Björn Westin

Gravidogram and Fetal Growth: Comparison with Biochemical Supervision

Abstract. The perinatal mortality rate at the Danderyd Hospital during 1968–70 (period I, 9 801 births) was 16 per thousand total births. In spite of inadequate resources for fetal heart rate monitoring, intrapartum mortality formed only 11% of perinatal mortality. Antepartum death constituted no less than 42% of the perinatal mortality. The majority of antepartum deaths occurred before admission to hospital and more than 50% were without congenital abnormality. In spite of being intensive the conventional antenatal care was therefore regarded as poor in predicting retarded, or accelerated fetal growth and twin pregnancies. Therefore the gravidogram system was designed for the supervision of pregnancy by means of graphic comparisons between changes in maternal Symphysis‐fundus (SF) distance, girth, weight and blood pressure, and known normal values. Increases of maternal weight, girth and SF‐distances in 100 uncomplicated term pregnancies (50 nulliparae and 50 multiparae) resulting in normal for dates infants (NFD=mean weight ± 1 S.D. for gestational week in question) are presented as means ± 2 S.D. SF‐distance had the smallest coefficient of variation and was therefore selected as an indirect indicator of fetal growth. SF‐curves for 50 large for dates (LFD) and 50 small for dates (SFD) infants were constructed. Already by the 20th week of pregnancy the SF‐growth curve for LFD‐infants differed significantly from that of NFD‐infants (p < 0.0l). The SF‐growth curve for SFD‐infants differed significantly from that of NFD‐infants by the 28th week of gestation (p < 0.01). Antenatal screening was performed by SF‐tape measurements (mean ± 1 S.D.) in a consecutive series of 428 women delivered between 37th and 42nd week of pregnancy. When SF‐growth charts were normal 80–84% of infants were NFD. The number of infants detected in this way comprised 64% of all NFD‐infants, which is close to statistical expectation. When SF‐growth charts were above the normal (> mean +1 S.D.) 65% of all LFD‐infants were correctly predicted. Similarly when SF‐growth charts were below normal (< mean −1 S.D.), static ordeclining, 75% of all SFD‐infants were predicted. SF‐growth charts were analysed in 69 twin pregnancies and the clinical diagnosis improved from the wellknown 50% level to 86%. If SF‐values greater than the mean +2 S.D. (NFD‐singleton) were considered as suspicious of twin pregnancy this suspicion could be confirmed in all but one case (99%). Average time for suspicion of a twin pregnancy was 24±4 (1 S.D.) gestational weeks. Human placental lactogen (HPL) and urinary estriol (U‐estriol) were determined 2–3 times weekly during third trimester in pregnancies resulting in LFD‐infants (n = 19) and SFD‐infants (n = 29). SF‐measurements were superior both to HPL and U‐estriol in detecting accelerated and retarded fetal growth. After the introduction of the gravidogram there was a prompt and persistent fall in the uncorrected perinatal mortality rate to 8.0 per thousand total births in the last 12 800 births. A normal SF‐growth curve implies normal fetal growth and the risk of intrauterine death from fetal growth retardation is practically nil. Biochemical and sonographic fetal supervision can therefore be limited to cases where the SF‐growth chart deviates from normal. The perinatal mortality in Sweden and at the Danderyd Hospital during the period 1961–1975 are compared and discussed.

A Technique for Perfusion of the Previable Human Fetus

A perfusion technique of the previable human fetus is described in detail. The fetuses survived 5–12 hours. ECG, blood pressure, and blood flow were recorded simultaneously. Examples of the oxygen consumption of hypo‐ and normo‐thermic fetuses are presented.

Hypothermia and transfusion with oxygenated blood in the treatment of asphyxia neonatorum.

body surface area in every instance, thus being normal. No correlation between the cardiopulmonary hemodynamics and the crea tinine clearance could be demonstrated. Preoperatively a high filtration fraction was frequently observed in cases with pulmonary hypertension or with shunts exceeding 40 % of the left ventricular output. A positive correlation existed between the shunt through the ductus and the filtration fraction. There was also a slight correlation between the pulmonary arterial pressure and the renal filtration fraction. Postoperatively the para-amino-hipcame entirely normal in the children with a normal pulmonary arterial pressure. In the group which before operation had pulmonary hypertension, the effective renal plasma flow and the renal fraction of the systemic blood flow remained at the lower limits of normal, and the filtration fraction was, on an average, still slightly above normal even postoperatively. However, the last postoperative investigation showed in three of these cases recanalization of the ductus. A high filtration fraction is necessarily not a sign of renal vascular disease. Increased tone in the efferent glomerular purate clearance and the renal fraction of arterioles seems to be of importance in the peripheral blood flow increased in maintaining a normal glomerular filtramost of the cases. The high filtration tion rate in children with patent ductus fraction decreased, on an average, and arteriosus despite decreased blood supply the creatinine clearance remained unto the kidneys. changed. Thus, the renal circulation be-

Fetal heart rate response to acoustic stimulation in relation to fetal development and hearing impairment

In twelve healthy pregnant women the fetal heart rate response to sound stimulation was tested every second week between the 22nd and the 34th week of the pregnancy. Habituation to the acoustic stimuli used was also investigated at the last examination. A high risk material for hearing impairment comprised 31 pregnant women.

