Haim Elrad

Effects of Acetylsalicylic Acid Ingestion on Maternal and Neonatal Hemostasis

Abstract In a case–control study, we evaluated the effects of maternal ingestion of acetylsalicylic acid (aspirin) within 10 days of delivery on maternal and neonatal hemostasis. Only one of 34 control maternal-neonatal pairs (3 per cent) had hemostatic abnormalities. In 10 pairs, when maternal aspirin ingestion occurred within five days of delivery, 6 of the 10 mothers and 9 of the 10 infants had bleeding tendencies. Seven maternal-neonatal pairs in which aspirin was ingested 6 to 10 days before delivery were free of clinical bleeding. Among seven other mothers who ingested aspirin in the immediate post-partum period four of the seven (57 per cent) also had impaired hemostasis. Neonatal hemostatic abnormalities included numerous petechiae over the presenting part, hematuria, a cephalhematoma, subconjunctival hemorrhage, and bleeding from a circumcision. Maternal bleeding was confined to excessive intrapartum or post-partum blood loss. We conclude that aspirin should be avoided during pregnancy. If ingest...

DECREASED PROSTACYCLIN PRODUCTION: A CHARACTERISTIC OF CHRONIC PLACENTAL INSUFFICIENCY SYNDROMES

Prostacyclin production in neonates born at various gestational ages (28 weeks to term) was compared with that in neonates born of pregnancies complicated by various acute and chronic placental insufficiency states. Prostacyclin levels were reflected by the amount of conversion of 14C arachidonic acid to 6-keto-PGF1 alpha (the stable end-product of prostacyclin) by umbilical arteries. The uptake of 14C arachidonic acid by the umbilical arteries was also determined, and since this was similar for all groups it was not the cause of the differences noted in prostacyclin production. Neonates born of normal pregnancies had similar levels of prostacyclin production regardless of gestational age. Prostacyclin production was very low in neonates born of pregnancies complicated by chronic placental insufficiency (intrauterine growth retardation, essential hypertension, and pre-eclampsia), but normal with acute placental insufficiency (abruptio placentae). Hence the decrease in fetal prostacyclin production in pre-eclampsia is not related to gestational age; furthermore, it is also seen in other chronic placental insufficiency states.

Fetal pulmonary maturity as determined by fluorescent polarization of amniotic fluid

Abstract A special technique, fluorescent polarization (F.P.) has been used to measure the microviscosity of amniotic fluid. A total of 151 samples of amniotic fluid from 118 patients, both normal and high-risk, were included in this study. The results were compared to L/S ratios and to the neonatal outcomes. The F.P. value was found to decrease as pregnancy progressed, and a value of 0.345 or less was found to be associated with apparent fetal lung maturity. The correlation between the F.P. value and the L/S ratio was good when mature results were compared (L/S >2 and F.P.≤0.345). When the L/S ratio was immature ( 345) developed RDS and three of these died with hyaline membrane disease. In 83 patients delivered within 48 hours of the amniotic fluid sampling, the predictive value of the F.P. increased to 100 per cent but that of the L/S ratio remained 14 per cent.

Trends in prenatal diagnosis of critical cardiac defects in an integrated obstetric and pediatric cardiac imaging center.

OBJECTIVE: Prenatal diagnosis of critical (requiring neonatal intervention) cardiac defects (critical congenital heart diseases (CCHD)) improves survival, yet detection of such malformations is poor. Our institution changed its practice and integrated a pediatric cardiologist into the perinatal team. The purpose of this study was to evaluate how this change affected the rate of detected congenital heart disease (CHD) and the diagnostic accuracy.STUDY DESIGN: Obstetrical ultrasounds of mothers at high and normal risk for fetal CCHD at a single center between 1991 and 2001 were reviewed. Rate of detected CCHD, positive predictive values and false positives were compared before and after pediatric cardiology integration.RESULTS: Between the first and second time periods, the rate of detected CCHD increased from 6.8/1000 ultrasounds to 12.9/1000 ultrasounds (p=0.007), and positive predictive value increased from 75 to 96%.CONCLUSION: Collaboration with pediatric cardiology can significantly improve the rate of detected CCHD. These findings have significant implications for sonographer education and patient care.

McDonald cerclage under pudendal nerve block

OBJECTIVE The purpose of our study was to evaluate McDonald cerclage placement with pudendal anesthesia. Patient pain and hospital charges were analyzed and compared with a control group. STUDY DESIGN This was a prospective, nonrandomized study. Pain was evaluated with a visual analog scale. Two groups were compared with the Student t test. RESULTS Of 69 patients, 20 had cerclage with pudendal anesthesia; 49 served as control and had cerclage with regional anesthesia. There were no statistical differences in pain between the two groups or complications from pudendal anesthesia, and there was a large cost savings. CONCLUSION All 20 patients had McDonald cerclage placed successfully with pudendal anesthesia. McDonald cerclage can be easily and safely placed under pudendal anesthesia, resulting in cost savings and improved use of time and resources for the patient and her physician.

Further investigation on the predictive value of human placental lactogen in high-risk pregnancies

Blood samples were taken from 254 women with pregnancies with various complications and 119 completely normal pregnant women for measurement of serum human placental lactogen (hPL) during the third trimester. The value of this test in the management of these pregnancies was retrospectively evaluated through details of outcome. Serum hPL and urinary estriol were compared as tools for assessment of fetal condition. Serum hPL was found to be very efficient in the prenatal diagnosis of intrauterine growth retardation associated with maternal hypertension. Low hPL levels were recorded in all severely hypertensive patients who were delivered of small-for-dates infants (a 100 per cent prediction rate), while 30 per cent of these patients had normal estriol values. Prediction rate of postmature infants by serum hPL level was 70 per cent as compared to 50 per cent by urinary estriol level. The diagnostic significance of low hPL levels is emphasized, with stress upon its value in early detection of unfavorable intrauterine environment. The importance of preterm deliveries in pregnancies involving intrauterine growth retardation and low hPL levels is discussed and demonstration cases are presented.

