Possible cocaine predisposition to adverse cerebrovascular and cardiovascular sequelae of bromocriptine administered postpartum.
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Adult↗
Biomedical subjects
B Kirshon
Publications and source records attributed to B Kirshon.
Doppler assessment of the fetal and uteroplacental circulation during nifedipine therapy for preterm labor.
To investigate the effects of nifedipine on the human fetal circulation, 11 fetuses whose mothers were treated with nifedipine for treatment of preterm labor were studied. Maximum velocity waveforms were obtained in the middle cerebral artery (n = 8), renal artery (n = 6), ductus arteriosus (n = 8), and umbilical artery (n = 10). Transvalvular maximal velocity waveforms were obtained across the aortic (n = 11) and pulmonary (n = 7) valves. Maternal uterine arteries also were studied (n = 7). Doppler data were collected before and 5 hours after nifedipine therapy. Patients received an oral loading dose of 30 mg of nifedipine followed by a second oral dose of 20 mg 4 hours later. No significant difference in the flow velocity waveforms was found in the vessels studied 5 hours after the initial dose. These results suggest that short-term nifedipine therapy does not influence either fetal or uteroplacental circulation as evaluated with the Doppler technique.
Adolescent↗
Doppler assessment of the pulsatility index of the middle cerebral artery during constriction of the fetal ductus arteriosus after indomethacin therapy.
To investigate the effects of constriction of the ductus arteriosus on the pulsatility index of the middle cerebral artery, maximum velocity waveforms were obtained in 13 fetuses (one set of twins) whose mothers were treated with indomethacin for preterm labor (n = 9) or polyhydramnios (n = 3). Eleven of the fetuses manifested ductal constriction within 48 hours of therapy, whereas two fetuses had constriction after 1 week of therapy. Six of the 13 fetuses also manifested tricuspid insufficiency in association with constriction of the ductus arteriosus. All abnormal cardiac changes resolved in utero after discontinuation of indomethacin. No difference in the pulsatility index values of the middle cerebral artery was observed in the fetuses with ductal constriction but without tricuspid regurgitation (n = 7) when the values were compared with those obtained in absence of ductal constriction (1.87 +/- 0.37 vs. 1.88 +/- 0.33). In the fetuses that manifested both ductal constriction and tricuspid insufficiency (n = 6), the pulsatility index values in the middle cerebral artery were significantly lower in the presence of ductal constriction when compared with the values obtained in the absence of ductal constriction (2.22 +/- 0.26 vs. 1.57 +/- 0.34). These results indicate that a response to indomethacin sufficient to cause both ductal constriction and tricuspid insufficiency decreases the pulsatility index of the middle cerebral artery.
Blood Circulation↗
Doppler assessment of the pulsatility index in the cerebral circulation of the human fetus.
To determine whether the pulsatility index was similar in all cerebral vessels, 30 fetuses at 23 to 37 weeks' gestation were studied. There were 12 normal fetuses, 14 growth-retarded fetuses, and 4 fetuses that were transfused in utero because of Rh isoimmunization. The middle cerebral artery and the internal carotid artery were studied in all fetuses. The proximal anterior cerebral artery was also studied in addition to the other two vessels in 12 fetuses from the three groups. The pulsatility index was significantly higher in the middle cerebral artery than in the internal carotid artery in all three groups. The pulsatility index of the proximal anterior cerebral artery was between the values shown for the middle cerebral artery and the internal carotid artery. The pulsatility index of the proximal anterior cerebral artery was significantly different from the index for the middle cerebral artery and not significantly different from the index for the internal carotid artery. These data indicate the importance of knowing exactly which cerebral vessel is being insonated, so that the Doppler waveform can be interpreted correctly.
Carotid Artery, Internal↗
Comparison of four types of intrauterine transfusion: effect on fetal hematocrit.
