Changes in the ST waveform of the fetal lamb electrocardiogram with hypoxemia

The ST waveform of the fetal electrocardiogram (ECG) was examined in 10 chronically instrumented fetal lambs from 115 days to term. Averaged ST waveforms were plotted at 5-minute intervals in six fetuses for 2 to 22 days. No diurnal or other rhythms were seen. To correct for changes in signal gain the amplitude of the T wave was measured relative to the amplitude of the QRS complex. The T/QRS ratio was normally less than 0.30. Persistently elevated ST waveforms with a T/QRS range 0.32 to 0.65 preceded fetal death by some days in three fetuses and were associated with anemia and/or hypotension in a further three. In these animals hypoxia produced a further rise in the ST waveform (mean T/QRS, from 0.48 to 0.81) and all died during labor. In lambs with a normal ST waveform there were differences in the response to hypoxia over 1 hour for a similar fall in Po₂. In eight experiments the ST segment and T wave increased (mean T/QRS, from 0.17 to 0.59) and promptly reverted to normal with normoxia. There was a significant rise in mean arterial blood pressure, plasma lactate, and glucose and a fall in pH. In four experiments there was little change (mean T/QRS, from 0.19 to 0.25), with a small rise in plasma lactate suggesting that these lambs were able to maintain aerobic myocardial metabolism. Overall there was a strong correlation of the T/QRS ratio to the rate of rise of lactate. These findings complement previous results in the acute fetal lamb preparation and suggest that ST waveform elevation expressed as the T/QRS ratio identifies a change to anaerobic myocardial metabolism.     

Factors influencing aortocaval compression in late pregnancy

The circulatory effects of postural change in late pregnancy were investigated in 20 healthy pregnant women. Maximum stroke volume (93.2 +/- 11.9 ml) was recorded with the subject in the left lateral position and was significantly (p less than 0.001) reduced in the supine, right lateral, and lithotomy positions, but was largely unchanged in the standing motionless position (89.9 +/- 12.6 ml). Diastolic, systolic, and mean arterial blood pressures and total peripheral vascular resistance were significantly (p less than 0.001) increased in the supine, right lateral, lithotomy, and upright motionless positions when compared to the same variables in the left lateral position. The following factors were found to be significantly correlated to the hemodynamic response to the supine recumbent position: maternal age (p less than 0.05), the position of the fetus in the uterus (p less than 0.05), and systolic (p less than 0.001) and diastolic (p less than 0.001) blood pressures measured with the subject in the left lateral position. The implications of the present findings for modern obstetric delivery care and the etiology of the supine hypotensive syndrome are discussed.     

Steroid production and responsiveness to gonadotropin in isolated stromal tissue of human postmenopausal ovaries

Specimens from the ovarian cortical stroma of 15 postmenopausal women were examined histologically and were incubated for 4 hours in Krebs' bicarbonate buffer containing 5.5 mM glucose and 1% bovine serum albumin. Specimens of normal postmenopausal stroma produced measurable amounts of androstenedione, estradiol, and progesterone in vitro. Specimens with stromal hyperplasia produced larger amounts of androstenedione and estradiol than those with normal stroma. Androstenedione was the predominant steroid produced in both groups. The nonnegligible formation of estradiol indicated an aromatizing capacity of the stromal tissue. The addition of hCG elicited a significant increase in cyclic AMP formation in specimens from ovaries with stromal hyperplasia, indicating a preserved responsiveness to gonadotropin in this type of ovaries.     

Human uterine fluid, examined in undiluted samples for osmolarity and the concentrations of inorganic ions, albumin, glucose, and urea

Human uterine fluid and serum, when analyzed, had the same osmolarity. Both the total cation concentration and that of albumin were lower in uterine fluid than in serum. Decreased cation concentration is probably a regulatory mechanism maintaining electroneutrality in uterine fluid when the protein concentration is decreased, since protein molecules have multiple negative charges. Compared with their serum values, concentrations of potassium were high, and those of sodium and calcium were low. Concentrations of potassium and calcium in uterine fluid were found to vary cyclically, both having lower values at midcycle than in the proliferative and luteal phases. The concentrations of chloride, urea, glucose, and fructose in uterine fluid did not differ significantly from those in serum. A possible influence of the ionic composition of uterine fluid on sperm migration at midcycle and on the implantation process in the luteal phase was also considered.     

