K.S. Karam

Preoxygenation of pregnant and nonpregnant women in the head-up versus supine position

The influence of preoxygenation in the supine (n = 10) versus the 45 degrees head-up (n = 10) position on the duration of apnea leading to a decrease in arterial oxygen saturation to 95%, as monitored by pulse oximetry, was investigated in 20 women undergoing elective cesarean section at term of pregnancy. The results were compared with those obtained in a control group of 20 nonpregnant women. In the supine position, the average time to desaturation to 95% was significantly shorter in the pregnant group (173 +/- 4.8 s [mean +/- SD]) than in the control group of nonpregnant women (243 +/- 7.4 s). Using the head-up position resulted in an increase in the desaturation time in the nonpregnant group (331 +/- 7.2 s) but had no significant effect in the pregnant group (156 +/- 2.8 s). We conclude that pregnant women desaturate their arterial blood of oxygen more rapidly than do nonpregnant women. Furthermore, the head-up position extends the duration of apnea that can take place before desaturation occurs in nonpregnant patients.

Imperforate hymen : report of an unusual familial occurrence

Background: Although imperforate hymen occurs in approximately 0.1¶ of female newborns, familial occurrence of imperforate hymen has been reported only once. Cases: We report two families in which imperforate hymen was diagnosed in three siblings of each family. One family is described in detail; the patients were two postmenarchal young women and one premenarchal girl. Conclusion: Imperforate hymen usually occurs sporadically but can be familial. We advise screening all female newborns and children for vaginal patency, especially family members of an affected child. Identification of other families with a similar problem might point to a specific mode of inheritance.(Obstet Gynecol 1993;82:655-6)

Ear length: a potential sonographic marker for Down syndrome.

OBJECTIVES: The purpose of this study was to determine if antenatal sonographic determination of fetal ear length is a useful screening method for identification of fetuses with Down syndrome. METHODS: Ear length measurements were recorded in 418 fetuses undergoing ultrasound scanning between 20 and 28 weeks of gestation. Four trisomy 21 and six trisomy 18 fetuses were identified by karyotyping. The relationship between ear length and gestational age in the normal population was determined by linear regression analysis: expected ear length = −6.000 + 1.075 gestational age. The ability of measured‐to‐expected ear length cut‐off ratios to discriminate between affected and non‐affected fetuses was assessed. RESULTS: The mean ear length and measured‐to‐expected ear length ratios were significantly lower in the affected group as compared to the normal one. A measured‐to‐expected ear length ratio of less than 0.8 was 75.0% sensitive and 98.8% specific in detecting Down syndrome fetuses, and resulted in an 8.5% positive predictive value in the general population. CONCLUSIONS: This preliminary study suggests that antenatal ear length measurements might be a promising sonographic screening method for the detection of Down syndrome in the second trimester of pregnancy.

Onset of vecuronium neuromuscular block is more rapid in patients undergoing Caesarean section

This investigation was carried out in ten patients undergoing elective Caesarean section and the results were compared with those of a control group of ten nonpregnant females of the same age group. The study investigated the onset of vecuronium neuromuscular block and the conditions of tracheal intubation when ketamine (1.5 mg · kg−1)-vecuronium 100 μg · kg−1) sequence was used for rapid-sequence induction of anaesthesia. The ulnar nerve was stimulated supra-maximally at the wrist with train-of-four stimuli every 20 sec, and the electromyographic response of the adductor pollicis muscle was displayed. The onset of 50% neuromuscular block as monitored by electro-myography was shorter in the Caesarean group (80 ± 30 sec) than in the control group (144 ± 43 sec). The conditions of intubation at 50% block were adequate in both groups. Also, the onset of 90% block was shorter in the Caesarean group. The time of recovery to T1/control ratio of 25% was longer in the Caesarean group (46 ± 10 min) than in the control patients (28 ± 10 min). The results show that administration of vecuronium according to body weight results in a more rapid onset and delayed recovery of neuromuscular block in pregnant women undergoing Caesarean section than in the nonpregnant control patients.RésuméCette étude fut conduite chez dix patientes devant subir une césarienne élective et les résultats furent comparés à un groupe contrôle de dix patientes non gravides ayant le même âge. Cette étude investigue l’installation du bloc neuromusculaire après vécuronium et les conditions d’intubation trachéale à la kétamine (1,5 mg · kg−1)-vécuronium (100 μg · kg−1) qui ont été utilisés pour une induction rapide de l’anesthésie. Le nerf cubital fut stimulé de façon supramaximale au niveau du poignet avec l’ondée-de-quatre (train-of-four) chaque 20 sec, et la réponse électromyographique de l’adducteur du pouce enregistrée. L’installation de 50% du bloc neuromusculaire, tel que démontré par électromyographie, fut plus courte dans le groupe césarienne (80 ± 30 sec) que le groupe contrôle (144 ± 43 sec). Les conditions d’intubation à 50% de bloc furent adéquates dans les deux groupes. Aussi, l’installation d’un bloc à 90% était plus court dans le groupe césarienne. Le temps de récupération pour un rapport T1/contrôle de 25% était plus long pour le groupe césarienne (46 ± 10 min) que le groupe contrôle (28 ± 10 min). Les résultats démontrent que l’administration de vécuronium selon le poids amène une installation du bloc neuromusculaire plus rapide et une récupération plus tardive chez les patients devant subir une césarienne que celles non gravides du groupe contrôle.

Postmortem cesarean section following maternal blast injury: case report.

We report a postmortem cesarean section resulting in fetal survival, performed 25 minutes after maternal blast injury. The time interval between cardiopulmonary arrest and delivery, prior maternal health status, and continued cardiopulmonary resuscitation represent important determinants of fetal survival. Improvement in maternal hemodynamic condition may potentially occur following the procedure. Postmortem cesarean section is advised in the event of fatal maternal trauma since it may result in fetal salvage.