Evaluation of a Feto-Pelvic Scoring System in the Management of Breech Presentations

Abstract. A feto‐pelvic scoring system comprising maternal pelvimetric data, estimated fetal weight, type of breech presentation and previous obstetric history was used in selecting patients for cesarean section or vaginal delivery. A maximum score of 20 points was possible. Twelve points or less indicated cesarean section. During 1973–1975 224 singleton breech deliveries were evaluated. In 29.5% cesarean section was performed and in 83% of these it could be planned in advance. In 70.5% of cases, patients were allowed to deliver vaginally under continuous electronic monitoring of the fetal heart rate. There was one intrapartum death and only one early neonatal death of a small premature child. In two cases intrauterine death had occurred already in the antepartum period. The uncorrected perinatal mortality was 17.9 per 1000 but not significantly different from the uncorrected perinatal mortality of 8.0 per 1000 for all patients delivered at the Danderyďs Hospital during the period 1972–1975 (12832 births). The corrected mortality resulting from breech presentation was 8.9 per 1000. The infants exhibited similar and excellent 5 min Apgar scores whether delivered vaginally or by cesarean section or matched with a randomized control series of 1000 cephalic presentations.

Transmission of Rapid Pressure Increase from the Peritoneal Cavity to the Bladder

The peritoneo-vesical transmission of pressure was estimated by simultaneous registration of the intraperitoneal and the intravesical pressure in women in connection with laparoscopy. Irrespective of the basal intraperitoneal pressure, the transmission was found to average 98%.

Fetal heart rate pattern before and after paracervical anesthesia

A prospective study of the fetal heart rate pattern during labor before and after paracervical blockade (PCB) was performed. The material comprised 469 women in labor, or 28% of 1 673 women delivered during a 6‐month period. The majority of the anesthesias (87%) were administered by specially trained midwives. Bupivacain (Marcain) was the anestethic used. The injections were made at four different points at a cervical diameter of 3 − 9 cm. The concentration of the anesthetic was 0.25 or 1.25% generally in 10 ml of normal saline. A second PCB was administered in 54 patients at least one hour after the preceding one. Fetal heart rate (FHR) was recorded via a scalp electrode and the pattern studied 15 min before and 30 min after the injection of the anesthetic. Bradycardia was defined as a persistent deceleration exceeding 3 min and occurring within 30 min of the PCB. Variability and acceleration pattern persisted independently of the PCB. Following PCB, decelerations of all types increased, while the basal rhythm decreased by on average 1.5 beats/min. Following PCB fetal bradycardia occurred in 1.9%. The bradycardia persisted on average for 6.5 min with a lowest average FHR of 73 beats/min. Retrospectively, 6 out of 9 infants exhibited recognized risk factors for bradycardia. All infants with bradycardia scored 9‐10/5 min, according to the Apgar rating scale and all had a normal development with regard to growth, motor and speech development at the age of 2 years. There were no significant differences in vaginal operative deliveries between the PCB and the non‐PCB group. However, the incidence of acute cesarean section was significantly and appreciably lower in the PCB than in the vaginally delivered non‐PCB group. Judging by the Apgar rating scale the general condition of the infants at birth was significantly better in the PCB than in the vaginally delivered non‐PCB group. In conclousion: Apart from a 2% incidence of fetal bradycardia following PCB, no untoward effects have been observed. The incidence of acute cesarean section was lower and the general condition of the infants better in the PCB than in the non‐PCB group. Adequate teching of the technique, contra‐indications to PCB and the side effects of the anesthetic agent are needed. Thereafter, it would seem appropriate not only that doctors but also specially trained midwives should be able to use paracervical blockade in order to alleviate pain during the first stage of labor.

Hypothermia in the resuscitation of the neonate: A glance in my rear‐view mirror

Recent research indicates that the outcome of perinatal hypoxia‐ischaemia can be improved by hypothermia. This was actually first observed about 40 years ago, as discussed in this article. Clinical application of whole‐body hypothermia in the asphyxiated neonate showed a positive effect. Reference is made to previous review articles on the subject. A large experimental study indicated that the degree of protection against hypoxic‐ischaemic damage, as judged by the conditioned avoidance response, was dependent on the fall in body temperature. The earlier reported resistance against hypothermia in the asphyxiated neonate is discussed and analysed.

I. One type of mesenchymal cell in the early stages of development of the spleen

PTA and lead hydroxide selectively stain particular structures in the cytoplasm of mesenchymal cells of the human embryo spleen. In the majority of the elements, these structures are represented by vesicles 100–200 mμ in diameter containing dense homogeneous material and mostly arranged in clusters close to ergastoplasmic cisternae. The vesicles can be observed also at the cell cortex and released in the tissue spaces where they appear in close association with collagen fibrils. At the conventional microscopy level, the clusters of vesicles are observed as PAS- and silver-positive granules. The material inside the vesicles appears to be a carbohydrate—protein complex, and its release in the interstitium seems to be related to the fibrillogenetic activity of the cells. In the few mesenchymal cells around the endothelium of arterial vessels, PTA and lead hydroxide bring in evidence prominent aggregates of highly dense, PAS- and silver-positive, material considered to represent a precursor of elastin.

DETERMINATION OF SODIUM AND PHOSPHORUS IN HUMAN CERVICAL MUCUS WITH ACTIVATION ANALYSIS

The technique for the determination of the sodium and phosphorus in human cervical mucus with activation analysis is described. The amount of Na was found to be relatively constant but the amount of P was directly correlated to the amount of dry substance. (auth)