Wayne B. Kramer

Nimodipine in the management of preeclampsia: Maternal and fetal effects

OBJECTIVE Our purpose was to determine the effects of orally administered nimodipine on selected maternal and fetal parameters in patients with preeclampsia. STUDY DESIGN Ten consecutive patients were given 30 mg of nimodipine orally every 4 hours from admission until 24 hours after delivery. Maternal and fetal cerebral blood velocity, umbilical artery blood velocity, fetal heart rate variability, maternal blood pressure and heart rate, and transplacental passage of the drug were studied. All 10 patients were delivered within 24 hours of the first dose of nimodipine. RESULTS There was an acute and significant reduction in the pulsatility index in the smaller diameter maternal cerebral arteries (ophthalmic and central retinal) and in the fetal middle cerebral artery. The umbilical artery systolic/diastolic ratio was also significantly reduced. Maternal blood pressure was controlled without the need for other antihypertensive medication, and although there was an increase in heart rate after administration of the drug, it was well tolerated. Nimodipine reached significant maternal and fetal levels within 2 hours. CONCLUSIONS Nimodipine is rapidly absorbed after oral administration and has significant maternal and fetal cerebral vasodilator activity. It is an effective, easily administered antihypertensive agent when used in patients with preeclampsia.

Acute genital injury in the prepubertal girl

In an effort to develop guidelines for the management of acute genital injuries in prepubertal girls, we categorized 32 cases by the object that allegedly caused the injury: straddle injuries, nonpenetrating injuries, penetrating injuries, and torque injuries. Using these categories and the anatomic features of symmetry and/or hymenal transection, we determined that the most dangerous injuries were the penetrating injuries that were symmetric and transected the hymen; in this series these were all the result of sexual assault. Future studies are needed to determine if these unique injuries can be managed with less physical and psychosocial trauma to the young patient.

Placental transfer of sulindac and its active sulfide metabolite in humans

OBJECTIVE Our aim was to investigate whether the human placenta is permeable to sulindac or its active sulfide metabolite. STUDY DESIGN Nine pregnant patients (median gestational age [range]: 31.8 [24.3 to 36.4] weeks) were given a 200 mg oral dose of sulindac 5.5 (4.4 to 6.7) hours before 18 intravascular transfusions for rhesus or Kell alloimmunization. At each procedure maternal and fetal serum levels of sulindac and the active sulfide metabolite were measured by high-performance liquid chromatography. RESULTS The maternal sulfide level was significantly higher than the fetal sulfide levels, but no significant difference was noted between maternal and fetal sulindac levels. The sulfide fetal/maternal ratio was significantly lower than the sulindac fetal/maternal ratio. The sulfide/sulindac ratio was significantly higher in maternal serum versus fetal serum. The sulfide/sulindac ratio correlated with time from drug ingestion to sampling on the maternal side only. In patients studied on more than one occasion no consistent relationship between fetal sulindac, fetal sulfide, or fetal sulfide/sulindac ratio, and gestational age could be demonstrated. CONCLUSION The placenta is permeable to sulindac but less so to its active sulfide metabolite. The reduction of sulindac to its active sulfide metabolite is decreased in the human fetus.

Effects of selected vasoconstrictor agonists on isolated omental artery from premenopausal nonpregnant women and from normal and preeclamptic pregnant women

