Volume 29, Issue 1

Objective: To compare maternal and perinatal outcome with the use of either intravenous ketanserin or dihydralazine in treatment of women with preeclampsia. Methods: The records from January 1989 to January 1997 of all patients receiving intravenous ketanserin or dihydralazine as first line antihypertensive therapy were reviewed and standardized data forms were completed. 315 charts of patients were identified and evaluated for effects on blood pressure, laboratory parameters, maternal and perinatal outcome. Results: During the study interval 169 patients received ketanserin and 146 dihydralazine. Significantly fewer antepartum (27% versus 38%, p = 0.04) and postpartum (25% versus 39%, p = 0.01) maternal complications were noted in patients receiving ketanserin. Occurrence of HELLP syndrome was significantly lower among patients who received ketanserin (20%) than among those who received dihydralazine (40%, p = 0.0001). Side-effects were reported with significantly higher frequency in patients receiving dihydralazine (60%) as compared to those receiving ketanserin (17%, p < 0.0001). Perinatal outcome was comparable, however, umbilical cord arterial pH values (mean ± SD) were higher with ketanserin compared to dihydralazine ( 7.25 ± 0.07 vs 7.23 ± 0.09, p = 0.038). The incidence of placental abruption was higher in patients receiving dihydralazine (5.5%) versus those receiving ketanserin (0.6%, p = 0.014). Conclusion: Ketanserin appears to be a better option than dihydralazine for treatment of severe preeclampsia since fewer maternal complications and side-effects were observed in patients receiving ketanserin.

It has been assumed that low birth weight and high placenta weight were key factors for predicting hypertension in human adulthood. Adeficiency in placental 11β-HSD-II enzyme activity was supposed to be the underlying cause. To possibly establish 11β-HSD-II as a leading factor, we determined 11β-HSD-II activities in 133 healthy pregnancies, 21 proteinuric pregnancies complicated by pregnancy-induced hypertension (PIH), 26 non proteinuric PIH pregnancies and 15 pregnancies complicated by fetal growth restriction (32 nd –41 st gestational week). We could not identify differences in 11β-HSD-II activity between pregnancies with the rare combination of small babies with big placentas and others (p 5 0,59; Kruskal-Wallis test). And although there was no correlation between 11β-HSD-II activity and birth weight, in the control gestational age correlated with 11β-HSD-II activity (r = 0,22; p < 0.05; Spearman). 11β-HSD-II activity in the proteinuric PIH group was significantly higher than in the controls (11,7 pmol/min/mg prot.; range 10–13,2 vs. 7,9; range 7,0–9,1; p < 0,05). The lowest, but not significant, enzyme activities were in the IUGR group (5,8 pmol/min/mg prot.; range 4,0–9,2). In this group, analysis of variance detected a correlation between enzyme activity and placental weight. In conclusion, we could not confirm that placental 11β-HSD-II deficiencies act as an indicator for the risk of adult hypertension in small fetuses with large placentas. However, in growth restriction 11β-HSD-II activity might play a role. To clarify the influence in this group, further research is needed. Increased 11β-HSD-II activities with gestational age in the control may serve to sustain fetal adrenal steroid genesis and to prepare the fetus for autonomic life.

Objective: This prospective case series was performed in order to assess pregnancy outcome of women with tentative diagnosis of cervical incompetence undergoing selective and emergency cervical cerclage. Methods: Women recruited in this case series were divided into two groups. The selective group (n = 13) was chosen among pregnant women with a history suggestive of cervical incompetence, but no clinical evidence of threatened miscarriage. The definition of cervical incompetence was dilatation of internal cervical os with shortening of the cervix less than 25 mm and “funnelling” of 25% and more, found on the ultrasound examination of the cervix. The emergency group (n = 12) had clinical symptoms of threatened miscarriage. After exclusion of infection and in the absence of uterine activity they were counseled and offered cerclage. Results: After cervical cerclage all women were treated in the same way as per our clinical protocol and monitored until delivery. The median gestational age at delivery was 36 weeks (19–39) in the selective group and 33 weeks (22–38) in the emergency group. This difference is not statistically significant. There was 1 miscarriage (8%), 5 pre-term deliveries (38%) and 7 term deliveries (54%) in the selective group; and 4 miscarriages (33%), 3 pre-term deliveries (25%) and 5 term deliveries (42%) in the emergency group. Total neonatal survival was 19/20 (95%) if pregnancy exceeded 24 weeks, making perinatal mortality 5%. There was no differences between selective and emergency groups (1 of 12 in selective vs. 0 of 8 in emergency). Conclusion: Overall, it can be concluded that both selective and emergency cerclage may have some benefits in patients with cervical incompetence. However, in the absence of a randomized-controlled study, these beneficial effects described cannot be considered as proved.

