Biomedical subjects
Publications and source records attributed to F G Cunningham.
Five patients with abnormal pregnancies were examined with ultrasound (US) and magnetic resonance imaging (MR). Three had a malformed fetus, 1 had a molar pregnancy, and 1 had an ovarian mass. Both maternal and fetal structures were clearly shown, although fetal motion may have resulted in image degradation in some cases. The authors suggest that MR may be useful in obstetric diagnosis.
Magnetic resonance imaging is a new noninvasive diagnostic technique that involves no ionizing radiation, has no known significant adverse biologic effects, and produces high resolution cross-sectional body images. When compared with sonography and x-ray computed axial tomography, magnetic resonance imaging may have several advantages. To investigate its clinical role in obstetrics, magnetic resonance imaging was used to examine 11 women with abnormal pregnancies. Prior ultrasound examination showed abnormal appearing fetuses in five, abnormalities of the amnionic fluid volume in five, and one each with a large adnexal mass and a molar pregnancy. Examples of images obtained from these women are presented and described. Maternal anatomy was well visualized in all women studied. Based on the preliminary experience, the authors believe that magnetic resonance imaging will be a useful adjunct for diagnostic visualization of normal and abnormal maternal anatomy. Detailed fetal imaging was also possible, and it is anticipated that magnetic resonance imaging will prove useful for fetal evaluation, especially fetal intracranial anatomy and fetal anatomy in pregnancies complicated by oligohydramnios. Because fetal subcutaneous fat is prominently depicted with magnetic resonance imaging, this technology may be useful for assessment of fetal nutritional status.
In this study the authors assessed human and economic consequences of low birth weight linked to the lack of prenatal care for indigent women. Low birth weight infants were defined as those who weighed between 860 and 2220 g, corresponding to the 50th percentiles at 26 and 34 weeks' gestation. Women seeking prenatal care had a significantly decreased incidence of low birth weight infants compared with those without such care. Concomitantly, low birth weight infants born to women with prenatal care had significantly better perinatal survival as well as less frequent respiratory distress and intraventricular hemorrhage. Because of these factors, infants born to clinic mothers used fewer neonatal intensive care days and had shorter hospitalizations. Hospital costs were reviewed for 175 surviving infants and failure to obtain prenatal care was associated with a 50% increase in costs for each infant. The frequencies of the most common pregnancy complications in women with and without prenatal care, coupled with corresponding obstetric interventions, suggest that such care facilitates identification and management of women at risk for delivery of low birth weight infants. The authors conclude that there are important human and economic advantages of antenatal care for indigent women.
During a 2-year prospective investigation of prolonged pregnancy in 727 women, 59 (8%) were delivered by cesarean section for fetal distress. This condition was diagnosed by means of electronic fetal heart rate monitoring in 47 of the women, and the patterns were unexpectedly characteristic of umbilical cord compression rather than uteroplacental insufficiency. Blinded sonar examinations were performed in 213 women, and the incidence of cesarean section for fetal distress as now described was significantly increased in those with oligohydramnios (two or fewer 1 cm pockets of amniotic fluid). We conclude that the pathophysiology of fetal distress in prolonged pregnancy is typically oligohydramnios that leads to compromised umbilical cord perfusion, rather than uteroplacental insufficiency.
Eight primigravid women with eclampsia underwent invasive hemodynamic monitoring shortly after admission and showed initial low right and left ventricular filling pressures, hyperdynamic left ventricular function, and elevated systemic vascular resistance. These findings persisted throughout 12 postpartum hours, with management that consisted of restriction of fluid, magnesium sulfate, and intermittent hydralazine for severe hypertension. Thereafter, those women without spontaneous diuresis had elevated pulmonary capillary wedge pressures despite hyperdynamic ventricular function. We hypothesize that this phenomenon was due to mobilization of extracellular extravascular fluid prior to diuresis. Comparison of these women with those with severe preeclampsia previously reported by others suggests that their hemodynamic status is significantly influenced by differences in fluid management.
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Since 1955, a standardized treatment regimen has been used to manage 245 cases of eclampsia at Parkland Memorial Hospital. Magnesium sulfate alone effectively controlled controlled convulsions in the great majority of cases. The only maternal death among the 245 cases reemphasizes the risk of respiratory arrest that is inherent in the administration of magnesium sulfate when given in large doses intravenously. Hydralazine to lower the diastolic blood pressure somewhat, when it was 110 mm Hg or higher, prevented intracranial hemorrhage. Avoidance of diuretics and hyperosmotic agents and limitation of fluid intake were not associated with severe renal failure. Pulmonary edema was rare. Vaginal delivery was achieved in the majority of cases. Oxytocin often proved effective for initiating and maintaining labor even remote from term. The results obtained with this regimen justify its continued clinical application.
A management plan is described for women with pregnancy-induced hypertension. The plan was derived from observations of well-defined methods in more than 20,000 pregnancies at Parkland Memorial Hospital. Even though the treatment regimens described are empiric, there are considerable data presented to justify their clinical application.
A previously unreported complication of acute pyelonephritis during pregnancy is described. Acute respiratory distress accompanied by varying manifestations of liver, kidney, hypothalamic, and hematopoietic dysfunction is chronicled in four women. Because these latter organ system effects are attributable to endotoxin, the authors postulate that endotoxin caused alveolar-capillary injury leading to respiratory failure in these pregnant women with acute renal infection.
In the present investigation we found that the catechol-O-methyltransferase (COMT) activity in erythrocytes of pregnant women with sickle cell disease was strikingly elevated compared with that in erythrocytes of men and pregnant and nonpregnant women. Moreover, the enzyme activity in erythrocytes remained high during and after transfusion or partial exchange transfusion even though the enzyme activity in donor cells was low. This finding is suggestive of the possibility that a factor(s) in plasma of persons with sickle cell disease activates erythrocyte COMT activity.
