P. Schreyer

THE OUTCOME OF PREGNANCY AFTER GONADOTROPHIN THERAPY

One hundred and ten women conceived 143 times following induction of ovulation by gonadotrophins. The abortion rate was 21 per cent. Some bleeding occurred in 38.7 per cent of pregnancies and 54 per cent of them ended in abortion. For the 112 pregnancies reaching 20 weeks, the multiple pregnancy rate was 26.8 per cent (21 twins, 5 triplets, 3 quadruplets and 1 sextuplet). Hypertension was present in 8.9 per cent of patients and in 3.3 per cent of those with multiple pregnancy. The length of gestation was related to the number of fetuses at birth and postmaturity did not occur. The Caesarean section rate was 32.1 per cent. The birth weight of the infants was normal and the male to female sex ratio was 0.64 for singleton births and 0.78 for twins. The fetal loss was 15.9 per cent (7.1 per cent for pregnancies of over 28 weeks). Growth and development of the children were apparently normal. The incidence of all congenital malformations was 7 per cent.

Amniotic fluid volume response to esophageal occlusion in fetal sheep

Although ovine and human fetuses swallow considerable volumes of fluid, the impact of absence of fetal swallowing on amniotic fluid volume regulation is unclear. To study the role of fetal swallowing on urine production and amniotic fluid, seven ovine fetuses (126 +/- 1 days) were chronically prepared with fetal bladder and vascular catheters, an esophageal flow probe, an inflatable esophageal cuff, and amniotic fluid catheters. In the five fetuses that underwent esophageal ligation after the control period, fetal swallowing averaged 0.27 ml/min before occlusion. In response to esophageal occlusion, significant increases were noted in fetal plasma arginine vasopressin (6.9 +/- 2.6 to 16.6 +/- 4.4 pg/ml) and urine osmolality (159 +/- 1 to 324 +/- 30 mOsm/kg), whereas urine volume (0.25 ml/min) did not change. Amniotic fluid volume increased nearly threefold after 3 days of esophageal occlusion (582 +/- 180 to 1530 +/- 271 ml). Amniotic fluid volume remained normal (334 to 419 ml) in the one fetus in which the occluder did not inflate. In the one fetus in which the esophagus was occluded at surgery, amniotic fluid volume was increased after the surgical recovery period (1489 ml). These data indicate an important role of fetal swallowing in amniotic fluid homeostasis and the potential interaction of swallowing with fetal urine production.

Ripening the Highly Unfavorable Cervix With Extra-Amniotic Saline Instillation or Vaginal Prostaglandin E2 Application

&NA; Extra‐amniotic saline instillation using a 26‐gauge Foley catheter and vaginal application of prostaglandin E2 (PGE2) were compared. Among 52 cases treated with extra‐amniotic saline instillation, the mean Bishop score increased from 1.7 to 7.8 in a mean of 2.8 hours. In all cases but one, an increase of the Bishop score of three or more points occurred during a 6‐hour period. Prostaglandin E2 tablets (3 mg) applied in the posterior vaginal fornix (once or twice) resulted in an increase in the Bishop score of three or more points in 39 of 54 cases during the 12‐hour study period. The mean Bishop score in these “successful” ripenings using PGE2 increased from 1.9 to 5.6 points during a mean time of 8.5 hours. No severe side effects were registered in either procedure. (Obstet Gynecol 73:938, 1989)

Fetal Rehydration Via Intraamniotic Fluid: Contribution of Fetal Swallowing

ABSTRACT: Amniotic fluid volume is regulated by a balance of fetal fluid production and resorption. Although fetal swallowing is believed to be a major site of fluid resorption, additional routes of fluid exchange also may contribute. In our present study, five chronically prepared, water-restricted, pregnant ewes with singleton fetuses (128 ± 1 d) were rehydrated via an intraamniotic infusion (100 mL/h over 90 min) of 0.075 M saline. In response to the maternal water restriction, significant increases were noted in maternal and fetal plasma osmolalities (306.6 ± 1.2 to 315.4 ± 2.4; 300.5 ± 1.5 to 311.0 ± 1.6 mosmol/kg, respectively) and arginine vasopressin concentrations (1.9 ± 0.2 to 22.6 ± 5.0; 1.5 ± 0.1 to 8.5 + 2.2 pg/mL, respectively). After the intraamniotic infusion, fetal plasma osmolality (311.0 ± 1.6 to 303.0 ± 1.2 mosmol/kg) and hematocrit (36.7 ± 1.9 to 33.8 ± 1.4%) significantly decreased although there was no change in maternal arterial blood values. Fetal swallowing averaged 0.39 ± 0.10 mL/min during the basal period and 0.34 ± 0.17 mL/min at maximum dehydration, and decreased significantly to 0.19 ± 0.07 mL/min in response to the intraamniotic infusion. These results indicate the rapid absorption of intraamniotic fluid by the dehydrated ovine fetus, despite the suppression of fetal swallowing. The volume swallowed during and after the intraamniotic infusion was insufficient to account for the observed changes in fetal plasma osmolality and hematocrit. Thus, alternative routes of fluid absorption (i.e. intramembranous flow) likely predominate under conditions of increased fetal plasma to amniotic fluid osmotic gradients.

