Norvald Sagen

Iron requirement in normal pregnancy as assessed by serum ferritin, serum transferrin saturation and erythrocyte protoporphyrin determinations

Summary. Serum iron, serum iron‐binding capacity, serum ferritin and erythrocyte protoporphyrin were determined during uncomplicated pregnancy in 45 healthy women; 22 were given oral iron while the others were given a placebo. When iron was not given, 15 out of 23 women had exhausted iron stores and iron deficiency at term, as judged from low serum ferritin, low serum transferrin saturation and high erythrocyte protoporphyrin values. Only seven of them had a haemoglobin concentration between 10 and 11 g/dl at term but none had values < 10 g/dl. In the iron‐treated group (n=22) none of the women developed iron deficiency. Serum ferritin was the most sensitive and specific test of iron deficiency. A practical procedure to detect iron deficiency and to control iron supplementation in pregnancy is suggested.

Serum Urate as a Predictor of Fetal Outcome in Severe Pre‐Eclampsia

Abstract. Maternal serum urate levels were studied in 50 normal pregnancies and 72 cases of severe pre‐eclampsia. Markedly elevated levels of serum urate were found in severe pre‐eclampsia, compared with normal pregnancy. In severe pre‐eclampsia significantly higher levels were found prior to parturition in cases of growth retardation and perinatal distress, compared with patients whose newborns were of normal size and condition. Particularly high serum urate levels were found early in the third trimester in cases of perinatal death. A slight but significant correlation was found between the weight centile of the newborn and the last maternal urate level before parturition. A rapidly rising urate level reliably predicted perinatal distress. The last maternal serum urate before parturition was correlated with the hemoglobin and erythrocyte volume fraction values in the same blood sample.

Fetal growth retardation associated with inadequate haemodilution in otherwise uncomplicated pregnancy

Abstract. The Hb level during pregnancy was followed in 113 non‐anaemic women with uncomplicated pregnancy and birth weight of the baby above the 2.5th percentile. There was an inverse correlation close to statistical significance between the birth weight of the baby and the lowest Hb level reached during pregnancy as well as the Hb level in late pregnancy (38th week). A group of seven non‐anaemic women with birth weight of the baby below the 2.5th percentile had a significantly higher (p<0.001) Hb level in late pregnancy than the normal group. Four of these cases had a statistically significant higher Hb level already in the second trimester. Trends in the reproductive history, complaints in the present pregnancy as well as results of hormone assays and the condition of the baby indicated that the seven cases represented a pathological group with fetal growth retardation. None of the women in the two groups were treated with diuretics. All had iron supplementation in high doses.

High Hemoglobin Levels During Pregnancy and Fetal Risk

In a series of 24 apparently uncomplicated pregnancies with small‐for‐dates newborn at or below the tenth percentile, 15 women had hemoglobin (Hb) levels 2 SD above the mean value of normal distribution in late pregnancy. Among these 15 was the only case with intrauterine death of unknown cause. In a series of 15 cases with intrauterine fetal death of unknown cause, before start of labor 10 had Hb levels 2 SD above the mean, while in a series of 16 cases of late abortion where the fetus was alive until labor started, only one had a Hb level 2 SD above the mean. In three cases with serial Hb estimations, the levels were 2 SD above the mean one week or more before intrauterine fetal death. Two of these cases also had been observed during a successful pregnancy in which the Hb levels were within normal limits. It is concluded that high Hb levels during pregnancy may indicate a fetus at risk. High viscosity of the mothers blood may impede the uteroplacental circulation, causing placental infarction, growth retardation and ultimately fetal death.

Smoking, hemoglobin levels, and birth weights in normal pregnancies

Of 811 otherwise healthy, nonanemic, pregnant Norwegian women, 43% smoked during the third trimester. No significant association existed between smoking habits and hemoglobin levels during the third trimester, but the fairly small number of heavy smokers (greater than 10 cigarettes per day) may have precluded the discovery of subtle true differences. Birth weights were transferred to a weight-for-dates percentile scale, based on the distribution of the total Norwegian birth population over an 11-year period. With a grouping in quartiles according to this scale, a strong correlation between smoking habits and low birth weights emerged, with 47% of newborn infants of heavy smokers falling in the lowest quartile. Levels of hemoglobin were inversely correlated to birth weight quartiles, equally in mothers who smoked and those who did not smoke. However, when birth weights were grouped according to maternal hemoglobin at term, the tobacco-related effect on birth weight appeared only with levels of hemoglobin above 12 gm/dl, being particularly strong for levels above 13 gm/dl. Hemoglobin levels of 9.0 to 11.9 gm/dl appeared to protect from growth retardation the fetuses of nonanemic mothers who smoked. Studying ponderal, or weight-by-length, indices, we found that growth-retarded babies of mothers who smoked tended to be thin, thus indicating that they had been deprived of nutrients.

