Laurence Burd

Prophylactic red-cell transfusions in pregnant patients with sickle cell disease. A randomized cooperative study.

Prophylactic blood transfusion has come to be regarded as necessary in the treatment of patients with sickle cell disease during pregnancy. Because of the risks associated with blood products and reports of successful outcomes without the use of blood transfusion, we conducted a prospective randomized controlled study of this issue. Seventy-two pregnant patients with sickle cell anemia were randomly assigned to one of two treatment groups: 36 received prophylactic transfusions of frozen red cells, and 36 received red-cell transfusions only for medical or obstetric emergencies. Twenty-eight patients with sickle cell anemia who did not qualify for randomization (mainly because they had other medical disorders), 66 with sickle cell-hemoglobin C disease, and 23 with sickle cell-beta-thalassemia were also followed and received transfusions only for emergencies. There was no significant difference in perinatal outcome between the offspring of mothers with sickle cell disease who were assigned to treatment with prophylactic transfusions and those who were not (15 vs. 5 percent). The occurrence of a perinatal death in a previous pregnancy and the presence of twins in the present pregnancy were two major risk factors for an unfavorable outcome; when they were present, perinatal mortality was 50 percent. Perinatal mortality was somewhat higher in the two groups that were randomized than in the three groups that were not. Prophylactic transfusion significantly reduced the incidence of painful crises of sickle cell disease (P less than 0.01) and substantially reduced the cumulative incidence of other complications of this disorder (P = 0.07). Other medical and obstetric complications occurred with nearly equal frequency in the two randomized groups. Increases in costs, the number of hospitalizations, and the risk of alloimmunization were disadvantages of prophylactic transfusion. We conclude that the omission of prophylactic red-cell transfusion will not harm pregnant patients with sickle cell disease or their offspring.

Uterine contractility and oxytocin sensitivity in preterm, term, and postterm pregnancy

The records of 117 patients who had serial nonstress tests (N = 285) and oxytocin challenge tests (N = 268) were analyzed to determine whether baseline uterine contractility and/or oxytocin sensitivity changed with increasing gestational age. The results obtained in patients who were delivered before, at, and after term were compared. Uterine contractility and oxytocin sensitivity increased in all groups as gestational age progressed. No significant differences in uterine contractility were noted among groups; however, oxytocin sensitivity was significantly increased in the preterm group (p less than 0.001) and decreased in the postterm group (p less than 0.001). Our results suggest that the response of the uterus to oxytocin early in pregnancy may help to identify patients who will be delivered before or after term.

Progesterone and pregnenolone sulfate in pregnancy plasma

Abstract The role of adrenocortical precursors in placental progesterone production in normal pregnancy has been investigated by measuring plasma steroid levels in blood samples obtained concomitantly from various vascular regions, maternal and fetal, in 28 women at the moment of delivery. Pregnenolone sulfate level was found in the highest concentration 170.0 μg per cent ± 26.5 in the umbilical artery supplying the placenta, significantly higher than in the umbilical vein draining this organ (124.0 μg per cent ± 17.7). Inversely, progesterone concentration was higher in the fetal umbilical vein 96.6 μg per cent ± 8.8 than in the artery 53.6 μg per cent ± 5.5. The highest progesterone level 133.9 μg per cent ± 12.4 and a very low pregnenolone sulfate level 37.1 μg per cent ± 5.3 were found in blood samples from the intervillous space. The lowest plasma levels of both steroids have been found in maternal venous blood: progesterone 12.5 μg per cent ± 1.2 and pregnenolone sulfate 27.8 μg per cent ± 3.5. Increasing markedly maternal plasma pregnenolone sulfate by intravenous infusion of this steroid or decreasing it by dexamethasone adrenal suppression did not affect maternal plasma progesterone level. It is concluded that pregnenolone sulfate of adrenal origin does not seem to act as a progesterone precursor to any significant extent.

Inhibition of uterine contractility in labor

Abstract Uterine contractility was recorded by the direct electronic method in 4 groups of 12 women in labor, in order to study the inhibitory effect of: (1) pregnenolone sulfate, precursor of placental progesterone, expected to block the sensitivity of the myometrial cell; (2) ethanol, known to inhibit the release of oxytocin; (3) rapid infusion of 1,000 ml. 5 per cent dextrose, used as the vehicle; and to compare these effects with that of all these factors, acting concomitantly through different mechanisms. Pregnenolone sulfate depressed the frequency of contractions to 67 per cent ± 5.7 ∗ and their activity to 75 per cent ± 8.0. The effect was immediate but transient. The effect of ethanol was delayed but prolonged and more marked (62 per cent ± 6.9 and 69 per cent ± 1.38, respectively). Rapid infusion of 5 per cent dextrose had a slight but prolonged inhibitory effect (93 per cent ± 5.7 and 83.1 per cent ± 4.1), attributed to the Henry-Gauer reflex which blocked oxytocin release. Neither of these treatments affected the intensity of contractions. The most marked synergistic effect was obtained by the combined pregnenolone-ethanol-dextrose treatment. It was immediate like pregnenolone and prolonged like ethanol; it inhibited not only the frequency (63 per cent ± 7.0) and activity (45 per cent ± 6.3) but also the intensity of uterine contractions (72 per cent ±8.6), although the latter effect tended to recover rapidly. Inhibited uterine activity was related to the elevated plasma progesterone level only during the combined treatment, not during other treatments, when inhibited uterine contractility was related to elevated plasma pregnenolone or ethanol levels, while the progesterone level remained unchanged.

