William E. Brenner

The characteristics and perils of breech presentation

To delineate the differences between breech and nonbreech deliveries, the characteristics of 30,359 consecutive, singleton deliveries at one institution were analyzed. Although many of the differences between breeches and nonbreeches were explained by the increased frequency of prematurity among breeches, certain specific differences remained after correction for gestational age: (1) lower fetal and placental weights, (2) higher rates of congenital abnormalities, (3) higher perinatal mortality rates, (4) lower Apgar scores, and (5) higher rates of complications in labor. Cesarean section was a safer method of delivery than vaginal delivery. While induction of labor appears as safe as spontaneous labor, augmentation of dysfunctional labor is associated with higher mortality rates than unaugmented labor. Data are compiled in a manner which allows the obstetrician to evaluate the relative risks to the fetus prior to labor, during labor, and in the neonatal period.

Cardiovascular effects of oxytocic drugs used post partum

Abstract The almost routine use of oxytocin and/or ergot drugs post partum for the prevention of or the control of postpartum hemorrhage is a widely accepted practice. It has been repeatedly demonstrated that the rapid intravenous administration of single large doses of either oxytocin or ergot preparation may have profound effects upon cardiovascular system. The almost immediate development of profound hypotension following such administration of oxytocin and the relatively longer hypertension following administration of ergonovine and methylergonovine maleate have been demonstrated in human subjects.

Reduction of cervical resistance by prostaglandin suppositories prior to dilatation for induced abortion

Several recent reports citing increased rates of prematurity among women who have had induced first-trimester abortion suggest that forceful cervical dilatation may result in cervical incompetence in future pregnancy. There appear to be conflicting clinical impressions regarding the effectiveness on cervical softening and the reduction of cervical resistance produced by various prostaglandins. The development of the Electronic Force Monitor which is capable of precise measurement of the forces encountered in overcoming resistance during dilatation provided objective evidence with which to evaluate the effects of vaginally administered prostaglandin E2 and F2alpha suppositories. Suppositories were administered 3 hours prior to cervical dilatation, after which suction curettage was performed. Compared to the nonmedicated control group, patients receiving PGF2alpha suppositories exhibited greatly reduced cervical resistance, in some cases permitting direct introduction of the suction curette without need for any preliminary dilatation. Those patients receiving PGE2 suppositories showed an intermediate degree of cervical softening.

Efficacy and tolerance of intravenous prostaglandins F2α and E2

Abstract With the increasing needs and demand for a safe, convenient abortifacient, the most promising of the natural prostaglandins, PGE 2 and PGF 2α , were investigated by the random, double-blind, intravenous-infusion technique to: (1) compare their abortifacient and oxytoxic activity; (2) determine the complications and their frequency in therapeutic dosage; (3) derive an infusion dosage with maximum effectiveness and minimum complications. Ten gravidas, from 7 to 20 weeks pregnant, desiring therapeutic abortion were infused with PGE 2 and PGF 2α between 2.5 and 20 μg per minute and 25 and 200 μg per minute, respectively, in progressively increasing doses for 12 hours. Both PGE 2 and PGF 2α were effective abortifacients. Nausea, emesis, and fever (temperature > 100° F.) complicated PGF 2α and increased in severity and frequency with progressive rates of infusion. Sixty per cent of the patients infused with 5 μg of PGE 2 per minute developed a transient phlebitis which increased in intensity with higher rates of infusion. The percentage of patients developing the minimum amount of uterine activity observed wth abortion increased as the rates of prostaglandin infusion were increased. No one infusion rate of either prostaglandin would produce a maximum rate of abortion with minimum complications. To attain this goal, it is recommended that the individual patient receive a progressively increasing rate of infusion until adequate uterine activity is achieved.

The obfuscation of eclampsia by thrombotic thrombocytopenic purpura.

All case reports of TTP in pregnancy were reviewed. In some cases the primary diagnosis of TTP may have been inappropriate, with severe pre-eclampsia or eclampsia being the primary problem. Some cases of eclampsia and severe pre-eclampsia satisfy all the criteria for the diagnosis of TTP syndrome. However, the prognosis is much better and management of these patients is very different from the nonpregnant patient with the TTP syndrome. The use of the term TTP syndrome to describe these patients may be confusing. Two cases of eclampsia are presented where the diagnosis of TTP could have been made but would have been inappropriate.

