Sten Ohrlander

Long-term ailments due to anal sphincter rupture caused by delivery--a hidden problem.

Questionnaires concerning ailments were sent postpartum (mean two years) to 62 women with anal sphincter ruptures (ASR), who were compared with a matched control population. The frequency of anal sphincter rupture at the hospital during delivery in the period, 1978-82, was 0.7% (n = 63). Primiparity, instrumental deliveries, abnormal presentation, large babies and oxytocin stimulation were all risk factors. Of 59 women answering the questionnaire 37 (63%) stated that they had had ailments three months postpartum, mainly with pain and involuntary passage of flatus but also with dyspareunia and occasional incontinence of faeces. Long-term symptoms were noted by 28 (48%) of the women, mainly with involuntary passage of flatus but also perineal pain, dyspareunia and occasional incontinence of faeces. Long-term symptoms occurred in 7 (88%) of women with ASR also involving the anal mucosa, but only in 21 (39%) of those with ASR only. Three of the patients subsequently underwent reconstructive surgery, and three complained of psychological problems.

Impact of betamethasone load given to pregnant women on endocrine balance of fetoplacental unit.

Corticosteroid administration to pregnant women for attempted prevention of the respiratory distress syndrome in infants (IRDS) involves the hazard of seriously altering the endocrine status in the fetoplacental unit. The effect of a betamethasone load (12 mg. daily for three days) to 19 pregnant women in the last trimester was studied, and a comparison was made with 13 control subjects. Amniocentesis was performed twice in most patients. There was a sharp reduction of cortisol in maternal serum and a significant decrease in cortisol concentration in amniotic fluid (p less than 0.05) after betamethasone treatment. Maternal urinary estriol excretion decreased; this was strongly correlated to the basal estriol excretion (r equals 0.945). A residual fraction of estriol excretion, not less than 2 mg. per 24 hour urine specimen, remained despite the high corticosteroid dose. The origin of the nondepressed part of urinary estriol might be multifactorial, e.g., nonadrenal production of estriol precursors and functional inhomogeneity of the fetal adrenal in response to adrenocorticotropic hormone stimulation. The corticosteroid treatment for prevention of IRDS transiently excludes the use of urinary estriol for assessment of fetoplacental integrity but does not influence the plasma level of human chorionic somatomammotropin.

Cortisol in amniotic fluid and cord blood in relation to prenatal betamethasone load and delivery

The influence of maternal corticosteroid administration on the cortisol concentration in fetal blood and amniotic fluid (AF) was studied in women receiving betamethasone for prevention of IRDS. Thirty-four pregnant women in danger of spontaneous or induced preterm delivery were treated with 12 mg. of betamethasone daily for 3 days. AF was obtained by amniocentesis on the day before and the day following the betamethasone treatment and by amniotomy at delivery; cord arterial and venous blood was taken at delivery. Corresponding samples were obtained from 17 pregnant control subjects. All samples were analyzed in duplicate for cortisol by radioimmunoassay. The basal AF cortisol level rose with gestational age. The AF cortisol concentration fell from the basal value of 24.5 +/- 1.8 to 5.4 +/- 0.4 ng. per milliliter 3 days after the start of treatment, and it remained low at delivery if the treatment-delivery time was less than 1 week. An almost significant positive correlation (r = 0.543) was found between the cortisol concentration in cord arterial blood and AF. The cortisol concentration in cord blood in the controls was 108.2 +/- 14.3 ng. per milliliter in the arteries and 106.4 +/- 18.6 ng. per milliliter in the vein. Also, the cord blood cortisol level was depressed in betamethasone had been given within one week before delivery. The multifactorial influence on cord blood cortisol level prevents interpretation of the results as support for the concept that the human fetal adrenal is involved in labor initiation. The duration of gestation was not altered by the betamethasone treatment. The analysis of cortisol in the easily accessible amniotic fluid is suggested for estimating the function of the fetal adrenal cortex.

Haemodynamic assessment of fetal heart arrhythmias

The effects of fetal heart arrhythmias were examined serially in two pregnancies by three non‐invasive methods: fetal ECG, fetal phonocardiography and ultrasonic measurement of fetal blood flow. In a case of supraventricular arrhythmia, there was evidence suggesting that the stroke volume varied with ventricular filling according to the Frank ‐ Starling law. In a case of total atrioventricular block the mean blood flow in the fetal descending aorta and in the umbilical vein was within the normal range. Blood flow velocity in the inferior vena cava of the fetus reflected atrial contractions. In the phonocardiogram, a phenomenon similar to‘bruit de canon’ was found. Both pregnancies had good outcomes and subsequent development of the infants was normal except for the persisting dysrhythmias. The two cases exemplify how fetal heart function can be assessed in utero.

