Rupinder Bhatia

Antenatal phenobarbital for the prevention of neonatal intracerebral hemorrhage

Forty-six pregnant women less than 35 weeks of gestation were enrolled in a prospective randomized controlled study evaluating the effects of antenatal phenobarbital on neonatal intracerebral hemorrhage. The women were randomly assigned to control (n = 22) or treatment (n = 24) groups; the treatment group received 500 mg of phenobarbital intravenously. The time interval between the dose of phenobarbital and delivery was 5.5 +/- 4.8 hours (mean +/- SD). The infants in the control group (n = 23) and those in the phenobarbital-treated group (n = 25) were comparable regarding birth weight, gestational age, and other obstetric and neonatal risk factors associated with intracerebral hemorrhage. The incidence of intracerebral hemorrhage was 56.5% (13 of 23 infants) in the control group and 32% (eight of 25 infants) in the phenobarbital-treated group (p = 0.08). Moderate or severe hemorrhage was diagnosed in six of 13 control infants and in none of the phenobarbital-treated infants (p less than 0.01). The mortality rate was significantly lower in the phenobarbital-treated group (two of 25 infants) than in the control group (eight of 23 infants; p less than 0.05). Our study suggests that antenatal phenobarbital administration results in a decrease in mortality and in the severity of intracerebral hemorrhage in the preterm neonate.

Single umbilical artery: Accurate diagnosis?

OBJECTIVE We sought to evaluate the accuracy of ultrasonographic, obstetric, and neonatal diagnosis of a single umbilical artery. STUDY DESIGN We studied 17,777 consecutive singleton births from women who had undergone ultrasonographic examination at our hospital. A single umbilical artery was confirmed in 37 cases (0.2%) by two clinical methods or by pathologic assessment. Outcome of neonates with a single umbilical artery was compared with the outcome of neonates with either two or three vessel cords. RESULTS Ultrasonographic diagnosis had a 65% sensitivity and positive predictive value. Obstetricians and pediatricians failed to diagnose 24% and 16% of the cases, respectively. On average, neonates with a single umbilical artery weighed 320 gm less, were delivered 1 week earlier, and had lower Apgar scores than neonates with three vessel cords (p < 0.01 in each case.) CONCLUSION Although early gestational age may account for some cases not diagnosed by ultrasonography, there is a little justification for missing the diagnosis after delivery. Greater emphasis on clinical examination of the umbilical cord is needed to identify neonates at risk of associated malformations.

Effect of pregnancy on pressure gradient in mitral stenosis.

Abstract Mitral stenosis is one of the leading cardiovascular diseases in young women. While pulmonary artery pressures during pregnancy have been shown to increase, 1 the serial changes in transmitral pressure gradients with pregnancy have not been previously reported. With the recent advent of Doppler echocardiography, 2,3 it has become possible to noninvasively assess mitral valve flow during pregnancy. We report the progressive increase in transmitral gradient from early pregnancy in 2 women.

Mechanisms for reduced colloid osmotic pressure in preeclampsia

The determinants of plasma colloid osmotic pressure were studied in 32 patients with preeclampsia and their matched control subjects. Although plasma colloid osmotic pressure was significantly related to preeclampsia, its severity, and proteinuria, it was most highly correlated with an elevated fibronectin level, suggesting that endothelial injury, rather than proteinuria, is the major mechanism of reduced colloid osmotic pressure in preeclampsia.

FIRST TRIMESTER DIAGNOSIS AND EARLY IN UTERO TREATMENT OF OBSTRUCTIVE UROPATHY

The earliest diagnosis and treatment of obstructed fetal bladder is reported. Placement of vesico‐amniotic shunt at 14.5 weeks of gestation enabled preservation of bilateral renal function and maintenance of normal amniotic fluid volume with normal pulmonary development. The shunt functioned adequately for more than 12 weeks. At birth, a mild ‘prune’ belly was the only deformity noted.

Is placenta previa a determinant of preeclampsia

Low implantation of the placenta has been reported to be associated with a decreased risk for preeclampsia and this has been attributed to increased placental blood flow. However, placenta previa is known to be associated with separation and bleeding, intrauterine growth retardation, and elevated umbilical blood flow resistance by Doppler studies, suggesting decreased umbilical blood flow. To better evaluate the relationship of placenta previa and preeclampsia, 6576 consecutive patients who had ultrasound examination after 28 weeks gestation and delivery at our institution were studied. The placental location, parity, maternal weight, development of preeclampsia, and gestational age were evaluated by using frequency tables and stepwise discriminant analysis. Results showed that placenta previa is not a significant determinant of the development of preeclampsia, but parity, maternal weight, and gestational age contributed significantly to the development of preeclampsia. The finding of decreased incidence of preeclampsia with previa is explained not by increased placental blood flow but by associated maternal characteristics, and particularly by the strong association of previa with premature delivery.