The advent of cordocentesis has made it possible to treat fetuses affected by severe red cell alloimmunization by infusing red cells into umbilical vessels. In addition, serial hematocrits can be followed between transfusions. Twenty fetuses underwent a total of 118 intrauterine procedures. Four transfusion techniques were compared to assess the effect of each method on the stability of the fetal hematocrit between procedures. The change in hematocrit per day for direct intravascular transfusion was -1.06 +/- 0.68%, for intraperitoneal transfusion: +0.03 +/- 0.6%, for combined exchange intravascular and intraperitoneal transfusion: +0.02 +/- 0.3% and for combined direct intravascular and intraperitoneal technique: -0.01 +/- 0.4%. The greatest fall in hematocrit was noted with the use of the direct intravascular technique alone (p less than 0.001). The combined direct intravascular/intraperitoneal approach produces a stable hematocrit between procedures and offers the possibility of performing intrauterine transfusions at less frequent intervals.
Blood Transfusion, Intrauterine↗
Intravenous pancuronium bromide for fetal neuromuscular blockade during intrauterine transfusion for red-cell alloimmunization.
Intravenous pancuronium bromide was administered into the umbilical cord by funipuncture to effect temporary fetal paralysis. Neuromuscular blockade was achieved in 12 fetuses undergoing a total of 34 intrauterine procedures for the treatment of severe red-cell alloimmunization. The same initial dose of 0.2 mg/kg fetal weight estimated by ultrasound was used in all cases, but anemic fetuses did not resume movement for prolonged periods. A relationship among fetal hematocrit, adjusted dose, and duration of paralysis was described by the equation: Duration (hours) = 5.24 + 10.30 adjusted dose (mg/kg) - 0.16 hematocrit (%) (R2 = 0.49; P less than .001). Intravenous pancuronium was found to be a safe and effective method for cessation of fetal movement during intrauterine procedures.
Blood Transfusion, Intrauterine↗
Effect of acetaminophen on fetal acid-base balance in chorioamnionitis.
The effect of antipyretic treatment with acetaminophen on fetal status was examined in eight laboring women febrile with chorioamnionitis. After a fetal heart rate tracing and scalp blood gas level were obtained near maximum maternal fever, a 650-mg acetaminophen suppository was administered. If the temperature remained greater than 101 degrees F, the dose was repeated in one to two hours. The fetal heart rate tracing was analyzed again after the mother's fever was reduced by acetaminophen. All patients delivered within four hours of the first dose. Umbilical artery blood gases were obtained at delivery. Significant improvements in the bicarbonate concentration and base deficit were noted at the time of delivery as compared to the scalp gas at the height of the maternal fever. The fetal heart rate tracings at the height of the maternal fever, characterized by tachycardia, poor variability and late decelerations, changed to a normal heart rate pattern without decelerations when the mother's fever was reduced. Hence, in the laboring gravida with chorioamnionitis, reducing maternal fever with acetaminophen improves fetal status and thereby may reduce the probability of cesarean section for fetal distress.
Acetaminophen↗
Fetal urine output in hydramnios.
Fetal urine output was evaluated in 12 pregnancies complicated by hydramnios. Six of these pregnancies were twin gestations with markedly elevated fetal urine output of the hyperperfused fetus. All six fetuses had urine output greater than the 95th percentile for their gestational age. These six patients were evaluated prior to and during the 29th week of pregnancy. Three singleton gestations had upper gastrointestinal obstruction and normal fetal urine output of 18.7, 18.0, and 12.3 mL/hour at 35, 35, and 31 weeks' gestation, respectively. Markedly elevated fetal urine output of 18 mL/hour (tenth to 95th percentile at 26 weeks, 4-7 mL/hour) was present in one fetus that was subsequently found to have diabetes insipidus. The remaining two singleton pregnancies with idiopathic hydramnios had upper limits of normal fetal urine output of 10 and 13 mL/hour at 31 and 32 weeks, respectively. It appears that hydramnios may be the result of polyuria of the hyperperfused twin in cases of twin-twin transfusion or diabetes insipidus. In upper gastrointestinal obstruction or idiopathic hydramnios, increased fetal urination does not appear to be present.
Adult↗
Effect of heparin on umbilical arterial blood gases.