OBJECTIVE Our purpose was to compare the responsiveness of omental resistance arteries from nonpregnant women and from normotensive and preeclamptic pregnant women to selected contractile agonists. STUDY DESIGN Omental artery rings with intact endothelium from normotensive premenopausal nonpregnant women and from normal and preeclamptic pregnant women were mounted in Krebs-bicarbonate solution in organ baths for isometric tension recording. After the presence of endothelium was confirmed, cumulative concentrations of norepinephrine, serotonin, U46619, and endothelin-1 were added. Concentration-response curves were constructed and expressed as percentage of a reference 60 mmol/L potassium chloride contraction. Data analysis was by repeated-measures analysis of variance. Newman-Keuls test, and paired or unpaired Student t test, as appropriate. Statistical significance was by two-tailed p<0.05. RESULTS Endothelin-1 and U46619 increased tension similarly in all three groups. Norepinephrine increased tension in nonpregnant vessels to a greater extent than in either preeclamptic or pregnant vessels (nonpregnant 114.3 +/- 5.42% vs pregnant 65.2 +/- 10.5%, p<0.05). Nonpregnant omental artery developed significantly greater tension than did pregnant tissue at three concentrations of norepinephrine (10(-5) mol/L, 3 x 10(-5) mol/L, 10(-4) mol/L), and preeclamptic vessels developed more tension than that from normal pregnant vessels at 3 x 10(-6) mol/L (p=0.06) and 10(-5) mol/L (p<0.05). There was a negligible change in tension with increasing concentrations of serotonin in the vessels from nonpregnant women; serotonin-induced contraction in the omental arteries from normotensive pregnant women and preeclamptic patients was <6% of the potassium chloride reference contraction, but this was significantly (p<0.05) different from that of the nonpregnant women. CONCLUSIONS Omental artery segments from nonpregnant, normotensive pregnant and preeclamptic women contract similarly to endothelin-1 and U46619 but exhibit variable responses to norepinephrine and serotonin.

Antibiotic Prophylaxis for Presumptive Group B Streptococcal Infection in Preterm Premature Rupture of the Membranes: Effect on Neonatal and Maternal Infectious Morbidity

Objective: The purpose of this study was to determine if the prevalence of neonatal and maternal infectious morbidity in patients with preterm premature rupture of membranes (PROM) who received ampicillin prophylaxis for presemptive group B streptococcal colonization is increased compared to those who received no prophylaxis. Methods: The charts of all patients with preterm PROM who delivered between January 1988 and December 1993 were retrospectively reviewed. The routine use of ampicillin prophylaxis was initiated in January 1991. Patients with singleton gestations were included in the analysis only if chorioamnionitis was excluded on admission. Variables used in the final analysis included gestational age at the time of preterm PROM, gestational age at delivery, duration of rupture of membranes, birth weight, method of delivery, use of steroids, tocolytics, or antibiotics for group B streptococcus prophylaxis, neonatal sepsis, neonatal mortality, and postpartum endomyometritis. Data were analyzed using Students t-test, chi-square test, Fishers exact test, and stepwise logistic regression analysis to evaluate the effect of chemoprophylaxis for group B streptococcus on the incidence of neonatal sepsis and maternal postpartum endomyometritis. A two-tailed P < 0.05 was used to denote statistical significance. Results: The charts of 206 patients were reviewed; 146 patients received ampicillin for group B streptococcal prophylaxis and 60 patients did not. There was a significantly higher incidence of postpartum endomyometritis among the patients who received ampicillin (62% vs. 22%; P < 0.01). The association between postpartum endomyometritis and chemoprophylaxis remained significant even after controlling for other confounding variables. There was no significant difference in the incidence of neonatal sepsis (5% vs. 7%; P = 0.7) or death (5% vs. 3%; P = 0.9) between both groups. Conclusions: Group B streptococcal prophylaxis with a short course of intravenous ampicillin increases the risk of postpartum endomyometritis in patients with premature PROM.

Hepatic hemorrhage/infarction and arterial thrombosis secondary to antiphospholipid syndrome: A therapeutic dilemma

26-year-old woman with antiphospholipid syndrome presented with pregnancy-induced hypertension at 25 weeks gestation. At cesarean section her liver was noted to have numerous small subcapsular hemorrhages. Her postoperative recovery was complicated by arterial thrombosis, hepatic infarction, and prolonged thrombocytopenia which responded to plasmapheresis and intravenous steroid therapy.

Adjunctive Measures for Control of Hemorrhage in Association with Abdominal Pregnancy

Fluoroscope-directed embolization of pelvic vessels and surgical abdominal packing were useful adjunctive therapies for uncontrollable hemorrhage in an advanced abdominal pregnancy. The patients postoperative course was complicated by massive pulmonary emboli, prolonged ileus, pelvic cellulitis, and sensitivity to oral anticoagulation. Nonetheless, mother and infant ultimately survived in satisfactory condition.