FEMUR FRACTURE DURING CESAREAN BREECH DELIVERY

by one of the authors (Z.P.), which permits differentiation of 100 subgroups after a double-digit identification of the chapter [l]. Four possible intrauterine death types are differentiated according to whether death has occurred at or outside the institute and prior to or during labor. Infantile death occurring within 1 week, 1 month or 1 year after birth are recorded separately. Besides taking note of the unit performing the pathological test we indicate the character of the samples the object of the test (yolk sack, chorion, amnion, embryo, fetus) and its findings, and any alterations in the embryo/fetus, placenta, amnion and the umbilical cord. The data describing pre-, periand postnatal events in more than 60 thousand pregnancies have been secured with assistance from the geneticjteratologic, obstetric, neonatal and pathological units in the three counties and have been organized into a database maintained daily on an IBM compatible AT computer. This computer registry is based on personal identification numbers of the Hungarian citizens, allows easy storage and access to the course and outcome of a large number of pregnancies, the data from prenatal screening programs and the disorders of fetuses/newborn infants as well as to follow-up examinations. We have introduced a personal ID control code into the database which

Hypergonadotropism with pregnancy

lenge test produced normal results. The serum estriol level at Khalid M. Ataya, M.D., Fuad Mudawwar, M.D., 35.5 weeks’ gestation, was I rig/ml. Two subsequent daily Charles Allam. M.D.. and Karam Karam, M.D. serum estrioi levels were 0. A; amniocentesis the lecithin/ sphingomyelin (L/S) ratio was 1.9 and no phosphatidylglycerol was present. A repeat nonstress test was reactive. Additional evaluation included a nonreactive VDRL test and negative toxoplasmosis culture, cytomegalovirus amniotic fluid culture, and antinuclear antibody titer. At 36 weeks, 5 days, on the seventh day of hospitalization, a repeat amniocentesis was performed, and the L/S ratio of 2.1. The fetus was noted to be in a transverse lie. .4 primary low-vertical cesarean section was performed with the patient under general anesthesia. The bicornuate uterus was noted at the time of operation with the pregnancy primarily located in the left horn with septal implantation. A 1.900 gm female infant was delivered, and Apgar scores were 5.5, and 8. No meconium was present. The small-for-gestational age infant (less than tenth percentile) recovered well without evidence of respiratory distress syndrome. A modified Dubowitz examination was consistent with 35 weeks‘ gestation. No congenital anomaly was noted. The infant’s neonatal course was benign. The patient was discharged on the sixth postoperative day after a benign course. Departments of Obstetrics and Gynecology, Pediatrks, rind Path.ology, The American Universi~ of Bcinrt .Mediru/ Cmter. Beirut, Lebanon

Reproductive outcome following abdominal metroplasty

Objective: To evaluate pregnancy outcome following uterine unification procedures in patients with uterine anomalies. Methods: A retrospective survey included all abdominal metroplasty procedures performed on 43 patients at the American University of Beirut Medical Center between January 1, 1974 and December 31, 1991. Age at metroplasty, type of anomaly and surgical procedures, as well as preoperative and postoperative reproductive performance were all recorded. Results: Forty (93%) out of 43 patients who underwent metroplasty had postoperative live births compared with five (12%) prior to surgery. The fetal wastage rate dropped from 93% pre‐ to 16% postoperatively. All seven patients with a history of primary infertility conceived and had live births. Conclusion: Our data suggest a remarkable improvement following abdominal metroplasty in patients with both typical and uncharacteristic preoperative reproductive performance.

High-velocity penetrating wounds of the gravid uterus: Review of 16 years of civil war

Objective: To evaluate the value of selective laparotomy in pregnant women with penetrating abdominal injuries. Methods: A retrospective survey was carried out at our center over 16 years of civil war, extending from 1975 to 1991. Fourteen pregnant women had uterine injuries secondary to high-velocity abdominal penetrating trauma. The corresponding management was evaluated carefully with respect to maternal and fetal outcomes. Results: Two maternal deaths occurred, neither resulting solely from intra-abdominal injuries. Visceral injuries were present when the entrance of the missile was in either the upper abdomen or the back. When the entry site was anterior and below the uterine fundus, visceral injuries were absent in all six women upon surgical exploration. Perinatal deaths occurred in half of the cases and were due to maternal shock or uteroplacental or direct fetal injury. Immediate cesarean delivery was performed because of either limited surgical field exposure, fetal injury, or distress. Three patients explored were managed by delaying delivery. All later delivered vaginally with successful fetal outcomes in all three. Conclusion: Selective laparotomy may be considered in pregnant women with anterior penetrating abdominal trauma, as the likelihood of intra-abdominal injuries may be predicted based on the location of the penetrating wound. (Obstet Gynecol 1994;83:259-64)

Conservative management of pelvic spleen

Adnexal tumors tend to originate from the female genital tract [l]. However, a rare occurrence of an adnexal mass can be due to a pelvic spleen. Surgical removal is recommended to avoid torsion and rupture [2,3]. We report a case of a pelvic spleen that was left in situ with no complications over a 15-year period. Our patient was a 21-year-old nulliparous female who was noted to have an asymptomatic left adnexal mass on routine examination. Pelvic ultrasound confirmed the presence of a 9 x 9 cm solid mass in the left adnexal region. She had been maintained on oral contraceptive pills for 6 months. At laparotomy, the uterus, ovaries and tubes were normal. A large red mass located posterior to the uterus was attached to a long pedicle originating from the left upper quadrant of the abdomen. Palpation of the other abdominal organs was normal. The diagnosis of ectopic pelvic spleen was made. It was not resected, however, as