Continuous transcutaneous oxygen monitoring in fetal surveillance during labor

Continuous transcutaneous oxygen (P_tcO₂) monitoring is a noninvasive technique for recording changes in central oxygenation. P_tcO₂ monitoring has been for some years a routine method in neonatal and adult intensive care. The technique is a potential tool in fetal surveillance during labor. Some recently published studies which have been critical of the use of P_tcO₂ monitoring in the delivery room reveal a lack of thorough understanding of the limitations of the technique. From the author's experience with the technique, it is obvious that, when the P_tcO₂ electrode is attached according to recommendations and when the monitoring situation fulfills certain criteria, P_tcO₂ reliably reflects changes in the fetal oxygenation during labor and may be used for the diagnosis of true hypoxemia. P_tcO₂ monitoring does not replace any other available routine monitoring for fetal surveillance, but when the technique is refined, it may become an additional means of diagnosing fetal jeopardy. As a research parameter, P_tcO₂ monitoring has already contributed to a more diversified understanding of the process of fetal asphyxia.     

Redistribution of cardiac output and oxygen delivery in the hypoxemic fetal lamb

In hypoxia, fetal cardiac output and the product arterial O2 content x blood flow to the fetal heart and central nervous system (CNS) tend to remain constant. As a consequence the percentage of cardiac output directed to the heart and CNS increases hyperbolically in inverse relation to the oxygen content of the fetal ascending aorta, [O2]as. The fetal lamb maintains [O2]as approximately 0.45 mM (0.45 +/- 0.02 SEM) higher than the O2 content in the abdominal aorta, [O2]ab, over a wide range of oxygenation. When [O2]as decreases below the 2 mM level, the [O2]as--[O2]ab difference (delta O2) decreases also. A mathematical model of the fetal circulation shows that delta O2 is a function of the ratio oxygen consumption of fetal upper body/abdominal aorta blood flow (VU/FA). The behavior of delta O2 in hypoxia can be explained by assuming that the VU/FA ratio is maintained in moderate hypoxia and decreases in sever hypoxia.     

Studies on the decreased gonadotropin response after administartion of LH-FSH-releasing hormone during pregnancy and the puerperium

The responsiveness of the pituitary to luteinizing hormone releasing hormone (LRH) during pregnancy and the puerperium was studied in 15 women 18-32 years of age (3 puerperal, 6 pregnant, and 6 eumenorrheic). 25 mcg LRH dissolved in 1 ml sterile water was administered iv to all the subjects. Blood samples were obtained 10 minutes prior to, immediately prior to, and 10-120 minutes following injection. LH and follicle stimulating hormone (FSH) were determined by double antibody radioimmunoassay. No significant (p more than .05) FSH response was observed 8-10 days postdelivery. However, 2 weeks postpartum the mean FSH response was significant (p less than .01) but not that of LH (p more than .05). 4 weeks postpartum revealed a significant LH (p less than .05) and FSH (p less than .01) response. The response of pregnant women to LRH was insignificant (p more than .05). The LH response in eumenorrheic women was significant (p less than .01) as was that of FSH (p less than .01). It is concluded that, like pregnant women, puerperal women are less responsive to LRH than are aumenorrheic women.     

Female sex steroid concentrations in the ampullary and isthmic regions of the human fallopian tube and their relationship to plasma concentrations during the menstrual cycle

The concentrations of estradiol-17β (E₂) and progesterone (P) were measured in the ampullary and isthmic portions of the fallopian tube of nonpregnant menstruating women and the cyclic fluctuations were related to the concentrations of these hormones in plasma. The steroid concentrations were determined by radioimmunoassays. There was no significant difference in the isthmic and ampullary concentrations of either steroid in any of the menstrual phases. The mean value for E₂ was highest in the ovulatory phase and for P during the luteal phase. The tissue (per gm)/plasma (per ml) ratio for the steroid concentrations was above unity in all measurements. The ratio for E₂ was highest (isthmus:12, ampulla:8) in the follicular phase and for P (isthmus:26, ampulla:18) during ovulation. Since these highest ratios were attained when plasma steroid concentrations were relatively low they were interpreted as reflections of a maximal receptor contribution.     

Vasoactive substances in the circulation of the pregnant dog during acute fetal ischemia

Uterine venous blood from anesthetized dogs in late pregnancy was assayed for vasoactive substances during acute uterine ischemia by means of the blood-bathed bioassay technique. Short periods of reduction of uterine perfusion pressure to 60 mm. Hg or less caused the liberation into the maternal circulation of two vasoactive materials. One of these materials resembled angiotensin II; the other was an unidentified relaxatory factor. These substances were not released during reduction of uterine perfusion pressure after ligation of all umbilical cords. The results are compatible with a role for vasoactive materials of fetal origin in maternal circulatory disorders associated with fetal insufficiency.     

