Prolonged maternal indomethacin therapy associated with oligohydramnios. Case reports.
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Amniotic Fluid↗
Biomedical subjects
B Kirshon
Publications and source records attributed to B Kirshon.
Management of ovarian hyperstimulation syndrome with chlorpheniramine maleate, mannitol, and invasive hemodynamic monitoring.
Ovarian hyperstimulation syndrome due to exogenous gonadotropin administration is life-threatening in its most severe form. Profound fluid shifts may occur, with concomitant cardiovascular changes. We present a case of severe ovarian hyperstimulation syndrome managed with chlorpheniramine maleate (previously shown to be effective in animal models) and invasive hemodynamic monitoring. Mannitol and albumin infusions were also used to maintain urine output and intravascular volume.
Adult↗
Teratogenic effects of first-trimester cyclophosphamide therapy.
Intravenous cyclophosphamide was administered for severe exacerbation of systemic lupus erythematosus to a patient not known to be in the first trimester of pregnancy. The patient received no other medication except prednisone. Her neonate was born with multiple anomalies, including absent thumbs, cleft palate, low-set ears, and multiple eye abnormalities. These anomalies probably reflect teratogenic effects of cyclophosphamide, and indicate that judgment is required before its use in the first trimester. Furthermore, this case illustrates the need for effective contraception and repetitive pregnancy testing when potentially teratogenic agents are administered to presumably nonpregnant women in the reproductive age group.
Abnormalities, Drug-Induced↗
Role of volume expansion in severe pre-eclampsia.
Fifteen primigravid patients with severe pregnancy-induced hypertension were studied by catheterization of the right side of the heart. A hemodynamic protocol was implemented that required maintaining colloid osmotic pressure above 17 millimeters of mercury, pulmonary capillary wedge pressure below 15 millimeters of mercury and the mean arterial pressure in a very narrow range throughout labor and delivery and for 48 hours postpartum. The initial colloid osmotic pressures and pulmonary capillary wedge pressures were 18.0 +/- 2.6 and 10.5 +/- 4.0 millimeters of mercury, respectively, and remained essentially unchanged throughout the post partum period. The only benefit derived from volume expansion in these patients appeared to be the absence of acute fetal distress after the initiation of antihypertensive therapy. Six of 15 patients had late fetal stress develop during labor, suggesting that aggressive volume repletion and colloid osmotic pressure correction in pregnancy-induced hypertension does not effect the over-all incidence of fetal distress. We recommend that correction of colloid osmotic pressure be restricted to instances in which extremely low values (less than 12 millimeters of mercury) or a prolonged negative colloid osmotic pressure to pulmonary capillary wedge pressure gradient are identified. Finally, the benefit of volume expansion in pregnancy-induced hypertension appears to be the prevention of sudden and profound drops in blood pressure with antihypertensive therapy--not the prevention of fetal distress during labor.
Antihypertensive Agents↗
Influence of short-term indomethacin therapy on fetal urine output.
Eight pregnancies ranging from 27-32 weeks' gestation were treated for preterm labor with oral indomethacin. The dosage regimen was 25 mg every four hours in four patients and 25 mg every six hours in the other four patients. The maximum duration of indomethacin therapy was 72 hours. In three patients, fetal ductus arteriosus constriction mandated discontinuation of indomethacin at 24 hours. Sonographic assessment of hourly fetal urine output was performed before therapy, at multiple regular intervals during therapy, and 24 hours after the last dose of indomethacin. A dramatic decline was noted from the mean baseline fetal urine output of 11.2 mL/hour. The mean fetal urine output at five, 12, and 24 hours during therapy was 2.2, 1.8, and 1.8 mL/hour, respectively (P less than .05). Twenty-four hours after completion of indomethacin therapy, the mean fetal urine output was 13.5 mL/hour. Poor correlation (r = 0.14, P less than .05) was noted between maternal serum indomethacin levels and hourly fetal urine output. This significant decline in urine output is consistent with other results in neonatal and adult animals and humans. Furthermore, it implies a role for prostaglandins in controlling urine output during fetal life.
Constriction, Pathologic↗
Pelvic adhesions in intrauterine device users.
A thorough inspection of the pelvis for adhesions was made at the time of laparoscopic tubal sterilization in 2131 patients. Contraceptive use was then compared in women with adhesions (cases) and those without adhesions (controls). Current or previous intrauterine device (IUD) use was not associated with a statistically significant increased incidence of adhesions (odds ratio = 0.98, 95% confidence limits 0.58-1.64). This risk was reduced to 0.62 for current IUD users. The IUDs removed at the time of laparoscopy included the Lippes Loop, Copper 7, and the Saf-T-Coil. These findings support the use of the IUD in the appropriate patient by demonstrating no increased risk for the development of adhesions in multiparous IUD users.
Adult↗
Favorable outcome after treatment with amantadine and ribavirin in a pregnancy complicated by influenza pneumonia. A case report.
