G. D. V. Hankins

Peripartum heart failure: Idiopathic cardiomyopathy or compounding cardiovascular events?

During a 12-year period, when more than 106,000 women were delivered, 28 women with peripartum heart failure of obscure etiology that initially was diagnosed as peripartum cardiomyopathy were studied. None had obvious underlying cardiac disease or iatrogenic fluid overload, and in all an assiduous search for underlying cardiovascular disease was launched. In 21 of these 28 women, heart failure was attributed to chronic underlying disease (chronic hypertension in 14, forme fruste mitral stenosis in four, and morbid obesity in one) or viral myocarditis. Importantly, these women also had multiple compounding cardiovascular factors--preeclampsia, cesarean section, anemia, and infection--which, when superimposed on those of pregnancy, acted in concert to cause heart failure. In seven women, the cause for cardiomegaly and global hypokinesis was not found, and peripartum cardiomyopathy was diagnosed. Compared with women with explicable causes of peripartum heart failure, these women did poorly: six had persistent cardiomegaly and heart failure, and four of these died within four months to eight years. From these observations, the authors conclude that idiopathic peripartum cardiomyopathy is uncommon, and that in most women with peripartum heart failure of obscure etiology, underlying chronic disease will be identified. Heart failure in these women ensues when the cardiovascular demands of normal pregnancy are amplified further by common pregnancy complications superimposed upon these underlying conditions that cause compensated ventricular hypertrophy.

Prolactin levels in umbilical cord serum and its relation to fetal adrenal activity in newborns of women with pregnancy-induced hypertension

ABSTRACT. The effect of hypertension in pregnant women on fetal maturation is an issue of considerable importance. Because of a possible role of prolactin in fetal adrenal steroidogenesis and in fetal lung maturation, we have investigated the relationship between hypertension in pregnant women and levels of prolactin and dehydroepiandrosterone sulfate in serum of newborn infants. It was found that with the mild-to-moderate form of pregnancy-induced hypertension (PIH), there was little effect on prolactin levels in newborn serum. In newborns of women with severe PIH, however, serum prolactin levels were significantly greater (p < 0.01) than those in newborns of women with uncomplicated pregnancies. Conversely, umbilical serum concentrations of dehydroepiandrosterone sulfate in newborns of women with severe PIH were significantly less (p < 0.05) than those in newborns of women with uncomplicated pregnancies. These findings are supportive of the view that pituitary function and adrenocortical function of fetuses of women with PIH are different from those of fetuses of normotensive women. These findings are suggestive that PIH alters the function of the fetal pituitary and adrenal cortex.

Early repair of episiotomy dehiscence

Early repair of episiotomy dehiscence was performed in 22 women with an initial fourth-degree episiotomy, four with third-degree episiotomy, and five with a mediolateral episiotomy. Early complications were limited to development of a pinpoint rectovaginal fistula in two women, both subsequently repaired by a rectal mucosal flap procedure. Of the 27 women now 1 year or more post-repair, all are completely continent and report resumption of normal coital activity.

Thyrotoxicosis complicating pregnancy

During the 12-year period from 1974 through 1985, nearly 120,000 women were delivered of infants at Parkland Hospital, and pregnancy was complicated by overt thyrotoxicosis in 60 of them (1:2000). Initial treatment was based on clinical assessment, and propylthiouracil was usually given in doses of 300 to 800 mg daily. In compliant women seen by midpregnancy, euthyroidism was achieved by a mean of 8 weeks; however, the daily dose was decreased to less than or equal to 150 mg by delivery in only 10%. Metabolic status at delivery correlated directly with pregnancy outcome, and women treated earlier in pregnancy were more likely to be euthyroid at delivery and to have good outcomes. Diagnosis of thyrotoxicosis antecedent to pregnancy was associated with earlier treatment, and 80% of 28 such women were euthyroid by delivery. Conversely, 32 women with a first diagnosis during pregnancy had the preponderance of morbidity, including five of six stillbirths and six of seven cases of heart failure. This group was characterized by a relative delay in gestational age at diagnosis. Preterm delivery, perinatal mortality, and maternal heart failure were more common in women who remained thyrotoxic despite treatment and in those who were never treated. Although we infrequently achieved maintenance doses recommended by most, because there were minimal adverse effects from therapy described here and because uncontrolled thyrotoxicosis caused significant maternal and perinatal morbidity, aggressive medical therapy seems appropriate, especially when pregnancy is advanced.

The ‘less than optimal’ cytology: Importance in obstetric patients and in a routine gynecologic population

Objective: To determine whether patients with less than optimal Papanicolaou tests constitute a low-risk group for developing subsequent abnormalities and thus do not need early repeat screening. Methods: For the 10-month period October 1989 to August 1990, all screening Papanicolaou tests were classified by the 1988 Bethesda System. Tests designated as less than optimal solely on the basis of lack of an endocervical component were the subject of the study. Prenatal patients with less than optimal tests had repeat tests at the postpartum visit (delayed-repeat group), whereas gynecologic less than optimal tests were repeated within 4 weeks (early-repeat group). The frequency of cytologic abnormalities in our routine gynecologic population was compared with that for both the delayed- and early-repeat testing groups. Results: The less than optimal rate in obstetric patients was 10.2% (153 of 1492), which was significantly higher than the 5.6% rate (473 of 8411) in the routine gynecologic population (P<.0001). The rates of dysplasia or combined abnormalities (dysplasia, human papillomavirus, or atypia) in the delayed-repeat group did not differ significantly from those in the routine gynecologic population (P=.69 and P=.33, respectively). However, the rates of dysplasia or combined abnormalities were significantly lower in the early-repeat group than in the routine gynecologic population (P=.02 and P=.003, respectively). Conclusions: Less than optimal cervical cytologies occurred almost twice as often in obstetric as in gynecologic patients. Prenatal less than optimal test results were not associated with important cervical pathology, and repeat testing may safely be deferred until postpartum. In addition, early repeat testing in gynecologic patients is a lowyield procedure.(Obstet Gynecol 1993;81:127-30)