Haemoconcentration in severe pre‐eclampsia

Summary. The last maternal haemoglobin (Hb) concentration before delivery was related to the perinatal outcome in 87 non‐anaemic women suffering from severe pre‐eclampsia. Abnormally high Hb concentrations were found in most women with evidence of placental dysfunction. An inverse correlation was found between the centile weight of the newborn and the maternal Hb. Significantly higher Hb levels were found in pregnancies complicated by fetal growth retardation and perinatal distress compared with those in pregnancies with good outcomes. Particularly high levels were found in pregnancies that ended in perinatal deaths. The hypothesis is put forward that raised haemoconcentration during severe pre‐eclampsia causes increased maternal blood viscosity which predisposes to placental pathology and initiates a vicious circle.

Heparin-induced inhibition of 1,25-dihydroxyvitamin D formation.

vise intrauterine transfusion because of the suspicion that normal clearance of the amniotic fluid bilirubin may be impeded by the presence of duodenal atresia, which keeps amniotic fluid bilirubin high. This theory has been previously published without case studies.’ Sources of error in amniotic fluid spectrophotometry included blood, maternal or fetal, meconium, urine, ascitic fluid, and congenital anomalies, such as anencephaly, duodenal atresia, jejunal atresia, and tracheoesophageal fistula. This report confirms that suspicion. It is believed that the bilirubin which enters the amniotic fluid returns to the fetal circulation and subsequently to the placenta by fetal swallowing and absorption from the fetal gastrointestinal tract.’ In cases of upper intestinal obstruction in the fetus, this amniotic fluid clearance of indirect bilirubin is impeded, with resulting abnormal AOD rises in amniotic fluid. To our knowledge, this is the first reported case of abnormal amniotic fluid AOD at 450 rnp with evidence of fetal duodenal atresia. The recently increasing incidence of amniocentesis for various reasons will undoubtedly create situations in which similar findings are observed, and, if so, the suspicion of fetal abnormalities should be raised in the absence of isoimmunization. Investigations done after delivery confirmed the absence of intrauterine or extrauterine hemolysis. The mild hyperbilirubinemia observed in this infant was the result of prematurity. Upper intestinal obstruction in the fetus may cause abnormal amniotic fluid spectrophotometric findings, and this should be taken into account when management of such cases is planned. Intrauterine transfusions in these cases are unnecessary and may be dangerous.

Serum Alkaline Phosphatase in Pregnancy: I. A Comparative Study of Total, L-Phenylanine-sensitive and Heat-Stable Alkaline Phosphatase at 56d`C and 65d`C in Normal Pregnancy

Abstract. 312 paired, serial estimations of total, L‐phenylalanine‐sensitive and heat‐stable alkaline phos‐phatase (at two temperatures, 56°C and 65°C) were performed on sera from 31 pregnant healthy women from 18 weeks to term. Heat‐stable alkaline phosphatase, determined at 65°C, enriched the serum in a smooth exponential course throughout the second and third trimester, whereas the other enzymic activities investigated showed more irregular increments. There was a slight, but significant correlation between total alkaline phosphatase activity of the placenta and serum heat‐stable alkaline phosphatase at term, whereas there was no correlation between the weight of the child at birth and heat‐stable alkaline phosphatase in the serum of the mother. It is concluded that to test the feto‐maternal unit, determination of serum alkaline phosphatase should be performed at 65°C with due regard to appropriate sampling and experimental design.

Serum Alkaline Phosphatase in Pregnancy

Abstract. This is a study of heat‐stable alkaline phosphatase (HSAP65°C) concentrations in the serum of pregnant women with hypertension (42 cases), mild preeclampsia (40 cases) and severe pre‐eclampsia (22 cases). The results are seen in relationship to the occurrence of intrauterine fetal death, growth retardation, intrauterine and neonatal asphyxia as well as the respiratory distress syndrome (RDS) in the newborn. The importance of a precise clinical classification of the patients is stressed. Pathological HSAP values are those which lie either over or under the normal range for HSAP activity. In addition “zig‐zag” curves with values within the normal range are characterized as abnormal. Thus, serial estimations give the most reliable results. Serial estimations of HSAP are especially valuable in severe pre‐eclampsia. Abnormal HSAP values in the 28th–38th week of pregnancy are a serious prognostic sign. False abnormal HSAP results were found in all 3 patient groups. One possible false normal HSAP curve also occurred.

Ketamine and diazepam as anaesthesia for forceps delivery. A comparative study.

In a clinically controlled trial in forceps delivery, a comparison was made between the general anaesthesia induced by ketamine and that by a combination of diazepam and N2O. Local anaesthesia was added in the diazepam group for episiotomy and suturation. The indication for operative delivery was in all cases a prolonged second stage of labour. In the ketamine group, awareness was noted in four cases out of 13, even if the analgesic effect was found to be good. Four patients showed marked, short‐lasting elevation of blood pressure and seven had unpleasant dreams. All thirteen mothers in the diazepam group found the anaesthesia effective and the recovery pleasant. The blood pressure was stable. One mother in each group required ventilation with oxygen due to respiratory depression of short duration.