The moderate impairment of cell-mediated immunity that occurs in pregnancy justifies concern when a pregnant woman develops influenza. We treated a woman for influenza pneumonia with respiratory failure at 33 weeks' gestation with oral amantadine and ribavirin inhalation therapy in conjunction with evacuation of the uterus and delivery.
Adult↗
Contraception: a risk factor for endometriosis.
Endometriosis was detected in 42 cases out of 566 patients undergoing laparoscopic tubal sterilization. The presence of endometriosis was then correlated with previous contraception. Those patients using no contraception, or barrier contraception alone, were regarded as controls. Previous oral contraceptive use was associated with a lower incidence of endometriosis, although the difference was not significant. A significantly higher incidence (P less than .05) of endometriosis was present in former intrauterine device users, possibly because of retrograde flow of increased menses.
Adult↗
Prompt resolution of hyperthyroidism and hyperemesis gravidarum after delivery.
Severe hyperemesis gravidarum has often been associated with elevated thyroid function. However, it has not been determined whether establishing euthyroidism will result in prompt resolution of nausea and vomiting. We report here a gravida with severe intractable hyperemesis gravidarum requiring four months of parenteral hyperalimentation. This patient consistently demonstrated biochemical evidence of hyperthyroidism with no symptoms and signs other than nausea and vomiting. Although no parenteral form of antithyroid medication is commercially available, methimazole suppositories were developed and administered until thyroid function tests normalized. Despite euthyroidism, nausea and vomiting continued unabated. After delivery, both the elevated thyroid function and the nausea and vomiting resolved within three days.
Female↗
Is vaginal birth after two or more cesarean sections safe?
Fifty-five patients with a history of two or more cesarean sections underwent a trial of labor. Forty-two had had previous uterine incisions of unknown type, 11 had had low cervical transverse incisions, and two had had low vertical incisions. Twenty-five women (45%) had successful vaginal deliveries, and 30 (55%) received oxytocin augmentation of labor. The incidence of vaginal delivery was significantly lower in patients who required oxytocin augmentation (30 versus 64%, P less than .01). Three of the 55 patients had scar separation detected at the time of delivery. Two patients underwent hysterectomy. There were no maternal or neonatal deaths. A history of multiple cesarean sections need not exclude the patient from the option of trial of labor.
Adult↗
Percutaneous umbilical cord blood sampling in the evaluation of fetal platelet counts in pregnant patients with autoimmune thrombocytopenia purpura.
Autoimmune thrombocytopenia purpura in pregnancy is associated with fetal thrombocytopenia. Twenty-one patients with autoimmune thrombocytopenia purpura (22 fetuses) underwent 26 umbilical cord punctures to assess the fetal platelet count. Blood could not be obtained from one fetus. Thrombocytopenia (less than 150,000/microL) was found in five cases, but in none was it of sufficient degree to preclude vaginal delivery. Persistent fetal bradycardia necessitating emergency cesarean delivery occurred in two cases. Umbilical cord puncture was found to be technically more difficult in the term fetus than in the second-trimester fetus studied in previous investigations.
Adolescent↗
Gordon's syndrome in pregnancy.
A case of Gordon's syndrome (short stature, defective dentition, hyperkalemic, hyperchloremic acidosis, and chronic hypertension) complicating pregnancy is presented. Rigid salt restriction with diuretic therapy not only controlled the hypertension but also reversed the metabolic abnormalities. This is the first case report of a pregnancy complicated by this rare syndrome.
Acidosis, Renal Tubular↗
The use of fetal neuromuscular blockade during intrauterine procedures.
Advances in fetal therapy have led to the utilization of such techniques as intravascular transfusion of the Rh-affected fetus, bladder shunt placement in the fetus with obstructive uropathy, and percutaneous umbilical blood sampling. Fetal movement makes these procedures technically more difficult while increasing the risk of fetal injury. However, maternal sedation rarely results in adequate suppression of fetal activity. Thus we tested the sedative effects of intramuscular d-tubocurarine (3 or 1.5 mg/kg) or pancuronium bromide (0.3 mg/kg) injected into the fetal gluteal region under ultrasound guidance in conjunction with 70 invasive in utero procedures. Short-term paralysis of the fetus was induced in all cases. No deleterious effects of this technique were noted on initial examination of the neonates. Neuromuscular blockade was found to be a very useful adjunct to both diagnostic and therapeutic procedures involving the fetus.
Adult↗
Invasive hemodynamic monitoring in the obstetric patient.
The pulmonary artery catheter, although initially used by internists and anesthesiologists, has recently entered the armamentarium of the maternal/fetal medicine specialist. Expertise in gaining central venous access and correct placement of the catheter is required. The physician should be familiar with the indications for its use in the obstetric patient, as well as the potential complications. With correct interpretation of the parameters obtained, the pulmonary artery catheter can be an invaluable aid in the management of the critically ill obstetric patient.
