Allen P. Killam

The effect of type of delivery upon neonatal outcome in premature twins

A retrospective study from January 1, 1976, through July 31, 1981, was performed to evaluate the relationship between type of delivery and perinatal morbidity and mortality in twins of birth weight less than 2,000 gm. Vaginally delivered second twins who weighed 601 to 999 gm had increased risk of neonatal mortality when compared to their siblings. Among twins who weighed 1,000 to 1,499 gm, vaginally delivered second twins had significantly lower Apgar score and increased risks of neonatal morbidity in comparison to their siblings, whereas second twins who were delivered by cesarean section had no difference in Apgar score or neonatal morbidity from those of their siblings. In twins who weighed 1,500 to 1,999 gm, a significant increase in neonatal complications in vaginally delivered second twins was not found, although the majority of neonatal complications did occur in vaginally delivered second twins. Cesarean section is proposed as the optimal route of delivery for all twins expected to have a birth weight less than 1,500 gm.

Induced abortion: A risk factor for placenta previa

A threefold increase in the incidence of placenta previa, from one in 318 deliveries (0.3%) in 1972-1974 to one in 109 deliveries (0.9%) in the twelve-month period ending June 30, 1980, was noted at Vanderbilt University Hospital. Two large groups of patients not present in 1972-1974 were found to be responsible for this increased incidence of placenta previa: one-way maternal transports and women who had had induced first trimester abortions. The frequency of maternal transports having placenta previa was 3.3% (p less than 0.0001), and the frequency of placenta previa in women after an induced first trimester abortion was 3.8% (p less than 0.0001). When correction for maternal transports was made, the endogenous induced first trimester abortion population had a frequency of placenta previa of 2.1% (p less than 0.004), whereas the remainder of the endogenous population had an incidence of placenta previa similar to that found in the years 1972-1974. Induced first trimester abortion is seen as a significant factor predisposing to placenta previa.

Elevated serum ferritin in the altered ferrokinetics of toxemia of pregnancy

The serum concentration of ferritin in 11 patients with toxemia of pregnancy was compared to that of normal women in the early third trimester of pregnancy and in labor at term. The mean concentration of ferritin for toxemic patients was 91.8 ng/ml compared to 18.4 ng/ml and 19.4 ng/ml for the two control groups, respectively. The biochemical and physiologic features of ferritin are reviewed, and the relationship between iron and ferritin is discussed. Despite elevated serum levels of ferritin in toxemia, it is noted to be less reflective of the clinical course of the syndrome than serum ion.

Elevated serum iron in toxemia of pregnancy

The records of 144 women with toxemia of pregnancy were evaluated retrospectively for clinical course and clinical laboratory parameters. A striking elevation of serum iron was noted when patients were most seriously ill. There was a prompt return to normal iron values with improved clinical status. The toxemia-associated rise in iron is out of proportion to the increase in other parameters, such as uric acid, blood urea nitrogen, and hematocrit. Possible explanations for this phenomenon are offered.

Altered Ferrokinetics in Toxemia of Pregnancy: A Possible Indicator of Decreased Red Cell Survival

Serum iron concentration was increased in women with toxemia of pregnancy (mean 135 mcg/dl) compared to normotensive parturients (62 mcg/dl) and chronic hypertensive parturients (72 mcg/dl). Mean iron for eclamptics was 203 mcg/dl; for severe preeclamptics, 137 mcg/dl, independent of hepatic or renal function. Recovery to normal postpartum levels occurred in 1-3 days. Concomitant increase in serum ferritin (mean: 59 ng/ml vs. 19 ng/ml for normals) persisted longer. When hepatocellular injury occurred, mean ferritin increased to 421 ng/ml. Increased iron was independent of transferrin concentration. Serum hemoglobin was detectable in 15 of 25 toxemic patients who had elevated serum iron; only 3 of these patients had clinically significant levels. Serum haptoglobin was significantly decreased in 4 of 25 patients. Reticulocyte count averaged 2.5%, with an average hematocrit of 38%. It is hypothesized that serum iron and ferritin increase in response to catabolism of released hemoglobin. The magnitude of iron increase is greater than could be derived from intravascular hemolysis and suggests an extravascular locus.

