Andrew M. Malinow

Increased body mass index has a deleterious effect on In vitro fertilization outcome

AbstractPurpose: Few studies have addressed the effect of weight on IVF outcome, with some showing a decrease in IVF success and some showing no change in overweight women (BMI > 25 kg/m2) compared to women with normal weight (BMI < 25 kg/m2). Methods: One hundred thirty-nine women <40 years old undergoing 180 IVF cycles with fresh embryo transfers were retrospectively evaluated between January 1997 and March 1999, stratified by body mass index (BMI) (cutoff of 25). Results: In the group with BMI > 25 kg/m2, basal FSH, implantation rates (IR), and pregnancy rates (PR) were significantly lower, while the duration of stimulation, gonadotropin requirements, and spontaneous miscarriages were slightly higher, compared to the BMI ≤ 25 group. Conclusions: Excess weight defined as BMI > 25 kg/m2 has a negative impact on IVF outcome. Future prospective studies evaluating oocyte and/or embryo quality, and androgen and insulin levels, between overweight women and those with normal weight are needed.

The effect of fundal pressure manoeuvre on intrauterine pressure in the second stage of labour

Objective To investigate the relationship between intrauterine pressure and the application of a standardised fundal pressure manoeuvre, and to determine the maternal, fetal and labour characteristics that modulate the relationship.

Anticoagulation with argatroban in a parturient with heparin-induced thrombocytopenia

Unfractionated heparin and low-molecular-weight heparin are currently the anticoagulants of choice for the prevention of recurrent thromboembolic disease during pregnancy. However, heparin-induced thrombocytopenia contraindicates the use of unfractionated heparin and low-molecular-weight heparin. We describe a patient who was admitted to our hospital with deep vein thrombosis at 18 weeks of gestation and who developed heparin-induced thrombocytopenia during her antenatal care. Therapeutic anticoagulation was initially achieved with argatroban, then changed to fondaparinux. During early labor, fondaparinux was discontinued and intravenous argatroban was substituted. Argatroban was discontinued during transition to active labor. After return of a normal partial thromboplastin time, combined spinal-epidural analgesia was induced for routine completion of labor and vaginal delivery. We discuss the decisions made in the maintenance of this patients anticoagulation during the peripartum period as well as timing of her neuraxial labor analgesia.

Effect of Epinephrine on Intrathecal Fentanyl Analgesia in Patients Undergoing Postpartum Tubal Ligation

Eighty women receiving spinal anesthesia for postpartum tubal ligation were entered into a double-blind, randomized protocol studying the effects of epinephrine on intrathecal fentanyl-induced postoperative analgesia. All patients received 70 mg hyperbaric lidocaine with either 0.2 mg epinephrine (LE), 10 micrograms fentanyl (LF), epinephrine and fentanyl (LFE), or 0.4 ml saline (L). Onset and regression of anesthesia, degree of intraoperative comfort, incidence of pruritus, and extent of postoperative analgesia were evaluated. The simultaneous administration of epinephrine and fentanyl prolonged the duration of complete analgesia (137 +/- 47 min (LFE); 76 +/- 32 min (LE); 85 +/- 44 min (LF); 65 +/- 36 min (L)) and the duration of effective analgesia (562 +/- 504 min (LFE); 227 +/- 201 min (LE); 203 +/- 178 min (LF); 198 +/- 342 min (L)). Administration of epinephrine decreased the incidence of pruritus associated with intrathecal fentanyl (1/18 (LFE); 1/21 (LE); 8/19 (LF); 2/19 (L)).

Epidural butorphanol-bupivacaine for analgesia during labor and delivery.

A double-blind, randomized, dose-response study of a combination of 0.25% bupivacaine combined with 0, 1, 2, or 3 mg of butorphanol was studied in 40 laboring parturients. The optimal dose of butorphanol combined with 8.5 to 10 ml 0.25% bupivacaine was 2 mg; with 2 mg, the duration of analgesia was significantly greater and the time to onset of analgesia significantly shorter than when no butorphanol was added, and the amount of bupivacaine could be reduced 50%. Adverse fetal effects were not observed except that of a low amplitude sinusoidal fetal heart rate pattern with doses of 3 mg butorphanol. All neonatal observations were normal. It is concluded that epidural butorphanol can be a useful and safe adjunct to bupivacaine used for epidural analgesia during labor.