Treatment of recurrent endometrial adenocarcinoma with a combination of doxorubicin and cisplatin

Nineteen patients with recurrent endometrial carcinoma and one patient with Stage IV endometrial carcinoma not previously treated with chemotherapy were treated with a combination of doxorubicin and cisplatin. The dose schedule was doxorubicin, 50 mg/m2 on day 1, and cisplatin, 50 mg/m2 with hyperhydration on day 1, with a new course every 4 weeks. Objective response 60% was obtained in 12 out of 20 patients (two with complete remission and 10 with partial remission). Furthermore, four patients had stationary disease. The two patients with complete remission both had distal vaginal metastases, and they are still alive after greater than 21 and greater than 40 months. The median survival period for those with partial remission was greater than 11 months (range of 4 to 26); for those with stationary disease, 7 months (range of 4 to 10), and for those with progressive disease, 4 months (range of 3 to 7). The response rate was higher for well-differentiated tumors. No serious side effects were noticed. To our knowledge no other reports have been published so far with the use of the same regimen in patients with recurrent endometrial adenocarcinoma with no prior chemotherapy. We find the objective response rate, the survival time, and the quality of life for the responding patients in our study so encouraging that we shall continue with a larger trial.     

Inhibition of glucose-induced insulin secretion by indomethacin and sodium salicylate in the fetal lamb

The modulation of fetal insulin secretion by prostaglandins was studied with the aid of the prostaglandin synthesis inhibitors indomethacin and sodium salicylate in 10 chronically catheterized fetal lambs. Glucose-induced fetal insulin secretion was inhibited within 60 minutes by preinjection of either indomethacin or sodium salicylate in the fetal lambs. In the sodium salicylate experiments a significant (p less than 0.01) dose-related response (degree of insulin suppression) was noted between doses of 100 to 350 mg/kg of fetal weight. In a selected group of sodium salicylate injections prostaglandin levels were found to fall to 58% of control by 2 hours after injection. Five neonatal lambs exposed to a similar regimen were noted to have an exaggerated insulin response to glucose infusion when compared to fetal lambs. However, indomethacin or sodium salicylate pretreatment resulted in no suppression of glucose-induced insulin release. This finding may be of importance in explaining the observation of an increased incidence of fetal growth retardation after long-term exposure to salicylates in humans and in animal models.     

The relationship between movements and accelerations in fetal heart rate at twenty-four to thirty-two weeks' gestation

The purpose of this study was to establish the relationship between fetal heart rate accelerations and fetal body movements in fetuses at 24 to 32 weeks' gestation. The results suggest that body movements in younger fetuses do not occur with accelerations that are readily recognizable (i.e., less than 15 bpm), but as fetuses get older, the interaction between body movements and fetal heart rate becomes more evident and accelerations become more recognizable (i.e., greater than or equal to 15 bpm). The data presented suggest that there is a maturational aspect to the relationship between fetal heart rate and fetal body movements as fetuses increase in gestational age from 24 to 32 weeks. The conclusion, therefore, is that the nonstress test, as presently defined for older fetuses, is not valid for gestations below 32 weeks, and new criteria must be established.     

Predominance of L-dopa in fetal plasma and the amniotic fluid during late gestation in the rat

The purpose of this study was to reevaluate catecholamine distribution in fetal and maternal compartments during late gestation in the rat. Fetal and maternal plasma and amniotic fluid were collected from anesthetized rats on consecutive days from day 17 to day 22, the day of parturition. The fluid was analyzed for dihydroxyphenylalanine (L-dopa), dopamine, norepinephrine, and epinephrine by radioenzymatic assays. Amniotic fluid volume was determined by a direct weighing method. L-Dopa concentrations constituted approximately 50% of total fetal plasma catecholamines and were significantly higher in fetal than in maternal circulation. Dopamine concentrations in fetal plasma were tenfold lower than those of L-dopa but were also significantly higher in fetal than in maternal plasma; norepinephrine levels were similar in both. Maternal plasma epinephrine levels remained relatively constant, whereas fetal epinephrine levels increased fiftyfold from day 17 to day 22. L-Dopa concentrations in the amniotic fluid were tenfold higher than those of dopamine, and the concentrations of both increased markedly during the last 2 days of gestation. However, this apparent rise could be attributed to the concomitant fivefold reduction in the amniotic fluid volume observed at this time. It is concluded that L-dopa is the predominant catecholamine in both the fetal plasma and the amniotic fluid during late gestation in the rat. At the present time, neither the source nor the possible physiologic functions of L-dopa during fetal life are known.     