Nuchal Cords and Neonatal Outcome

To assess the significance of nuchal cords, 110 affected woman-infant pairs at term gestation were compared with 110 control pairs. Newborns with a nuchal cord had an increased prevalence of umbilical artery acidemia (22 of I10 versus 13 of 110; P < .05) and more variable fetal heart rate (FHR) decelerations in the first stage of labor (mild = 41 versus 20; P < .0001; moderate-severe = 21 versus 5; P < .0001) and the second stage of labor (moderate-severe = 46 versus 21; P < .0001). In newborns with a nuchal cord, the umbilical artery acidemia was usually mixed (68%) or respiratory (23%) in origin, and pure metabolic acidemia was infrequent (9%). We conclude that nuchal cords are associ- ated with an increased prevalence of variable FHR deceler- ations in the first and second stages of labor and with an increased incidence of umbilical artery acidemia.

The effect of oxytocin infusion on the pharmacokinetics of intramuscular magnesium sulfate therapy

The effect of oaytocin infusion on the plmnuacokinetics of intramMcahr magnesium Solf8te therapy Blos JD; Hankins GDV; Hauth JC; Gilstrap LC III USAF, MC. WiIford Hall USAF Medical Center/SGHPG, Lackland AFB, TX 78336-5300. USA AM. J. OBSTET. GYNECOL.; 157/l (156160)/1987/ The effect of oxytocin infusion on the pharmacokinetics of standard intramuscular magnesium sulfate therapy was determined in 18 women with preeclampsia; the results were compared with those in seven women with preeclampsia who did not receive oxytocin. Oxytocin had no significant effects on the maternal serum magnesium and calcium ion concentrations, nor did oxytocin appear to affect the magnesium or calcium concentrations in fetal umbilical cord blood. Urinary excretion of magesium rose 21-fold and calcium excretion rose threefold in patients receiving intramuscular magnesium sulfate in both the oxytocin and the noncytocin groups. Sixty-five percent of the administered magnesium was excreted during the treatment period. again with no significant differences between the oxytocin and the nonoxytocin groups. These results indicate that oxytocin does not affect the pharmacokinetics of intramuscular magnesium sulfate and no dosage adjustment of magnesium sulfate is required when oxytocin is used to induce or augment labor or when it is given during the postpartum period.

Pulmonary injury complicating antepartum pyelonephritis

Over a 7-year period, 15 pregnant women admitted to Parkland Memorial Hospital for acute pyelonephritis developed respiratory insufficiency characterized by dyspnea, tachypnea, hypoxemia, and radiographic evidence of pulmonary infiltrates. Clinical manifestations usually appeared 24 to 48 hours after the patient was admitted and varied from mild respiratory distress to pulmonary failure in three; these three required tracheal intubation and mechanical ventilation. We found no evidence that pulmonary edema was caused by intravenous fluid overload. Oxygen therapy and ventilation were given to maintain the arterial PO2 at 80 mm Hg or greater, and erythrocyte transfusions were given to six women to correct anemia. Women with pulmonary injury were more likely to have multisystem derangement than a control group without respiratory involvement, but there were no clinical risk factors that were predictive at admission. This syndrome was probably caused by permeability pulmonary edema, likely mediated by endotoxin-induced alveolar-capillary membrane injury since other evidence of endotoxemia was common. Thrombocytopenia, hemolysis, intravascular coagulation, renal dysfunction, and transient cardiomegaly concomitant with hyperdynamic ventricular function are all explicable from endotoxin effects.

Effect of Type of Anesthesia on Blood Loss at Cesarean Section

Halogenated anesthetic agents have been used to supplement nitrous oxide during balanced general anesthesia for cesarean delivery to decrease maternal awareness. However, these agents can interfere with uterine contractility and hence have the potential to increase blood loss at the time of cesarean section. To ascertain the effect of the addition of halogenated anesthetic agents for cesarean section anesthesia versus conduction or a simple balanced general anesthetic, we retrospectively assessed three aspects that may reflect operative blood loss at the time of cesarean section. Significantly more women whose balanced general anesthesia for cesarean section was supplemented with a halogenated agent (usually 0.5% halothane) versus those with a conduction or balanced general anesthetic required transfusion therapy, had a postpartum hematocrit less than 30 vol % and had a decrease in the pre- to postdelivery hematocrit of at least 8 vol %. The addition of halogenated anesthetic agents to a balanced nitrous oxide anesthesia for the purpose of decreased maternal awareness must be weighed against the risk incurred from the increased requirement for blood replacement and/or from postpartum anemia.