Care of obstetric patients during the immediate postanesthesia period

STUDY OBJECTIVE To determine the level of care available to obstetric patients during the immediate postanesthesia period. DESIGN Mail and telephone survey of members of anesthesia departments in Michigan. SETTING All Michigan hospitals with licensed obstetric beds. PATIENTS Patients recovering from general or major regional anesthesia following an operative delivery. INTERVENTIONS The factors determining patient care were the physical suitability of the recovery site, skills and experience of personnel providing care in postanesthesia care units (PACUs), and adjustments in care patterns by anesthesia personnel. MEASUREMENTS AND MAIN RESULTS Most obstetric PACUs are staffed by labor and delivery nurses whose assignment to the unit is only part of their overall patient care responsibilities within the labor and delivery area (88.2% of hospitals with more than 2,000 annual births and performing cesarean deliveries in the obstetric suite; 92.3% of hospitals with 500 to 1,999 annual births and performing cesarean deliveries in the obstetric suite). Obstetric PACUs in the remaining hospitals in either group are staffed by dedicated nurses who are permanently assigned to these units. Preparation of labor and delivery nurses for PACU duties varies greatly, but 60.0% of hospitals with more than 2,000 annual births and 30.8% of hospitals with 500 to 1,999 annual births provide no special training. Concern about the level of expertise available in obstetric PACUs staffed by labor and delivery nurses was expressed by almost every respondent and has led to a practice pattern followed by most anesthesia personnel of transferring patient care responsibility only after patients have regained consciousness, cardiovascular stability, and ventilatory adequacy. Several institutions also allow anesthesia personnel to summon nurses from the surgical PACU or to transfer patients to alternate recovery sites, such as the surgical PACU or the intensive care unit (ICU). CONCLUSIONS In many obstetric PACUs, the level of expertise of personnel needs to be upgraded to ensure the safety of patients recovering from general or major regional anesthesia and to comply with existing care standards.

1519 ANTENATAL PHENOBARBITAL FOR PREVENTION OF NEONATAL IANTRAVENTRICULAR HEMORRHAGE

A prospective randomized controlled study was performed evaluating the effects of antenatal phenobarbital (PB) on neonatal intraventricular hemorrhage (IVH). Forty-six pregnant women in labor <35 wks gestation were assigned to control (n=22) or treatment groups (n=24); the treatment group received 500 mg PB by slow intravenous infusion prior to delivery. Echoencephalograms were performed on all infants. The time between dose of PB and delivery was 5.6 ± 4.6 hrs (all values mean ± SD). Maternal PB levels at delivery were 8.72 ± 2.01 μg/mL and cord serum PB levels were 8.85 ± 1.57 μg/mL. The infants in the control group and those in the PB treated group did not differ regarding delivery route, presentation, Apgar scores, ventilatory support, episodes of acidosis, hypoxemia, hypercarbia, hypotension and fluid therapy in the first 3 days. The results indicate a significant decrease in mortality and occurrence of moderate and severe IVH in the PB treated group as compared to the control group.

Maternal Total β-Endorphin Immunoreactivity During Labor and Delivery

Circulating plasma β-endorphin (BIR) levels underestimate the BIR levels in the blood. To determine the effect of epidural anesthesia on BIR, we measured total blood (plasma + erythrocytes) BIR during labor and delivery (19 epidural, 6 control patients). Total BIR levels seem to predict the anesthetic need in patients during labor. Acute changes in the pain status in patients were better predicted by the plasma than the total BIR activity.

IS PLACENTA PREVIA A DETERMINANT OF PREGNANCY INDUCED HYPERTENSION

Low implantation of the placenta has been reported to be associated with a decreased risk for the development of pregnancy-induced hypertension (PIH). This has been attributed to increased placental blood supply. However, a decreased incidence of PIH in placenta previa has not been observed in other studies. No studies are known to have examined uterine blood flow in placenta previa. Doppler umbilical blood flow studies have demonstrated decreased blood flow and increased risk for intrauterine growth retardation in previa which is incompatible with the increased placental blood flow. None of the studies controlled for the effect of parity, maternal weight, and gestational age; important variables in the development of PIH. To better evaluate the relationship of placenta previa and PIH, if any, 6576 consecutive patients who had ultrasound examinations after 28 weeks gestation and delivery in our institution were studied. The placental location, parity, development of PIH, and gestational age were evaluated. The analysis of data were done by using frequency tables and stepwise discriminant analysis; p < 0.05 considered significant. Comparing patients of all parities showed a significant lower incidence of PIH in patients with previa (ChiSq = 3 .9; p < 0 .05) . Stepwise discriminant analysis (n = 6198) of the possible determinant of PIH are shown below.