Joy D. Steinfeld

Obesity-related complications of pregnancy vary by race.

OBJECTIVE To evaluate racial effects on obstetric complications in obese gravidas. METHODS The obstetric database was reviewed for the period 6/1/94 to 3/31/97. All clinic patients delivering singletons were included. Obesity was defined as a body mass index (BMI) of 29 kg/m2 or more, or a pre-pregnancy weight of 200 pounds or more. Complications studied included hypertension, diabetes, cesarean delivery, and fetal macrosomia. RESULTS Of 2,424 eligible subjects, 168 were obese (6.9%). Obese patients had higher rates of chronic hypertension and pregestational diabetes, as well as increased rates of preeclampsia, gestational diabetes, fetal macrosomia, cesarean delivery, and operative vaginal delivery compared to nonobese patients. Of the obese patients, 105 (63%) were Hispanic, 39 (23%) were African American, and 24 (14%) were White; no Asian or Mixed/Other patients were obese. Mean BMIs of the obese subgroups did not differ (P = 0.14), but prepregnancy weights were greater in Whites than Hispanics (P < 0.002). Obese Hispanics had an increased rate of gestational diabetes (P = 0.04) and of infant weight > or =4,500 g (P =.03). Obese Hispanic and African American women were more likely than obese Whites to deliver by cesarean (P = 0.03). CONCLUSION Racial differences affect the complication rates in obese gravidas, and may influence prenatal counseling and pregnancy management.

The utility of the TDx test in the assessment of fetal lung maturity

Accurate assessment of fetal lung maturity is essential in the management of high-risk obstetric patients. New rapid techniques have been developed to supplement time-consuming chromatographic methods. We compared one of these newer methods, the TDx-FLM, to the standard tests for fetal pulmonary maturity. There was an excellent correlation between the TDx and the lecithin-sphingomyelin ratio (r = 0.78). Although a TDx value of 70 or greater is considered mature, we found a value of 50 or greater predictive of fetal lung maturity in 100% of cases, and have chosen to redefine a mature value as 50 or greater in our institution. This value has greatly enhanced the clinical applicability of the test, allowing use of a large number of specimens from the previously poorly understood and often disregarded borderline category.

Prenatally Diagnosed Sacrococcygeal Teratoma: A Unique Expression of Trisomy 1q

Partial duplication of the long arm of chromosome 1 has been observed in fetal intracranial teratomas. We sonographically diagnosed a 19-week fetus with sacrococcygeal teratoma, cerebral ventriculomegaly, and cerebellar hypoplasia. Chromosomal analysis of amniocytes showed an unbalanced translocation between chromosomes 1 and 15, resulting in trisomy 1q21-->1 qter. Duplication or over expression at more than one locus on the long arm of chromosome 1 may be required for the development of an extra-gonadal teratoma.

INTENTIONAL IRON OVERDOSE IN PREGNANCY—MANAGEMENT AND OUTCOME

The objectives of our study were to 1) determine if peak maternal serum iron level or toxicity stage after intentional overdose is associated with adverse maternal-fetal outcome, and 2) describe the use of deferoxamine antidote therapy in obstetric patients. A computer search of the English language literature from 1966-1998 used the key words iron toxicity, iron poisoning, deferoxamine, and pregnancy to identify peer-reviewed papers reporting intentional iron overdoses in pregnancy. Two investigators independently extracted data from articles and their references including stage of toxicity (0 = asymptomatic, 1 = gastrointestinal symptoms, 2 = metabolic disturbance, 3 = organ failure), with differences resolved by consensus. Statistical analysis used the Student t-test, Fisher exact test, or ANOVA, as appropriate. Fourteen publications were identified, describing 61 cases of obstetric iron overdose, including one recent case at our institution. Compared with women who had lower peak levels, women with peak serum iron levels > or =400 mcg/dL were more frequently symptomatic (12/13 vs. 5/10, respectively, p = 0.05). Peak iron level > or =400 mcg/dL was not associated with increased risk of spontaneous abortion, preterm delivery, congenital anomalies, or maternal death. However, patients with stage 3 toxicity were more likely to spontaneously abort (1/3 vs. 1/56, respectively), deliver preterm (2/3 vs. 6/56, respectively), or experience maternal death (3/3 vs. 0/56, respectively). The proportions of patients treated with deferoxamine and total dosages of deferoxamine were similar by peak iron level (> or =400 vs. <400 mcg/dL) and toxicity stage (0-3). Peak iron levels > or =400 mcg/dL are associated with symptomatic iron overdose. Stage 3 toxicity is associated with spontaneous abortion, preterm delivery, and maternal death.

