to achieve an optimal outcome of both the mother and the newborn. Of the two cases reported, both had an underlying cardiac condition. The first was due to rapid supraventricular tachyarrhythmia and responded favorably to intrauterine medication with digoxin and the subsequent delivery of a well baby. In the second case, cesarean section was performed unnecessarily for a fetal indication, since the hydropic infant died soon after birth from a severe cardiac malformation which was not unequivocally diagnosed prior to birth.

Detachment of posterior uterine cervical lip associated with spontaneous delivery

Various forms of detachment and amputation of the uterine cervix during labor have been described as an unusual and uncommon obstetrical complication (Jeffcoate and Lister, 1952). These cases most probably are not so rare as the few papers dealing with them would suggest. Since most of these papers deal with total amputation (annular detachment) of the uterine cervix and detachment of anterior uterine cervical lip, a case of spontaneous detachment of posterior uterine cervical lip is described.

Long-interval masculinizing Krukenberg tumor of the ovary

Abstract Bilateral Krukenberg tumor of the ovary associated with testosterone production causing masculinization, was detected in a postmenopausal woman who had undergone subtotal gastrectomy for infiltrative adenocarcinoma 8 yr previously. The case described is exceptional in the length of the quiet asymptomatic period of 8 yr between the appearance of the primary tumor of the stomach and the metastatic spread to the ovaries.