Cardiovascular and respiratory responses to intravenous infusion of prostaglandin F2α in the pregnant woman

Abstract Because of the occurrence of an asthmatic attack in a patient undergoing therapeutic abortion with intravenous prostaglandin F 2α (PGF 2α ) the cardiovascular and respiratory systems were studied by a strict protocol in 11 physically healthy gravid women infused intravenously with PGF 2α . Cardiac output was measured by the indocyanine green dye-dilution and direct Fick oxygen techniques. Pulmonary function studies, i.e., vital capacity (VC), forced expiratory volume in the first second of expiration (FEV 1 ), maximal mid-expiratory flow rate (MMEF), and maximal expiratory flow rate (MEFR), were performed with a Stead-Wells recording spirometer. Studies were conducted before and after premedication, during infusion of PGF 2α at 50 μg per minute and at 200 μg per minute, and after discontinuation of the infusion. No significant changes in cardiac output, central venous pressure, blood pressure, or heart rate were noted. In contrast, pulmonary function studies revealed a significant average decrease in VC of 15.5 per cent; FEV 1 , 15.7 per cent; MMEF, 18.8; and MEFR, 26.9 per cent during the infusion of PGF 2α at 200 μg per minute. These results suggest that intravenous PGF 2α in high dosage increases airway resistance, probably by producing bronchoconstriction.

Improving survival with liver rupture complicating pregnancy

The reported maternal mortality of 59% that results from rupture of the liver in pregnancy is probably excessive if modern diagnostic and treatment techniques are fully utilized. The rarity and variable presentation should not lead to an incorrect diagnosis and possible fatal outcome. Pregnant patients or patients who recently have undergone delivery, especially those with hypertension, who complain of epigastric and/or discomfort in the right upper quadrant of the abdomen should be considered to be candidates for rupture of the liver. Ultrasound, which is generally available, is an adequate diagnostic technique in most patients. Computed tomography and technetium scanning are helpful tools. Ligation of specific bleeding points, compression, deep hepatic sutures, omental pedicles, topical agents, ligation of the hepatic artery, hepatic artery embolization, and other techniques should be used prior to performance of lobectomy. Drainage is recommended. Replacement of blood, correction of coagulation defects, monitoring of respiratory function, and attention to known postoperative complications should improve the outcome of patients with this serious complication.

Laparoscopic sterilization with electrocautery, spring-loaded clips, and silastic bands: technical problems and early complications

Among 2283 patients, rates of technical failure, technical difficulty, and operative and early postoperative complications were evaluated for different methods of tubal occlusion at laparoscopy: electrocoagulation (980 cases), spring-loaded clip application (991 cases), and Silastic band application (312 cases). Rates of technical failure and technical difficulty at surgery were significantly higher (P less than 0.05) for the spring-loaded clip technique than for the electrocoagulation and Silastic band techniques. Mechanical and optical difficulties with the prototype spring clip applicator were the major sources of technical difficulties. Rates of operative (1.2%) and early postoperative (1.9%) complications were not significantly different for the three techniques of tubal occlusion. It is concluded that all three study techniques appear to be practical, and large, long-term, randomized, comparative studies to determine rates of failure and subsequent gynecologic problems are necessary to determine the best method of sterilization.

Toxemia of pregnancy: Relationship between fetal weight, fetal survival, and the maternal state☆

Abstract Among 27,270 deliveries, there were 947 cases of pre-eclampsia available to study. It was found that both the fetus and the placenta of the women with toxemia of pregnancy weighed less than did the product of conception of a nontoxemic pregnancy at an equivalent week of gestation. The woman with toxemia tends to deliver earlier than does the woman without toxemia. The perinatal mortality rate among infants born to toxemic mothers is approximately twice that of infants born to nontoxemic mothers; almost the entire increase in deaths is because of an increased incidence of antepartal and intrapartal deaths. The incidence of pre-eclampsia was found to be approximately threefold higher among primigravidas than among multigravidas. It occurred with exceptionally high frequency among women who harbored some serious systemic disease prior to the index pregnancy and in women of poorer socioeconomic status.

Intramuscular administration of 15(S)-15-methyl-prostaglandin E2-methyl ester for induction of abortion

An intramuscular dose schedule of 15(S)-15-methyl-prostaglandin E2-methyl ester (15-(S)-ME PGE2) was evaluated for its application as a midtrimester abortifacient route. 20 healthy gravidas aged 18-42 years and 8-22 menstrual weeks of gestation were aborted in the Clinical Research Unit of the University of North Carolina Memorial Hospital. The subjects were given 5 mcg of the PGE2 methyl ester every 4 hours. 85% (17/20) aborted within 48 hours, 65% (13/20) of these within 24 hours. Mean induction-abortion interval was 21 hours. Trials were defined as complete in 55%, incomplete in 30%, and failure in 15%. Shivering, fever, pain, vomiting, and diarrhea were the most common side effects. The transient shivering occurred in 13 (65%) of the subjects within 20 minutes of the first dose. Fever usually started after shivering, and both resolved spontaneously. 2 patients had estimated blood loss exceeding 500 ml, but they were not given transfusions. No clinically significant changes occurred in mean hemotocrit, platelet count, serum creatinine, bilirubin, alkaline phosphatase, electrolytes, serum glutamic oxalacetic transaminase, and serum glutamic pyruvic transaminase. Mean blood cell and neutrophil counts increased, but neither increase was statistically significant.