Glucagon-induced hypocalcemia in the rat: effects of maturation and insulin.

Summary: In adults of several species including man, a small transient decrease in serum calcium concentration follows glucagon administration in doses of 1 to 10 mg/kg. The effects of maturation and insulin on this phenomenon were assessed by comparing the response of newborn and adult rats to equivalent doses of glucagon with and without prior insulin administration. After injection of 1 μg/g of glucagon, the decrease in serum calcium concentration at 60 min was significant in the newborn rats (-1.75 mg/dl; P < 0.001) and not significant in the intact adults (-0.07 mg/dl; P > 0.1).In pancreatomized adults, the decrease in serum calcium after the same dose of glucagon became significant (-1.23 mg/dl; P ≤ 0.01). This hypocalcemic effect was prevented in the pancreatectomized adult rat if insulin in a dose of 0.01 μg was given 15 min before glucagon. In the newborn rats, the same dose of insulin decreased the hypocalcemic effect, but the change was still significant (-0.74 mg/dl; P ≤ 0.01).Glucagon decreased serum calcium at one hr in newborn rats but not in adults. After pancreatectomy, the adult response to glucagon was significant and similar to that of the newborn. Insulin cancelled this effect of glucagon in the pancreatectomized adults and reduced it in the newborns.Speculation: Hypocalcemia in the neonatal period is a common and probably multifactorial disorder. Glucagon is known to be a hypocalcemic agent; this effect is decreased by insulin. Because insulin secretion is sluggish in the neonatal period, glucagon may have a clinically significant effect on serum calcium concentration at this time.The frequency and severity of hypocalcemia within the first 48 hr of life are increased by prematurity, perinatal trauma, hypoxia, and maternal diabetes (3,10). Functional hypoparathyroidism has been demonstrated in some of these situations (3,10), but not all instances of hypocalcemia can be explained on this basis (3). Inasmuch as neonatal hypocalcemia is evidently a multifactorial disorder, all agents capable of affecting calcium homeostasis deserve consideration. Glucagon can lower serum calcium concentration in a variety of mammals including man (2, 6–9, 11), but no studies of this phenomenon in the neonatal period have been reported. Grajwer el al. (5) have pointed out that a large increase in immunoreactive plasma glucagon occurs within the first two hr after delivery. Because the newborn infant is particularly susceptible to disturbances of calcium homeostasis, we designed the following experiments to test the effects of maturation on the response of serum calcium concentration to exogenous glucagon.

1030 INCREASED PLATELET PROSTAGLANDIN FORMATION IN INFANTS OF DIABETIC MOTHERS

Infants of diabetic mothers have an increased incidence of thrombosis. In an attempt to evaluate the role of the platelet in the etiology of this thrombotic tendency, platelet rich plasma (PRP) from 15 control maternal-neonatal pairs was compared to PRP from 6 pairs in whom maternal diabetes mellitus was present. Platelet Malonyldialdehyde (MDA) formation (n moles per 109 platelets) in the presence of N-ethyl maleimide (NEM) or thrombin was measured as an indicator of platelet prostaglandin synthesis. Control maternal MDA values in the presence of NEM or thrombin were 3.23±0.31 (1SD) and 1.30±0.17 respectively, with control cord blood values being 2.46±0.61 and 0.90±0.19. There was a significant increase in platelet MDA to 3.74±0.49 (NEM) and 1.51±0.35 (thrombin) in the diabetic mothers. This finding was associated with platelet hyperaggregability in 3/6. Platelet MDA formation was also significantly increased in the infants of these diabetic mothers to 3.66±0.53 (NEM). Platelet hyperaggregability was present in 3/6 infants and was absent in all 15 control neonates. Platelet sizing did not differ significantly between the control or patient groups. Platelet prostaglandin synthesis appears increased both in the diabetic mother and her infant. The observed platelet hyperaggregability and increased Prostaglandin synthesis may contribute to the thrombotic tendency in the infant of the diabetic mother.

667 THE EFFECT OF PRENATAL ACETYL SALICYLIC ACID (ASA) INGESTION ON MATERNAL AND NEONATAL HEMOSTASIS

The effect of prenatal ASA ingestion on hemostasis was investigated in 59 maternal-neonate pairs. Group I consisted of 36 control pairs in whom a negative ASA drug history was substantiated by normal maternal and neonatal platelet aggregations and values for the prostaglandin byproduct malonyldialdehyde (MDA). Group II consisted of 16 pairs in whom a positive history for maternal ASA ingestion was confirmed by the expected abnormalities in platelet aggregations and MDA. Group III comprised 7 maternal-neonate pairs where maternal ASA ingestion occurred within 6 hours post partum. All groups were evaluated for hemostatic abnormalities. Maternal blood loss was considered excessive, if a drop of >10% between initial and discharge hemoglobin occurred (vaginal delivery), or >25% (C section). In Group I, no maternal hemostatic abnormalities were noted, although 1/34 neonates demonstrated facial ecchymoses. In 10/16 Group II pairs where maternal ASA ingestion had occurred 0-5 days prior to delivery, clinical evidence of bleeding occurred in 90% (9/10) of the infants, and 60% (6/10) of the mothers. In contrast, in 6/16 Group II pairs, where ASA ingestion had occurred 6-10 days prior to delivery, no abnormalities were found. Group III infants were normal, although 57% (4/7) mothers in this group bled abnormally. ASA ingested in the 5 days prior to delivery, or immediately post partum, is associated with hemostatic abnormalities in both mother and neonate.