The relationship of changes in mammary blood flow and plasma progesterone at the time of parturition in the ewe

Previous studies indicate that there is a fall in maternal plasma progesterone and a marked increase in mammary blood flow (MBF) at the time of parturition in ewes. In this experiment the role of progesterone as a cause of this increase in MBF was investigated. Progesterone was infused (9.9 mcg. per minute) into a branch of the mammary artery in five sheep during the induction of premature labor by fetal dexamethasone infusion (1 mg. per 24 hours) to prevent the normal fall in concentration of local mammary artery progesterone. Five ewes used as controls received a mammary artery infusion of cholesterol (9.9 mcg. per minute). In the cholesterol-infused group MBF increased significantly from baseline after 13 +/- 4 hours (mean +/- standard error) to a peak flow of 235 +/- 9 ml. per minute. In the group receiving the progesterone the increase in MBF was delayed to 35 +/- 7 hours, reaching only 161 +/- 22 ml. per minute. These results were significantly different from control group results (p less than 0.01). This study suggests that the fall in maternal plasma progesterone which occurs at the time of parturition may play a role in the increase in MBF that occurs prior to the onset of labor, delivery, and lactogenesis.

Lack of relationship between prolactin and adrenal steroidogenesis in the ovine fetus

The role of fetal prolactin (PRL) as a fetal adrenotropic hormone was investigated in eight chronically catheterized fetal lambs. Catheters were placed for measurement of plasma prolactin (PRL), cortisol (F), dehydroepiandrosterone (DHEA), dehydroepiandrosterone sulfate (DHEA-S), and androstenedione (A). Daily (9 AM) samples were obtained until the onset of labor. In four animals 2-Br-alpha-ergocryptine (BC) was administered subcutaneously (1 mg/12 hours) for 11 to 21 days prior to delivery. Four animals served as controls. No difference between groups was noted in the duration of gestation. PRL increased in the control animals from 8.4 +/- 2.4 to 43.0 +/- 5.6 ng/ml (mean +/- SEM) at the time of delivery whereas in animals that received BC it decreased within 24 hour of administration and remained below 3 ng/ml throughout the study period. No differences were noted in the concentration of F, DHEA, DHEA-S, and A between groups. These results suggest that PRL does not play a role in adrenal steroidogenesis or in the initiation of parturition.

Automated Quantitation of Uterine Contractility and Fetal Heart Rate in Labor Surveillance

Real time quantitation of UC and FHR could increase the obstetrician’s expertise in evaluating data obtained by electronic monitoring. A subjective-visual assessment of these tracings, as usually done in a busy labor unit, is subject to errors. If the analog UUFHR tracings could be reliably quantitated by a computer, then data stored, analyzed and averaged would create an objective basis in discriminating between the healthy and compromised fetus. Several pioneering efforts have been carried out with large amounts of work invested (1 3). Unfortunately, some results reported were disappointing (46) , shutting off sources of funding for the above research line for years. Others continued with guarded enthusiasm limiting the number of studies to only high-risk patients (710). Our aim is to present a continuous around-theclock automated surveillance system, being developed in our laboratory for simultaneous monitoring of up to 10 patients in labor. The voltages moving the UC and FHR pens, and pen-lift on each monitor are fed into a 2100 Hewlett-Packard minicomputer. They are sampled by an A/D converter every 1/3 of a second. Due to the time constraints of real time processing and the memory constraints of a small system, only the FHR variability is calculated from raw data in three second averages, omitting artefacts. Subroutines reduce, analyze and store data in files in three-minute intervals. Each of the following parameters of UC and FHR is recalculated and tabulated in half-hour averages.

Laparoscopic removal of intraperitoneal Dalkon shields: a report of three cases.

The management of perforation of the uterus by an intrauterine device (IUD) and its removal by laparoscopy is discussed in this paper. The 3 cases presented here deal with uterine perforation by the Dalkon shield. In each case the IUD was inserted 6 weeks postpartum and after perforation each was removed by laparoscopy from the intraperitoneal space without difficulty. It is suggested that Dalkon shields not be inserted before 8 weeks postpartum and that a routine follow-up be done in 2 weeks in an effort to make early diagnosis of perforation.