Arterial blood gas analysis was performed utilizing different heparin volumes and concentrations on 20 umbilical cord blood samples. A significant decrease in the bicarbonate concentration and base excess was found when 10,000 instead of 1,000 U/mL heparin was used to coat the syringe. When 0.2 mL of 1,000 U/mL heparin was added to 0.8 mL of blood, significant decline in the PCO2, base excess and bicarbonate concentration occurred. When 0.2 mL of 10,000 U/mL heparin was added to 0.8 mL of blood, a significant decline in the pH, PCO2, bicarbonate concentration and base excess was noted. Increasing the dilution and/or quantity of heparin in an umbilical arterial blood specimen may result in a significant misinterpretation of the fetal acid-base status by indicating a more significant chronic metabolic acidosis component than really exists.
Blood Gas Analysis↗
Endometriosis in multiparous women.
The incidence of endometriosis in the general population has been reported to range from 4% to 32%. A more realistic figure is probably 7.5%. An incidence of 7.4% was found in 42 of 566 multiparous women undergoing tubal sterilization at Baylor College of Medicine, Houston. Twelve of the 42 (29%) were less than five months postpartum. Hispanics had an incidence of endometriosis similar to that of whites and blacks. Indigent status had no bearing on the presence of endometriosis. A higher incidence of spontaneous abortion was found in patients with endometriosis, but the difference was not statistically significant.
Abortion, Spontaneous↗
Implications of sino-aortic baroreceptor reflex dysfunction in severe preeclampsia.
Loss of sino-aortic baroreceptor reflex sensitivity has been associated with various forms of hypertension. Baroreflexive dysfunction antedates elevation of blood pressure (BP) in some forms of hypertension, and may play a role in their pathogenesis. We studied baroreflex function in seven women with severe preeclampsia being treated with intravenous hydralazine. As indices of baroreflex sensitivity and hemodynamic competence, we measured the reflexive elevations in heart rate (HR) (delta HR/delta BP) and cardiac index (CI) (delta CI/delta BP) in response to hydralazine-induced falls in blood pressure. The change in cardiac index per unit change in systemic vascular resistance index (SVRI) (delta CI/delta SVRI) served as an additional measure of hemodynamic competence. The results indicated that a higher baseline blood pressure was associated with a dramatic reduction in baroreflex sensitivity (delta HR/delta BP) and baroreflex control of blood pressure (delta CI/delta BP and delta CI/delta SVRI). In patients with higher baseline blood pressures, the severe impairment of baroreflex function eliminated the normal circulatory buffer against vasodilator-induced hypotension. Abrupt and profound reductions in blood pressure and the development of fetal distress in response to hydralazine occurred in the patients with higher initial blood pressures. In addition, the present results suggest that phenomena such as the blood pressure lability and increased responsiveness to angiotensin that characterize preeclampsia are, at least in part, reflections of baroreflex dysfunction.
Adult↗
Quantitative hemodynamic effects of acute volume expansion in severe preeclampsia.
In a study of eight patients with severe preeclampsia, cumulative rapid infusions of 500 mL (set of eight patients) and 1000 mL (subset of five patients) of 5% albumin in normal saline were followed with invasive hemodynamic measurements at 5 and 30 minutes. Pulmonary capillary wedge pressure and central venous pressure rose. Cardiac index rose 23 and 34% at 5 minutes after the 500-mL and 1000-mL infusions, respectively; at 30 minutes, it remained at 17 and 34%, respectively, above control. The systemic vascular resistance index fell 24 and 29% below control values at 5 minutes after the respective infusions; at 30 minutes, it remained at 15 and 25%, respectively, below control. Mean systemic arterial pressure was unchanged, except for a small reduction shortly after the initial 500-mL infusion. In contrast, mean pulmonary arterial pressure rose significantly. Hence, the dominant effects of acute volume expansion in severe preeclampsia include an unchanged (or slightly reduced) mean systemic arterial pressure, resulting from marked elevations in cardiac index and concomitant, proportionate declines in systemic vascular resistance index.
Adult↗
Indomethacin in the treatment of premature labor. Effects on the fetal ductus arteriosus.