Predictors of fetal growth in maternal HIV disease

We sought to determine predictors of fetal growth restriction in maternal HIV disease. Pregnant HIV-positive women on antiretroviral therapy were monitored with serial viral load and CD4 counts. Individualized growth potential (GP) percentile was calculated for birth weight (BW). BW <10th GP percentile defined fetal growth restriction (FGR). Multiple medical and social factors, CD4 count, viral load, and antiretroviral therapy were tested for impact on fetal growth using chi-square and multiple regression analysis. Two hundred eleven women were studied. CD4 count <200 in the first trimester was strongly associated with FGR (odds ratio 8.75, 95% confidence interval 2.88 to 26.52). Maternal age ( P = 0.02) and smoking ( P = 0.03) were independent cofactors for FGR (Nagelkerke R(2) = 0.33). No other factors demonstrated an independent effect. Severity of maternal HIV disease as indicated by the CD4 count, rather than placental exposure to viral load, predicts FGR. Smoking has an independent detrimental effect on fetal growth.

Neonatal acid-base status following general anesthesia for emergency abdominal delivery with halothane or isoflurane

STUDY OBJECTIVE To determine whether halothane or isoflurane as anesthesia for emergency abdominal delivery is associated with better fetal acid-base parameters. DESIGN Randomized study. SETTING Inpatient Level III perinatal referral center in a university hospital. PATIENTS Sixty-six gravidas undergoing emergency abdominal delivery under general anesthesia for fetal distress. INTERVENTIONS Randomization to receive halothane or isoflurane at 0.7 minimum alveolar concentration as part of a standard anesthetic technique. MEASUREMENTS AND MAIN RESULTS Umbilical artery and vein blood gases were obtained and compared for hydrogen ion concentration, partial pressure of carbon dioxide, partial pressure of oxygen, and base deficit. There were no significant differences between the isoflurane and halothane groups. CONCLUSIONS There is no difference in the frequency or severity of acidosis associated with isoflurane or halothane when used for general anesthesia for emergency abdominal delivery of a distressed fetus.

Topical nasopharyngeal anaesthesia with vasoconstriction in preeclampsia-eclampsia

We report the case of a 38-year-old eclamptic patient undergoing emergency Caesarean section who required awake nasotracheal intubation because of her massively swollen and lacerated tongue. Vasoconstriction, in addition to topical anaesthesia, was required due to thrombocytopaenia. Theuseof three per cent lidocaine with 0.125 per cent phenylephrine for anaesthesia and vasoconstriction is described with successful maternal and neonatal outcome.RésuméOn rapporte le cas ďune patiente àgée de 38 ans atteinte ďéclampsie devant subir une césarienne ďurgence et requérant une intubation nasotrachéale éveillée à cause ďune lacération et ďun oedème massif de sa langue. Une vasoconstriction était requise à cause ďune thrombocytopénic. Ľutilisation ďune solution de lidocaïne à trois pour cent avec 0.125 pour cent de phényléphrine pour ľanésthésie et la vasoconstriction est décrite amenant une issue favorable tant maternelle que néonatale.

Decreased placental oxygenation capacity in pre-eclampsia: clinical application of a novel index of placental function preformed at the time of delivery

Abstract Objective: We have previously described placental oxygenation capacity as an index of placental function. The aim of this study was to utilize this test to evaluate placental gas exchange capacity in pre-eclampsia and fetal growth restriction (FGR). Study design: Two nested case-control studies were conducted between: (i) pre-eclamptic appropriate-for-gestational-age fetus (AGA) and non-pre-eclamptic AGA; and (ii) pre-eclamptic FGR and non-pre-eclamptic FGR based on gestational age match. Umbilical A-V gas differences were compared between groups. Results: Pre-eclamptic AGA was associated with smaller A-V pO2 and A-V pCO2 differences compared to non-pre-eclampsia (A-V pO2, 7.1±3.8 mm Hg vs. 11.3±5.9 mm Hg, P=0.001; A-V pCO2, 7.8±5.7 mm Hg vs. 10.7± 5.9 mm Hg, P=0.01). Pre-eclamptic FGR was associated with smaller A-V pO2 and A-V pCO2 differences compared to non-pre-eclampsia (A-V pO2, 6.6±3.1 mm Hg vs. 10.8±8.1 mm Hg, P<0.001; 6.7±4.5 mm Hg vs. 10.9±10.3 mm Hg, P=0.044). Pre-eclamptic FGR also had significantly lower venous pO2 but not arterial pO2 (Venous pO2, 20.3±6.3 mm Hg vs. 25.4±11.9 mm Hg, P=0.003). Conclusion: Pre-eclampsia decreases the placental oxygenation capacity as measured by the umbilical arterial-venous oxygen difference.

Carcinoid tumor and intravenous octreotide infusion during labor and delivery

There are limited numbers of reports concerning the management of pregnancy complicated by carcinoid tumors. Octreotide, the synthetic analogue of somatostatin, has been found to be beneficial in preventing the perioperative exacerbation of carcinoid syndrome. We present a case of the successful use of neuraxial analgesia/anesthesia for labor and vaginal delivery in a symptomatic parturient afflicted with carcinoid syndrome, who received an intravenous infusion of octreotide throughout labor and vaginal delivery.