The aim of our study was to evaluate a feasible method to quantify the immunoglobulin A concentration in the cervical mucus of women with a normal singleton pregnancy. In 60 immunologic healthy pregnant women cervical mucus samples were taken at a random time in pregnancy using an absorbing cylindrical cotton-swab stick. In this cervical mucus immunoglobulin A concentration was measured by radial immunodiffusion. A vaginal bacterial swab was taken from each woman. Concentration of immunoglobulins in maternal serum was estimated. There was no statistically significant difference of cervical immunoglobulin A concentration between the investigated groups (p = 0.952): 18–24 gestational weeks (gw): 52.8 (6.6–258.4) mg/l; 25–29 gw: 89.3 (4.8–193.8) mg/l; 30–34 gw: 55 (1.4–326) mg/l; 35–40 gw: 59.2 (4–400.9) mg/l. Women with a normal vaginal flora showed a significantly higher cervical immunoglobulin A concentration than those with a pathological colonization: 92.2 (6.6–400.9) mg/l vs. 42.5 (1.4–326) mg/l (p < 0.05). The serum levels of immunoglobulins A, A1, A2, M and G do not correlate to cervical immunoglobulin A levels nor to gestational age. In normal pregnancy, cervical immunoglobulin A concentration does not change with advancing gestational age, but a pathological vaginal colonization seems to be associated with decreased immunoglobulin A levels.

Aims: Routinely antepartal CTG will be recorded for 30 minutes to obtain normal resting phases, a decrease of irregulatory due to hypoxia or to differentiate these from each other. In case of early onset of hypoxia first pathological findings might only be seen by chance in incidentally recorded CTG. The goal of this study was, if a continuous 24 hour-CTG will allow an earlier detection of beginning hypoxia in case of placental insufficiency compared to a routine CTG of 30 minutes. Methods: 21 normal pregnancies and 17 patients with placental insufficiency of ≥ 36 weeks had 24 hour-CTG's by means of telemetry. In both study groups fetal heart rate (FHR) tracing included a full qualitative and quantitative description. Comparison of the results of both groups was done to look for early signs of pathological findings concerning reduced fetal well-being. Results: In comparison to normal pregnancies patients with placental insufficiency had in 4.5% oscillation frequency type A and an increase of saltatory and silent oscillation. The number of accelerations and Dip 0 was significantly reduced as well as accelerations in combination with undulatory oscillation. Baseline tachycardia and bradycardia showed significantly increasing quantity. Conclusions: 24 hour-CTG is a good screening method to detect early onset of hypoxia in case of beginning placental insufficiency. The failure to find any clinically significant difference in the diurnal variation of both groups suggests, that less than 24 hour testing is required. 8 hour-CTG could be a compromise and a big help to detect a fetus at risk earlier.

Introduction: Chlamydial infections of the genital tract are thought to often lead to preterm birth, which is the most important perinatal problem in Hungary. Aim of study: A multicenter study was carried out to determine the prevalence of Chlamydia trachomatis infection, risk factors for the infection and to relate the infection to perinatal mortality, accounting for potential confounding effects. Methods: The nucleic acid hybridization method (PACE2 Gen-Probe) was applied for the examination of Chlamydia trachomatis . Logistic regression analysis was used to assess risk. Results: A total of 6156 pregnant women were examined for the occurrence of Chlamydia trachomatis . The observed overall rate of chlamydial infection was 5.9%. Young age (less than 24 years old) (OR and 95% CI:1.6 (1.3–2.0)), unmarried status (1.5 (1.2–1.9)) and the high unemployment rate (2.1 (1.6–2.7)) were statistically significant predictors of the infection. In logistic regression analysis, chlamydial infection (1.9 (1.1–3.3)), high unemployment rate (1.5 (1.2–2.2)) and low birth weight (1.7 (1.1–2.7) were significant predictors of perinatal mortality. Conclusions: Testing pregnant women for diseases that can be transmitted perinatally is an important part of obstetric care. Screening for C. trachomatis of unmarried women under 24 years of age is suggested and need increased observation during labor.

We performed a retrospective study of twin pairs under 36 weeks gestation admitted to a regional neonatal unit over a three year period to determine if the larger twin of a twin pair is at increased risk of respiratory distress in the immediate postnatal period compared to the smaller twin. Gestation, gender, birth weight, mode and reason for delivery, birth order, and Apgar at 5 minutes were correlated with the need for added oxygen at 4 hours, the need for ventilation, oxygen requirement at 28 days and mortality. One hundred and twenty-four twin pairs were analyzed with a median gestation of 31 weeks (range 23–35). There were 47 female-female pairs, 40 male-male pairs and 37 mixed pairs. Multiple logistic regression revealed no significant increased risk for ventilation in male, heavier or second twins. The need for oxygen at 4 hours was strongly associated with being male and being the second twin, but not with being the heavier twin. However, on analysis of twins of 28 weeks gestation or above a significant association was found between a persisting oxygen requirement at 4 hours and being male (OR 2.2; 95% CI 1.15–4.16), being the heavier twin (OR 1.9; 95% CI 1.03–3.46), and being the second twin (OR 2.7; 95% CI 1.48–4.99). No association was found between mortality and being male, and being the second or smaller twins. Conclusion Heavier twins above 28 weeks gestation are at increased risk of short term mild respiratory problems following delivery compared to lighter twins at the same gestation. This is not as strong a factor as birth order or male gender, but it is important to be aware of this in ante natal counselling of the parents as the smaller twin is usually perceived to be at greater risk of morbidity.