Lack of correlation between a high caesarean section rate and improved prognosis for low-birthweight twins (<2500 g)

Summary. The impact of birth by caesarean section on perinatal mortality was estimated for 9368 low‐birthweight twins (<2500 g) born in Sweden between 1973 and 1985, by using national data from the Medical Birth Registry, National Board of Health and Welfare, Stockholm. During this period the caesarean section rate increased from 7–10% to 45–50% while concomitantly a sharp decrease in the perinatal mortality rate occurred. A causal relation between the increased rate of abdominal delivery and the improved prognosis for low birthweight twins might be expected. However, analysis of the results failed to show any correlation between these two variables. Factors other than route of delivery seem to have a greater impact on fetal outcome.

Fetal Cardiac Arrhythmia: Clinical outcome in 113 cases

In 113 cases of fetal cardiac arrhythmia, i.e. 94 with supraventricular arrhythmia, 5 with atrioventricular block and 14 with ventricular arrhythmia, the clinical outcome was studied and compared with the general pregnant population. The arrhythmia group was afflicted with a significantly increased frequency of congenital malformations, 6.2% vs. 2.0%; fetal distress in labor, 20.4% vs. 13.5%; perinatal mortality, 3.5% vs. 0.7%; and neonatal mortality, 1.8% vs. 0.1%. In 4 cases, pharmacological cardiac treatment was needed in utero due to fetal heart failure. Fetuses with cardiac arrhythmia thus constitute an obstetric and pediatric high‐risk group that should be subjected to an intensified supervision to detect fetal heart failure or fetal distress. When indicated, these complications can be treated in utero.

Intravascular Coagulation in Pregnancy-Treatment with Heparin

Abstract. Two pregnant women with a history of miscarriages or premature labour are described. In the 25‐27th week of pregnancy routine examinations showed high levels of FDP in serum. Subsequent extensive coagulation studies revealed a positive ethanol gelation test, low levels of fibrinogen, plasminogen, α2‐macroglobulin and P&P and high level of AHF related protein for the stage of pregnancy, i.e. findings in dicating abnormal proteolysis with activation of the coagulation and fibrinolytic system. Continuous intravenous heparin treatment caused the coagulation system to return to normal throughout the rest of pregnancy. Both women gave birth to healthy babies without any complications. But the placenta showed numerous infarcts. The heparin treatment may have prevented later development of placental dysfunction.

Routine Hospital Care Does Not Improve Prognosis in Twin Gestation

The effects of routine hospital care in twin gestation were evaluated by comparing the gestational outcome in two neighbouring university departments in southern Sweden. In Malmö, 79% (175/223) of all women with a twin pregnancy were given routine hospital care between the 26‐28th and 35th gestational week, whereas in Lund only 4% (16/409) received such treatment. Hospitalization averaged 9 weeks in Malmö, versus 2 weeks in Lund. We found no significant differences between the two areas regarding gestational length, birth weight, or perinatal mortality. This study indicates that routine hospital care does not improve the prognosis in twin gestation.

Changes in Amniotic Fluid Phospholipids On Treatment with Glucocorticoids to Prevent Respiratory Distress Syndrome

Abstract. Amniotic fluid was obtained by transabdominal amniocentesis in 51 women in the 29th–36th week of pregnancy. the lecithin/sphingomyelin ratio was determined. in 28 patients, the ratio was <2.2. Betamethasone was given for three days to 14 of them; the rest served as controls. On the fourth day, a second amniocentesis was performed on all patients. the lecithin/sphingomyelin ratio rose to a value >2.2 in 4 of the patients in the betamethasone‐treated group and in one of the controls. the percentage of palmitic acid in the lecithin increased concomitantly with increasing lecithin/sphingomyelin ratio. These results suggest that glucocorticoid‐induced acceleration of fetal pulmonary maturation may be reflected in the amniotic fluid as changes in its phospholipid composition. the lecithin/sphingomyelin ratio was found to be >2.2 in 23 patients at the first amniocentesis. in such cases treatment with glucocorticoids can be avoided.

Fetal and neonatal breathing movements in man after betamethasone

Abstract Nineteen women in the last trimester of pregnancy were treated with betamethasone 12 mg daily for three consecutive days. The fetal breathing movements were monitored by an ultrasonic method before and after the treatment and the patterns of movements were compared to those in controls. In seven treated cases the recording of breathing was performed also in the neonatal period. Betamethasone in the given dose, which causes pronounced alterations in the fetal corticosteroid balance, does not influence the pattern of breathing movements in the fetus and newborn. Although corticosteroids are known to affect several functions of CNS, the maturation of mechanisms regulating breathing movements in the perinatal period is apparently not accelerated by betamethasone.