Plasma concentration of endothelin-1 in women with cocaine-associated pregnancy complications

OBJECTIVE The purpose of this study was to determine if the plasma concentration of endothelin-1 is elevated in pregnant women abusing cocaine and to determine how these levels differ from those in patients with preeclampsia and in women with uncomplicated pregnancies. STUDY DESIGN Plasma endothelin-1 levels were measured in 30 women with acute cocaine intoxication, 32 women with preeclampsia, 14 pregnant women with chronic hypertension, 26 women with uncomplicated pregnancies, and 16 nonpregnant individuals. Serial samples after delivery were obtained in 12 women with preeclampsia, 10 with cocaine abuse, 4 with chronic hypertension, and 7 with uncomplicated pregnancies. RESULTS The mean endothelin-1 concentration in those with cocaine abuse was 18.2 +/- 8.1 pg/ml (95% confidence interval 15.2 to 21.2). This was similar to that in women with preeclampsia (21.1 +/- 5.9 pg/ml, 95% confidence interval 19 to 23.3) (p = 0.2) but significantly different from that in women with chronic hypertension (11.5 +/- 3.6 pg/ml, 95% confidence interval 9.4 to 13.6) (p < 0.001) and women with uncomplicated pregnancies (6.7 +/- 3.9 pg/ml, 95% confidence interval 5.1 to 8.2) (p < 0.001). CONCLUSIONS Endothelin-1 levels in women abusing cocaine are comparable to those in women with preeclampsia and are significantly higher than those in gravid women with chronic hypertension and women with uncomplicated pregnancies. Elevated levels of endothelin-1 may contribute to some of the pregnancy-related complications in women abusing cocaine.

Unexplained elevated midtrimester maternal serum levels of alpha fetoprotein, human chorionic gonadotropin, or low unconjugated estriol: Recurrence risk and association with adverse perinatal outcome

OBJECTIVE To determine if women experiencing an unexplained elevated maternal serum alpha fetoprotein (MSAFP; > or =2.0 MoM) or human chorionic gonadotropin (hCG; > or =2.0 MoM), or low unconjugated estriol (E3; < or =0.5 MoM) in one pregnancy are at increased risk for similar results in a subsequent pregnancy, and to determine if recurrence of these analyte extremes is associated with adverse perinatal outcome. METHODS We identified all women delivering two consecutive singleton pregnancies at one hospital between 1992-1997 for whom second trimester trisomy 21 serum screen was performed in each pregnancy. All screens were performed in a single laboratory. Each pregnancy delivered after 20 weeks and had gestational age confirmed by ultrasound prior to 24 weeks. Subjects were excluded if a fetal anomaly or aneuploidy was present. Adverse outcomes included abruption, oligohydramnios, preeclampsia, preterm membrane rupture, preterm delivery, stillbirth, birthweight <10th centile, and admission to neonatal intensive care unit (NICU). RESULTS A total of 538 women had 1,076 pregnancies meeting inclusion criteria; 12/515 (2.3%) of women with a normal MSAFP, 28/470 (6.0%) with a normal hCG, and 11/504 (2.2%) with a normal E3 in the first pregnancy had an anomalous result for the respective analyte in the second pregnancy. In contrast, only 4/23 (17.4%) patients with an elevated MSAFP (P = 0.003), 14/44 (31.8%) with an elevated hCG (P < 0.001), and 2/10 (20.0%) with a low E3 (P < 0.025) in the first pregnancy had the same analyte anomaly recur in the second pregnancy. The odds ratios for recurrent elevated MSAFP, hCG, and low E3 were 7.5, 5.3, and 9.2, respectively. Adverse perinatal outcomes occurred with similar frequency, regardless of MSAFP, hCG, or E3 results in consecutive pregnancies, using women with normal MSAFP, hCG, and E3 results in one or both pregnancies as controls. CONCLUSIONS Women experiencing an anomalous serum analyte in one pregnancy are at significant risk to experience the same analyte result in a subsequent pregnancy.

