Zion J. Hagay

Uriscreen, a rapid enzymatic urine screening test: useful predictor of significant bacteriuria in pregnancy

Objective To establish the reliability of a new rapid enzymatic screening test, the Uriscreen, in the detection of significant bacteriuria in pregnancy. Methods During a 6-month period, from July 1 to December 30, 1993, 313 consecutive pregnant patients were evaluated. Randomly voided, midstream, clean-catch urine specimens were used. Each sample was tested by routine laboratory culture and four rapid screening tests: the nitrite and leukocyte esterase dipstick, microscopic examination for pyuria, and the Uriscreen test. Results of the four rapid tests were compared with those of the urine culture. Results Twenty-four women (7.6%) had urine culture results indicating significant bacteriuria. The sensitivity of the nitrite test, the leukocyte esterase test, and a microscopic examination for pyuria was low (37, 52, and 56%, respectively). The Uriscreen test showed very high sensitivity (100%), lower specificity (81%), a high predictive value of negative results (100%), and a low positive predictive value (30%). Conclusions The Uriscreen test is a reliable alternative to culture screening of all pregnant patients. A policy of performing a urine culture during pregnancy only on patients with a positive Uriscreen test will save as much as 80% of unnecessary cultures.

Single fetal demise in twin gestation resulting in the resolution of severe pre-eclampsia.

A primigravida presenting with a twin pregnancy and severe pre-eclampsia which developed during early pregnancy is described. Complete resolution of symptoms and signs of pre-eclampsia were evident following the death of a growth-retarded single fetus. Pregnancy continued successfully until 35 weeks of gestation, when a single healthy infant was delivered. Few such cases of complete resolution of pre-eclampsia following the death of a single fetus are reported in the literature. The possibility that genetic susceptibility to pre-eclampsia is conferred by homozygosity for the same single recessive gene expressed by both mother and fetus is discussed.

The impact of prenatal care on the outcome of pregnancy

In a 12-months prospective project all women delivering at the Soroka Medical Center, Beer-Sheba, Israel, were studied with regard to the type of prenatal care (P.C.) and the outcome of pregnancy. The Soroka Medical Center is the sole medical facility providing obstetric and neonatal services to the 300,000 inhabitants of the region. Prenatal care is delivered by a uniform network of 70 community-based stations. The availability, type and quality of services were uniform for all women and were not altered throughout the study period. The project encompassed 7308 deliveries. 2154 Bedouin women were excluded in order to avoid possible bias due to cultural and genetic characteristics. Data regarding 5154 Jewish women were analysed. Perinatal mortality was inversely proportional to the number of prenatal contacts. The uncorrected mortality rates were 12.7% in women entirely lacking P.C. and 6.2%, 1.9% and 1.0% in patients who had 1-6, 7-10 and 11 or more prenatal contacts respectively. The low-birthweight rate was significantly increased in women lacking prenatal care (22.8%) or having rudimentary care (17.4%) as compared to those who had 11 or more prenatal contacts with medical personnel (5.9%). Prenatal care reduced neonatal morbidity as expressed by the length of hospitalization, the frequency of infants with multiple diagnoses and the incidence of specific pathologies such as respiratory distress syndrome, light for dates and asphyxia. The incidence of some complications of pregnancy (abruptio placentae, premature labor, PROM) was significantly increased in women lacking P.C. or having inadequate P.C. (1-6 prenatal contacts). Moreover, lack of prenatal care was clearly connected with high-risk delivery, thus increasing the danger to the baby. It is suggested that many adverse effects of various socio-economic, genetic and general health factors may be diminished by proper prenatal care coupled with adequate obstetric and neonatal services.

Development of proliferative retinopathy in a gestational diabetes patient following rapid metabolic control

Rapid glucose control was achieved by insulin therapy in a patient diagnosed to have gestational diabetes at 8 weeks of pregnancy. A decrease of the initially high hemoglobin A1c level (16.2%) to normal values (5.9%) was achieved within 12 weeks. At 31 weeks severe bilateral proliferative diabetic retinopathy developed. To our knowledge this case is the first report of a patient with gestational diabetes who developed de novo proliferative diabetic retinopathy.