Indomethacin is a potent agent in the treatment of premature labor, but its use has been limited because of concern about its constrictive effects on the fetal ductus arteriosus. To study these effects we used serial fetal echocardiography in 13 pregnant women in premature labor who received indomethacin according to three different dose schedules, ranging from 100 to 175 mg per day, for a maximum of 72 hours. The gestational ages of the fetuses ranged from 26.5 to 31.0 weeks. The detection of ductal constriction in 7 of the 14 fetuses by echocardiography led to the discontinuation of indomethacin. Three fetuses also had tricuspid regurgitation. There was no statistically significant difference between the mean (+/- SEM) gestational age of the fetuses with ductal constriction and that of those without constriction (29.3 +/- 0.59 and 28.4 +/- 0.52, respectively). There was no relation between serum indomethacin levels in the mothers and ductal constriction. In all seven fetuses affected, ductal constriction had resolved by the time they were restudied 24 hours after the discontinuation of indomethacin. Persistent fetal circulation was not detected in any of the 11 neonates studied after delivery. Indomethacin used to treat premature labor appears to cause transient constriction of the ductus arteriosus in some fetuses, even after short-term use.
Adolescent↗
Polyhydramnios associated with a ring chromosome and low maternal serum alpha-fetoprotein levels managed with indomethacin.
A case of polyhydramnios associated with a ring chromosome is described. The condition was also associated with a low maternal serum alpha-fetoprotein level. The polyhydramnios was managed by initial therapeutic amniotic fluid decompression followed by indomethacin, which reduced fetal urine output and prevented reaccumulation of polyhydramnios.
Chromosome Aberrations↗
The effects of magnesium sulfate therapy on Apgar scores.
When intravenous magnesium sulfate is infused in women with pregnancy-induced hypertension, the hypermagnesemia does not result in lower Apgar scores. The mean maternal serum and cord magnesium levels at delivery were 5.3 +/- 0.72 and 5.3 +/- 1.1 mEq/dl, respectively. The most common negative Apgar score was assigned for color, not for muscle tone.
Apgar Score↗
Effects of low-dose dopamine therapy in the oliguric patient with preeclampsia.
Central hemodynamic and renal responses to low-dose dopamine (1 to 5 micrograms/kg/min) infusion were studied in six oliguric (less than 0.5 ml/kg/hr) patients with severe preeclampsia. Hemodynamic parameters were measured and renal function tests were done before and during therapy. There was a significant rise in urine output from a mean (+/- SD) of 21 +/- 10 to 43 +/- 23 ml/hr, accompanied by a rise in cardiac output from 6.8 +/- 1.8 to 8.0 +/- 2.3 L/min (p less than or equal to 0.05). There were no significant changes in blood pressure, central venous pressure, or pulmonary capillary wedge pressure. The fractional excretion of sodium, negative free water clearance, and osmolar clearance tended to rise during dopamine therapy. No adverse maternal or fetal effects occurred. We conclude that low-dose dopamine produces a significant increase in urine production with resolution of oliguria in severe preeclampsia.
Adult↗
Unknown uterine scar and trial of labor.
A review of 393 patients undergoing trial of labor after one or more previous cesarean sections was performed. Three hundred patients had an unknown uterine scar, 88 patients had a documented low cervical transverse incision, and five patients had a prior low vertical incision. The rate of vaginal delivery and maternal and fetal morbidity was no different in those patients with an unknown prior uterine incision compared with those having a known prior low cervical transverse incision. In 66 of the patients with a documented low cervical transverse incision, the original operative record was reviewed in regard to single-layer closure of the uterine incision versus double-layer closure or imbricating technique. No patient with a double-layer uterine closure had a subsequent dehiscence, whereas three patients with a prior single-layer closure exhibited scar separation. These data suggest that neither an unknown scar nor a single-layer uterine closure places the mother or fetus at greater risk.
Cesarean Section↗
Conservative management of abdominal gunshot wound in a pregnant woman.
An abdominal gunshot wound in pregnancy warrants prompt surgical exploration but does not mandate uterine evacuation. Despite an entry and exit bullet wound to the uterus an apparent desire for pregnancy termination, a conservative approach was adopted with primary repair of the uterus, in conjunction with surgical repair of associated injuries.
Abdominal Injuries↗