To evaluate the effects of intravenously administered ritodrine hydrochloride on sodium and water metabolism, a pregnant baboon model was studied. Animals given ritodrine retained significantly more sodium (p less than 0.001) and administered fluids (p less than 0.002) compared with control animals. Although plasma volume did not change significantly within or between the two groups, extracellular volume increased by a mean of 1,480 ml in those given ritodrine compared with 790 ml in the control animals. There was no significant difference between animals given ritodrine and their controls regarding serial hematocrits, serum sodium, or colloid oncotic pressures. From this we conclude that the retained sodium and water was in the interstitial space. Since plasma volume was unaltered by ritodrine administration it seems unlikely that pure volume overload can explain the pulmonary edema induced by beta-mimetics. Combined with the prior observation that direct pulmonary capillary membrane toxicity does not occur, the likely pathophysiology of beta-agonist-induced pulmonary edema involves left ventricular failure.
One hundred eighteen women who developed endomyometritis after cesarean section in Parkland Memorial Hospital were treated with parenteral cefotaxime sodium. The requirement for additional antimicrobial therapy was significantly higher at an initial daily dose of 3 g/day (16.4%) than when the dose was 6 g/day (4.8%) (P less than .05). The latter clinical efficacy and the observed in vitro susceptibility of 88% of isolates indicate that cefotaxime is well suited for single-agent parenteral therapy for this polymicrobial pelvic infection. Subsequently, 120 women with the same diagnosis were randomly treated with cefotaxime or clindamycin and gentamicin. Patient populations, surgical variables, in vitro microbiologic data, and side effects were similar for both groups. Clinical success observed was also similar: it was 97.5% for women given cefotaxime and 95% for women given clindamycin and gentamicin.
Eighty-six women with suspected acute salpingitis were treated with parenteral cefamandole. From 53 (62%) of these Neisseria gonorrhoeae was recovered from an anogenital site(s) at admission. These women were younger, of lower parity, had pain for a shorter period of time, responded more rapidly to therapy, and required less antimicrobial agent for clinical cure than those from whom N gonorrhoeae was not recovered. The clinical success observed in these women was 94%, and only 2% of 122 gonococcal isolates were resistant to cefamandole in vitro.
To determine neonatal risk of exposure to intrapartum antimicrobials given to reduce maternal infection following cesarean delivery, 642 mother-infant pairs were evaluated. In 464, the mother was given an initial dose of antimicrobial(s) before cord clamping, whereas in the remaining 178 administration of these drugs was not begun until after delivery. Despite the facts that all infants were at equivalent risk for infection and that none were proved to have bacteremia, 28% of those exposed to intrapartum maternal antimicrobials were evaluated for sepsis whereas only 15% of those not exposed were evaluated (P less than .001). Excess hospital charges for infants in whom sepsis workup was initiated was $127 greater than that for infants not suspected of having sepsis (P less than .025). Of 305 women given three-dose perioperative antimicrobial therapy, 255 were given the initial dose before cord clamping and 24% experienced a subsequent uterine infection. This was not significant when compared with a uterine infection rate of 22% in 50 women in whom three-dose therapy was not initiated until after cord clamping. As maternal benefits that accrue from such intrapartum therapy are equivalent regardless of the timing of three-dose treatment, and as fetal exposure to these drugs has significant clinical and economic impacts, it is concluded that antimicrobials given to these women at high risk should be withheld until after cord clamping.
Maternal morbidity and perinatal outcome in 108 pregnancies complicated by sickle cell anemia (hemoglobin SS disease), sickle cell-hemoglobin C disease (hemoglobin SC disease), or sickle cell-beta-thalassemia disease were analyzed. Women given prophylactic red cell transfusions (1973-1982) during pregnancy were matched with historic controls whose care was almost identical except that blood was not given unless indicated (1955 to 1972). In women with hemoglobin SS disease who received prophylactic red cell transfusions, there was a sevenfold reduction in perinatal mortality and negligible maternal morbidity. In pregnancies complicated by hemoglobin SC disease during which transfusions were given, there were no perinatal losses, whereas there were in 18% of women not given transfusions. Maternal morbidity in women given transfusions was negligible; however, half of those not transfused experienced morbidity and, importantly, pulmonary complications were common. Transfusion-related complications included hepatitis and alloimmunization. From these experiences the authors conclude that prophylactic red cell transfusions reduce maternal morbidity and perinatal mortality appreciably, although perinatal morbidity is not eliminated. Transfusion therapy is justifiably started early in pregnancy for women with hemoglobin SS disease; however, transfusions may be withheld until the end of the second trimester for women with hemoglobin SC or sickle cell-beta-thalassemia disease.
Two grams of moxalactam was given intravenously to 28 women at high risk for infection following cesarean delivery. After a mean time of 48 minutes from infusion, maternal sera, cord sera, and uterine tissue obtained at delivery had concentrations of moxalactam of 62 micrograms/ml, 22.2 micrograms/ml, and 9.6 micrograms/gm, respectively. The maternal serum half-time was calculated to b e 2.1 hours. R and S epimeric distribution was determined in these sera and tissues, and the mean R/S ratios were 0.95, 0.93, and 1.22 for the three groups, respectively. The significance of these observations is discussed. A new method in which a high-pressure liquid chromatographic assay is used is described, and results are compared to those obtained with the microbiological assay. The high-pressure liquid chromatographic method was found to be quick, accurate, an reproducible.