Serial nephelometric urine IgG measurement and the management of pregnancy-induced hypertension

Serial IgG analysis was performed on the urine and serum of 16 patients with pregnancy-induced hypertension. Significant immunoglobulinuria developed prior to the development of azotemia, significantly decreased creatinine clearance, significant proteinuria (greater than or equal to 3+ dipstick or greater than or equal to 5 gm per 24-hour urine collection), or oliguria. Nephelometric measurement of urine IgG concentrations appears to be a rapid and accurate method for confirming the severity of clinical disease, the degree of renal involvement, the benefit of treatment modalities on renal function, and the likelihood of postpartum maternal morbidity.     

Intrapartum fetal asphyxia: clinical characteristics, diagnosis, and significance in relation to pattern of development.

The clinical and fetal heart rates and acid-base characteristics and their sequelae have been reviewed in 587 patients. The relevant clinical factors in the asphyxia group were the preterm fetus, the intrauterine growth retarded fetus, maternal toxemia, and midforceps delivery. The duration of the developing metabolic acidosis in the asphyxia group ranged from terminal to the last two hours of labor. Marked patterns of total decelerations and moderate and marked patterns of late decelerations are of predictive value in the diagnosis of intrapartum fetal asphyxia with a trend to an increased incidence in the longer duration categories, between four and two hours prior to delivery, and a significant increase in all categories during the last two hours of labor. The significance of intrapartum fetal asphyxia to the newborn infant is evident from the low Apgar scores, increased incidence of moderate and severe respiratory distress syndrome, and central nervous system complications in the asphixia group in relation to the normal group.     

Problems and approaches in the surveillance and control of sexually transmitted agents associated with pelvic inflammatory disease in Africa

The problems in surveillance of sexually transmitted disease (STD) in Africa are numberous and are based mainly on socioeconomic barriers. Policies for controlling STD are either inadequate or nonexistent in many African countries. Gonococci are becoming increasingly insusceptible to penicillin and other drugs because of widespread use of inadequate therapy. Gonorrhea is recognized as the major pathogen of pelvic inflammatory disease in Africa. The magnitude of the PID problem is so great that current efforts are directed at case treatment rather than surveillance and control. The formation of the African Union Against Venereal Diseases and Treponematoses is an important step, and its suggestions and resolutions form a sound basis for improved STD control in Africa.     

Blood flow in the intervillous space and fetal blood flow. II. Relation to placental histology and histometry in cases with and without high fetal risk

The blood flow in the intervillous space and the fetus was studied with ¹³³Xe in 44 pregnancies at term. In 21 cases, fetal distress attributable to placental insufficiency appeared during labor. The values for both flows fell outside the limits of reliability of the straight line regression calculated for the 23 normal cases. In 23 cases we were able to study the placentas histologically and morphometrically; these placentas were classified as mature, hypermature, and senescent. The relationship between the histologic aspect of the placenta and the flows in the intervillous space and in the fetus was investigated. Cases of fetal distress were usually associated with hypermature and senescent placentas that have abnormal blood flows.     

The use of ultrasound in the prediction of fetal pulmonary maturity

Previous studies suggest that ultrasound criteria of biparietal diameter (BPD) and/or placental grade permit elimination of amniocentesis for pregnancy dating. To evaluate the potential risks and benefits of such a modified approach to determining fetal maturity, this prospective study, in which a BPD of ≥9.2 cm or a Grade III placenta was used instead of amniotic fluid analysis, was undertaken. One hundred fifty-three infants were delivered electively between March 1981, and January 1982, on the basis of ultrasound parameters of pulmonary maturity. None of the electively delivered infants developed respiratory distress syndrome. We conclude from these preliminary results that the ultrasonically determined BPD of ≥9.2 cm Grade III placenta is at least as sensitive as the lecithin/sphingomyelin ratio in predicting pulmonary maturity in our patient population.     

The ultrasonic changes in the maturing placenta and their relation to fetal pulmonic maturity.

A practical classification of placental maturity changes has been developed based on a review of multiple ultrasound evaluations of placental texture over a 4 year period. This classification grades placentas from 0 to 3 according to specific ultrasonic findings at the basal and chorionic plates as well as within the substance of the organ itself. The placentas of 129 patients were graded according to this system at the time of ultrasound evaluation. Eighty-six patients had placentas classified as Grade 1 or greater and all of these had lecithin-sphingomyelin (L/S) ratio determinations performed. Mature L/S ratios (2.0) were found in 68% of Grade I (21/31), 88% of Grade II (28/32), and 100% of Grade III placentas (23/23). These results suggest a correlation between maturational changes of the placenta as seen by ultrasound and fetal pulmonic maturity as indicated by L/S ratio.