In order to elucidate intestinal blood flow after birth in infants with intrauterine growth retardation, we measured superior mesenteric artery blood flow velocity in uncomplicated small for gestational age infants with a birth weight of < 1500 g by pulsed Doppler ultrasound in days 1 to 7 of life. Peak systolic blood flow velocity, time-averaged mean blood flow velocity and end-diastolic blood flow velocity in the superior mesenteric artery significantly increased with time. The resistance index and relative vascular resistance in the superior mesenteric artery significantly decreased after birth. Compared with gestational age matched appropriate for gestational age infants and birth weight matched appropriate for gestational age ones, peak systolic blood flow velocity, time-averaged mean blood flow velocity and end-diastolic blood flow velocity in the superior mesenteric artery were lower in the small for gestational age infants. The difference between the small for gestational age group and the gestational age matched appropriate for gestational age group was statistically significant. The resistance index and relative vascular resistance in the superior mesenteric artery tend to be higher in the small for gestational age group than in the appropriate for gestational age groups. In conclusion, although intestinal blood flow velocity in infants with intrauterine growth retardation increases after birth, it is lower than appropriate for gestational age infants during the early neonatal period.

We report on a fetus with intrauterine growth restriction detected at 27 weeks' gestation, who was longitudinally followed up until delivery by cesarean section 33 days later (31 + 5 weeks) due to severe decelerations in CTG. Longitudinal Doppler assessment of the umbilical artery (UA), the middle cerebral artery (MCA) and the main branch of the right pulmonary artery (RPA), the ductus venosus (DV) and the left coronary artery was compared to clinical course and computerized CTG. At first presentation (day –33) increased resistance in both the UA and uterine arteries with bilateral notches was found. Absent enddiastolic flow (AED) in the UA was found at day –19 and reverse flow (RED) at day –11. The MCA showed a decreased pulsatility first at day –19 and again at day –11 together with RED in the UA. The RPA initially (day – 33) showed increased PI which returned to normal values at day –19 but increased again at day –1, when the DV showed RED and the coronary arteries became visible. The DV was normal until day –11, then its PI began to increase together with occurence of RED in the UA, but reverse flow in the DV occurred only on the eve (day –1) of severe decelerations in CTG. Short-term variability in computerized CTG was stable at 6 to 7 ms, except for an intermediate drop to 4 ms at day –10. Maternal hypertension was found at day –19 and mild preeclampsia developed at day –12. A reduction of fetal movements was noticed at day –5. This report shows that at 29 weeks gestation despite detection of AED resp. RED in the UA a prolongation of pregnancy for 19 resp. 11 days is possible. In addition to abnormal CTG, late signs of fetal deterioration are reverse flow in the DV and visibility of the coronary arteries. The role of increased resistance in the main branches of the pulmonary arteries should be examined in the future.

Options for the treatment of thoracoabdominally conjoined twins are dependent on the anatomy of the cardiovascular system. It is important to increase the accuracy of diagnosis of conjoined twins with a fused heart. Color Doppler imaging performed in a 23-year-old nulliparous Japanese woman at 12 weeks of gestation revealed synchronized blood flow in 2 aortic arches arising from a single heart. The patient underwent a therapeutic abortion, and the diagnosis of conjoined twins with a fused heart was confirmed. Thus, color Doppler imaging is useful for investigating the cardiovascular anatomy in conjoined twins suspected of having a fused heart, even in an early gestational age.

Gestational diabetes compromises fetal development and induces a diabetogenic effect in the offspring, including the development of gestational diabetes and the transmission of the effect to the next generation. Changes are not limited to glucose and insulin metabolism, and appear to be modulated by alterations at the hypothalamo-hypophyseal axis. In the present work, serum concentrations are given for the non-protein amino-acids taurine and gamma-aminobutyric acid (GABA), both neurotransmitters essential for normal brain development, and for the endogenous neuroprotector carnosine, a known anti-oxydans. Taurine levels are significantly below normal values in mildly diabetic mothers, in their fetal and adult offspring, virgin and pregnant, and in the fetuses of these pregnant offspring. GABA and carnosine levels are at the limit of detection in the diabetic mothers and their offspring at every stage. It is concluded that the low taurine, GABA and carnosine levels in diabetic mothers and their fetuses might compromise the normal structural and functional development of the fetal brain. When adult, these offspring present a deficiency of the circulating levels of these neurotransmitters involved in the hypothalamo-hypophyseal regulation of insulin secretion. This might contribute to the development of impaired glucose tolerance and gestational diabetes, thereby transmitting the effect to the next generation.