Changes in amniotic fluid lecithin-sphingomyelin ratio following maternal dexamethasone administration.

The effect of dexamethasone on amniotic fluid lecithin-sphingomyelin (L/S) ratio was measured in 15 fetuses of 34 weeks or less of gestation. Six of the patients presented with premature rupture of the membranes. A rise in the L/S ratio is mature levels (two or more) was observed 24 hours to 11 days after the start of treatment in 12 patients. In 2 patients (one second twin and one anencephalic fetus), no rise in L/S ratio occurred. Of 12 cases whch ended in premature delivery (29 to 35 weeks) only one infant, a second twin delivered at the thirtieth week with a posttreatment L/S ration o1.4 weighing 1,240 grams, developed severe respiratory distress syndrome and died. Tt is suggested that dexamethasome accelerates fetal lung maturation by increasing surfactant synthesis or release, and this may be achieved as early as the twenty-eighth week of pregnancy.

Triplet, quadruplet and quintuplet pregnancies: Management and outcome

The management and outcome of 46 pregnancies, 37 triplets, 7 quadruplets and 2 quintuplets, were analysed. Management of pregnancies, initiated upon diagnosis of multiple pregnancy, included bed rest, β‐mimetic agents, dexamethasone late in the second trimester and selective cerclage. The mean gestational age at labor was 235 days in triplet pregnancies, 241 for quadruplets and 220 days for quintuplets. Fifty‐four percent of the deliveries were by cesarean section and the remainder per vaginam. The mean weight of the neonates was 1809 g for the triplets, 1837 g for quadruplets and 1284 g for the quintuplets. The mean overall Apgar score was 8.13, total perinatal mortality 14.8% and 9.4% in cases more than 28 weeks. There was no statistically significant difference in the outcome for triplets born vaginally or by cesarean section. In recent years there has been a pronounced reduction in neonatal mortality, dropping from 17.3% during 1970–78 to 5.9% from 1979 to 1983 (p<0.05), probably due to the improved neonatal treatment.

Nonimmune hydrops fetalis associated with angioosteohypertrophy (Klippel-Trenaunay) syndrome.

A case of nonimmune hydrops fetalis in association with angioosteohypertrophy (Klippel-Trenaunay) syndrome is reported for the first time.

Brucella septicemia in pregnancy

A case of Brucella melitensis septicemia in a second-trimester pregnancy causing intrauterine fetal death and Gram-negative septic shock with diffuse intravascular coagulation is reported. The literature is reviewed. This is the first reported case of human brucellosis in association with Gram-negative sepsis and DIC during pregnancy. The importance of blood cultures and agglutinins for Brucella in febrile pregnant patients is re-emphasized.

Metabolic Effects of Intravenous Ritodrine Infusion in Pregnancy

The effects of intravenous administration of Ritodrine on blood glucose, insulin, electrolytes, plasma and red cell potassium and venous pH were investigated.

Fluorescein angiography in hypertensive pregnancies

A retrospective study in two university hospitals investigating retinal changes in pregnancies complicated by hypertension, seldom revealed retinal vascular changes in pre‐eclamptic toxemia. Fluorescein angiography was performed on 16 severe pre‐eclamptic toxemias and 14 chronic hypertension pregnancies. Normal caliber retinal vessels and normal filling time, with no subretinal or subepithelium leakage, was found in all pre‐eclamptic toxemic patients. Four out of the 14 chronic hypertensive patients showed signs of mild hypertensive retinopathy. A review of the literature on fluorescein angiography in pregnancy showed that vascular changes in pre‐eclamptic toxemia are choroidal rather than retinal.