Twinning in southern Israel; Secular trends, ethnic variation and effects of maternal age and parity

Twin births in southern Israel between 1970 and 1986 were examined in the Jewish and Bedouin populations. An increase in dizygotic twinning in the whole population, largely due to an increase of rate in the Bedouin population was found. The dizygotic twinning rate in the Bedouin population rose until it reached the level found in the Jewish population. No change with time was found in the monozygotic twinning rates in either population. This suggests that while dizygotic twinning rates are influenced by environmental factors, the monozygotic twinning rates are not. The effects of maternal age and parity on dizygotic and monozygotic twinning rates differed in the two ethnic groups examined. In the Jewish population the dizygotic twinning rate was related to maternal age and parity, while in the Bedouins only maternal age affects the rate. The monozygotic twinning rate has an inverted U shape with maternal age in the Jewish population and is linearly related to maternal age in Bedouin women. No effect of parity on the Jewish monozygotic twinning rate is found but this rate is directly affected by parity in Bedouin women. The effects of maternal age and parity together were examined in both populations. Both maternal age and parity affected the twinning rates; however, the effects are not additive and no interaction between maternal age and parity was found.

THE EVALUATION OF ACCELERATED FETAL GROWTH

The timely recognition of fetal macrosomia may reduce the complications associated with vaginal delivery of a macrosomic fetus. Today, the most frequently used tool for identification of fetal macrosomia is ultrasound. Although many different calculations have been applied, the most commonly used is the estimation of fetal weight. Generally, the detection rate for fetal macrosomia is 33–82%, with a specificity of 70–100%, a positive predictive value of 40–83%, and negative predictive value of 66–92%. Adding amniotic fluid volume, cheek-to-cheek diameter or fetal subcutaneous tissue:femur length ratio may improve the accuracy of the diagnosis. Other promising diagnostic tools include the echo-planar imaging and the neural network. Despite the progress that has been achieved since the use of Nageles rule, our ability to detect fetal macrosomia remains limited.

Oligohydramnios, intrauterine growth retardation and fetal death due to umbilical cord torsion.

Intrautrine fetal death was observed in a woman at 35 gestational weeks shortly after she was admitted to hospital due to suspected placental insufficiency expressed by oligohydramnios and fetal growth retardation. The pathologic examination showed umbilical cord torsion and an organized thrombus at the site of the torsion. This findings could imply that both the fetal death and the placental insufficiency were the results of the cord torsion.

Plasma antithrombin III levels in pre-eclampsia and chronic hypertension

Plasma levels of antithrombin III were tested during pregnancy in a control group of normal patients and in a study group that included patients with moderate and severe pre‐eclampsia and chronic hypertension. The control group showed mean antithrombin III activity of 97.9 ± 20.9%, the severe pre‐eclamptic patients 22.33 ± 18.22%, the moderate pre‐eclamptic patients 56.0 ± 7.56%, and the chronic hypertensive patients 77.5 ± 6.69%. The difference between normal pregnancy and moderate pre‐eclampsia was significant at P < 0.002, normal pregnancy and severe pre‐eclampsia P < 0.002, moderate and severe pre‐eclampsia P < 0.002, chronic hypertension and normal pregnancy P < 0.1, and chronic hypertension and severe pre‐eclampsia P < 0.002. All the severe pre‐eclamptic patients and 2 out of 6 of the moderate pre‐eclamptic women were below 55.7% (x – 2S.D.) of normal antithrombin III activity. Patients with heavy proteinuria had depressed antithrombin III activity. However, chronic hypertensive pregnancies, although rather a small group, had almost normal values of plasma antithrombin III activity. The plasma antithrombin III value may thus help to distinguish between chronic hypertension and severe pre‐eclamptic disease.

Plasma and urine beta-thromboglobulin in severe preeclampsia.

SummaryBeta-thromboglobulin (BTG) has been shown to be a specific platelet protein and can be used as a marker of platelet activation in preeclampsia. Concomitant studies of BTG levels in plasma and urine were performed with eight primiparous severe preeclamptic patients and eight normal primiparous women matched for age. The mean plasma BTG in the severe preeclamptic patients was 186.62±29.93 ng/ml, and in the control group 45.38±31.84 ng/ml. TheP-value for the difference was highly significant (P=0.000). In contrast, the mean urine BTG in the study group was 8.42±4.61 ng/ml, while the mean value for the control group was similar, 5.00±3.20 ng/ml. TheP-value for the difference was not significant (0.05<P<0.10). These results show that urinary BTG cannot be considered an indicator of platelet activation in severe preeclampsia. A low rather express renal impairment. Failure of BTG renal clearance would contribute to further raising the level of plasma BTG.

The Effect of Maternal Hypocalcemia on Fetal Heart Rate Baseline Variability

Marked decrease in fetal heart rate variability during labor was observed in a term fetus, borne by a mother with severe hypocalcemia due to idiopathic hypoparathyroidism and nutritional vitamin D deficiency. During the period of decreased baseline variability, fetal scalp pH was normal. a marked increase in fetal heart rate variability was observed within 5 minutes of intravenous administration of 1 gram calcium gluconate to the parturient. It seems that the recognition of the effect of maternal hypocalcemia on baseline fetal heart rate variability is important for accurate interpretation of fetal monitor tracing.