Meralgia paresthetica: an unusual complication of post-cesarean analgesia

Intramuscular (IM) injections may be associated with nerve injury, classically the sciatic nerve after intragluteal injection. We describe an unusual injury of the lateral femoral cutaneous nerve following an IM injection of 100 mg meperidine and 25 mg promethazine in the anterolateral right thigh. Although the thigh is advocated as a relatively safe site for IM injection, iatrogenic neuropathy may result. Awareness of the anatomy of the lateral femoral cutaneous nerve and avoiding injections into a partially anesthetized extremity may decrease the likelihood of recurrences.

Fetal triploidy: a unique cause of the stuck twin sign

The stuck twin sign is diagnosed sonographically, when one fetus of a diamniotic gestation resides in a severely oligohydramniotic sac, and appears adherent to the uterine sidewall despite maternal positional changes. The cotwin might be surrounded by normal or increased amniotic fluid. Although cases of stuck twin are often attributed to complications of monochorionic twinning, such as twin-twin transfusion syndrome, clinical evidence rarely supports this conclusion. The following case shows that the stuck twin sign is not pathognomonic for monochorionicity or monozygosity. A novel approach to amniocentesis is a useful adjunct to diagnostic evaluation of the stuck twin.

Twin vaginal birth after cesarean

OBJECTIVE To determine both success rate and maternal-fetal outcome of vaginal birth after cesarean in twin gestations. METHODS We identified all women from a single center attempting vaginal birth of twins after cesarean from 1988-98. Twin pairs were excluded for delivery < or = 25 weeks gestation, monoamnionicity, nonvertex twin A, or major anomaly or death of either twin. Cases were matched to the next three consecutive twin gestations attempting vaginal delivery without a prior cesarean. Variables matched were gestational age at delivery (+/- 1 week), presentations of both fetuses, labor onset (spontaneous or induced), and prior vaginal delivery (yes or no). The primary outcome was successful vaginal delivery of both fetuses. Secondary maternal outcomes included chorioamnionitis, hemorrhage requiring transfusion, hysterectomy, uterine rupture, and length of stay. Neonatal outcomes included one and five minute Apgars, NICU admission, and length of NICU stay. RESULTS Twelve parturients were matched to 36 controls. There were no differences between the groups with respect to maternal demographics, intrapartum variables, fetal genders, birthweights, or chorionicity. Women with a prior cesarean (10/12) delivered both twins vaginally compared to 31/36 parturients without a prior cesarean (P = 1.0). There were no differences between cases and controls with respect to maternal morbidity (1/12 vs 4/36, P = 1.0), or postpartum stay (2.5 +/- 1.0 vs 2.5 +/- 2.3 days, P = .25). Neonatal outcomes were similar by birth order, except that second-born twins of cases had significantly longer NICU stays than controls (22.7 +/- 3.8 vs 10.4 +/- 7.8 days, P = .04). CONCLUSION Twin trial of labor after cesarean is associated with a high success rate of vaginal delivery but may be associated with a more lengthy NICU stay for the second twin.