Assessment of third trimester choline phosphotransferase activity in uncomplicated human pregnancies.

Summary: CDP-choline: 1,2-diglyceride choline phosphotransferase (CPT; EC 2.7.8.2) undergoes a marked surge in activity in human amniotic fluid when assayed from 30 weeks of gestation to term. The activity of this enzyme, plotted against gestational age, follows a highly significant regression correlation from which an equation can be obtained for the prediction of gestational age.Speculation: In addition to its potential use in obstetrics, it is possible that a rapid and inexpensive assay for CPT or phosphatidic acid phos-phohydrolase could be applied to pharyngeal or gastric secretions in neonates. These assays could be used to differentiate between pulmonary surfactant deficiency states and other pulmonary and cardiac disease states.

PRENATAL INTERVENTION FOR CHILDREN WITH IN UTERO EXPOSURE TO MATERNAL DRUG USE. 643

In our Infant Care Project we integrate prenatal, substance abuse, and child services for pregnant women who are abusing drugs and their children. Three groups are identified to study the intervention and the relative contributions of biological and environmental factors: women recruited prenatally (early intervention), those identified postnatally (late), and a matched comparison group with no known drug use.

Epiphyseal Ossification Centers in the Assessment of Fetal Maturity: Sonographic Correlation with the Amniocentesis Lung Profile

The epiphyseal ossification centers of the distal femur (DFE) and proximal tibia (PTE) appear and enlarge during the third trimester of pregnancy. Late in the third trimester, the epiphysis of the proximal humerus (PHE) begins to ossify in some fetuses. Using the amniocentesis lung profile to determine the value of sonographic epiphyseal visualization as a predictor of pulmonary maturity, we studied 50 fetuses prospectively and compared the sonographic epiphyseal findings with results from the amniocentesis lung profiles. Nine fetuses with a visible PHE had a mature amniocentesis lung profile (accuracy of positive prediction = 100%), and then fetuses with an immature amniocentesis lung profile had no visible PHE (conegativity = 100%). Fetuses in which the combined DFE and PTE diameters were greater than 11 mm or in which the DFE and the PTE diameters were similar in size (DFE less than or equal to 1 mm larger than PTE) also yielded positive results. Copositivity and accuracy of prediction of an immature amniocentesis lung profile, on the other hand, were low (22%-25%) for the same epiphyseal parameters. These data suggest that antenatal visualization and measurement of the epiphyseal ossification centers of the fetal knee and shoulder may help to identify fetuses that would have a mature amniocentesis lung profile.

Hydrops Fetalis: Sonographic Evaluation and Clinical Implications

A systematic sonographic evaluation of hydropic fetus is presented, based on 21 cases and a literature review. The clinical implications of fetal ascites with or without anasarca, maternal hydramnios, maternal oligohydramnios, or an abnormally thick placenta are discussed as they relate to fetal outcome. It is concluded that sonography could play a major role in determining the optimal approach to perinatal management of the fetus in hydrops fetalis, and thus contribute to a reduction in the perinatal mortality and morbidity associated with this disorder.

Fetal ascites complicating amniocentesis and intrauterine transfusion

first month were more or less the same in the two groups. Thereafter, differences became apparent. In Group I, 8 IUDs were rejected and 11 were removed; in Group 2, 19 were rejected and 30 were removed. Reasons given by both groups were pain, irregular bleeding, and anxiety. The late complication most frequently complained of was intermenstrual bleeding, with 69 cases in Group 2 and only 22 in Group 1. Irregularity of bleeding in relation to rhythm, days, and amount of flow was seen, with 87 cases in Group 2, and 32 in Group 1. The rate of occurrence of dysmenorrhea, congestive pelvic pain, and pelvic infection as late complications was about the same in both groups. The application of the IUD resulted in greater frequency of difficulties in Group 2 (high socioeconomic level), due perhaps to a lower pain threshold. The effectiveness of the IUD as a contraceptive measure was found to be the same in both groups, but the acceptability was not. Expulsions and requests for removal were much more frequent in Group 2, perhaps because of a smaller uterus or of different psychological attitudes. These preliminary findings cause us to assume that this contraceptive method will be more effective among the lower socioeconomic levels of the population.