Catheterization↗
Indirect blood pressure monitoring in the postpartum patient.
Direct intra-arterial blood pressure (BP) measurements were compared with simultaneous standard cuff sphygmomanometry and automated inflatable cuff manometry in 12 postpartum patients. An adjustable arterial damping device was used to correct overestimations of systolic values due to distorted pressure waveforms. No significant differences in diastolic pressure with and without arterial damping were noted between noninvasive techniques and direct intra-arterial values. The systolic readings obtained with the standard cuff were significantly lower than the intra-arterial values with or without the arterial damping device (P less than .001 in both cases). However, mean systolic BP by automated cuff did not differ significantly from intra-arterial readings in the presence of the damping device (P = .10, not significant). We recommend indirect BP monitoring by automated cuff manometry in nonobese critically ill patients requiring frequent BP readings, and arterial catheter in situations requiring frequent arterial blood samples or oxygenation assessment.
Blood Pressure Determination↗
Reduction in the middle cerebral artery pulsatility index after decompression of polyhydramnios in twin gestation.
Amniotic fluid decompression was performed for symptomatic polyhydramnios complicating four sets of discordant twin gestations. Doppler ultrasound waveforms of the middle cerebral artery were determined before and after the procedure in seven of the eight fetuses. After amniocentesis, the pulsatility index of the middle cerebral artery (PIMCA) was reduced in all fetuses (p < 0.01). When one considers only the larger twin in each set, the magnitude of the change in PIMCA was relatively consistent among the different sets (-0.60 +/- 0.14; p < 0.01; range, -0.45 to -0.79). The smaller twins showed a much more variable response (-0.82 +/- 0.70; range, -0.05 to -1.75). The pulsatility index of the umbilical artery (PIUA) showed no consistent trend in the five subjects in which it was determined. In principle, the cerebrovascular dilation indicated by the PIMCA measurements may in part be due to acute increases in maternal and fetal carbon dioxide tensions following relief of maternal restrictive lung dysfunction. More importantly, the acute fall in amniotic fluid pressure--the external pressure to which the fetoplacental unit is exposed--leads to pooling of blood in fetal and placental veins, and thereby reduces the effective blood volume of the fetoplacental unit. This effective hypovolemia, functionally analogous to that produced by fetal hemorrhage, elicits changes in regional vascular resistances that favor cerebrovascular perfusion. The impact of acute amniotic fluid decompression on the fetal circulation reflected in the marked changes in PIMCA suggests a role for monitoring to avoid large acute changes in pressure during therapeutic amniocentesis.
Amniocentesis↗
Correlation of ultrasonography and bacteriology of the endocervix and posterior cul-de-sac of patients with severe pelvic inflammatory disease.
We evaluated 30 patients admitted with a diagnosis of pelvic inflammatory disease (PID) by culdocentesis and ultrasonography to determine the severity of disease in relation to endocervical and culdocentesis bacteriology. Specimens from the endocervix were cultured for Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma hominis, and Ureaplasma urealyticum. In addition, culdocentesis fluid was cultured for aerobes and anaerobes. Patients with N. gonorrhoeae or C. trachomatis had significantly milder disease (P less than 0.05) compared with patients whose specimens were negative for those organisms. Furthermore, those patients with ultrasound confirmation of a tubo-ovarian complex had significantly (P less than 0.0001) greater recovery of aerobes and anaerobes from culdocentesis fluid than did patients with milder disease.
Adult↗
Subjective ultrasonographic assessment of amniotic fluid depth: comparison with the amniotic fluid index.
The purpose of this study was to evaluate the ability to identify abnormalities in amniotic fluid volume by subjective ultrasonographic assessment compared to a semiobjective method. In 886 consecutive ultrasound examinations subjective assessment of the amniotic fluid volume was performed and graded into 3 categories: normal, decreased, and increased. Following that, a four-quadrant sum (amniotic fluid index) was performed by the same experienced ultrasonographer and divided into 3 categories using the 5th and 95th percentiles. The sensitivity of the subjective analysis to diagnose a decreased amniotic fluid volume when compared with the amniotic fluid index was 58% (95% confidence interval, CI: 40-70%), with a false-positive rate of 17% (CI 8-32%). The sensitivity of the subjective analysis to diagnose an increased amniotic fluid volume when compared with the amniotic fluid index was 100% (CI 70-100%). However, the false-positive rate was 74% (CI 55-85%). Diagnosis of a normal amount of amniotic fluid by the subjective technique had a sensitivity of 96% (CI 95-97%) and a false-positive rate of 3% (CI 2-4%). Subjective ultrasonographic assessment of the amniotic fluid volume may serve as a screening test for the experienced ultrasonographer. However, when a decreased or increased amount of amniotic fluid volume is suspected, one may elect to use the amniotic fluid index for confirmation of the subjective impression.
Amniotic Fluid↗