Preterm delivery is not predicted by serial plasma estradiol or progesterone concentration measurements

Previous studies suggest that plasma estradiol-17 beta and progesterone concentration values differ between patients who deliver before term and those who deliver at term. To determine if these values would aid in preterm delivery risk prediction, we measured plasma estradiol-17 beta and progesterone concentrations serially in 90 patients at high risk for preterm delivery. Measurements from 17 patients who developed documented preterm labor and/or were delivered before term were compared to the tenth and ninetieth percentiles of 42 patients who were delivered at term. The sensitivity of these measurements to predict preterm delivery was very low. Also, the mean plasma estradiol-17 beta and progesterone concentrations in patients with preterm labor who had term deliveries and in patients with preterm labor that progressed to preterm delivery were not different from each other or from patients delivering at term. No change in plasma estradiol-17 beta or progesterone concentration was noted preceding labor. We conclude that serial measurements of plasma estradiol-17 beta and progesterone concentrations do not improve preterm delivery risk prediction.     

Comparative pharmacokinetics of cefoxitin in postpartum normotensive and pregnancy-induced hypertensive patients

Limited pharmacokinetic data exist on cefoxitin, a semisynthetic cephamycin antibiotic, in the obstetric patient. Thirteen normotensive and five subjects with severe pregnancy-induced hypertension were identified within the first two postpartum days after cesarean section. After a 2 gm intravenous infusion, serial samples of blood were obtained and analyzed for cefoxitin by high-pressure liquid chromatography. Peak cefoxitin concentrations after infusion were 53.3 ± 18.6 and 50.8 ± 25.2 μg/ml for the normotensive and pregnancy-induced hypertensive groups, respectively. The only significant difference in pharmacokinetic parameters between these groups was a higher serum trough concentration of cefoxitin in the patients with pregnancy-induced hypertension as compared to the normotensive group. Because of diminished trough levels in our study patients, attention may need to be given to the adjustment of dosages in postpartum women with serious infections.     

Cardiovascular alterations in severe pregnancy-induced hypertension: acute effects of intravenous magnesium sulfate

The central hemodynamic effects of intravenous magnesium sulfate were studied in five patients with severe pregnancy-induced hypertension. All five patients had a Swan-Ganz and a radial artery catheter placed prior to initiation of magnesium sulfate therapy. Four grams of magnesium sulfate was given over 15 minutes followed by a continuous infusion of 1.5 gm per hour. There was a 12.5% increase in cardiac index immediately after the infusion but cardiac index returned to pretherapy values by 15 minutes after infusion. The mean arterial pressure was significantly (p less than 0.01) decreased 30 minutes after the 4 gm loading dose but had returned to baseline values by 1 hour. There were no other significant changes in any of the hemodynamic or oxygen-related variables measured. Our data confirm previous hemodynamic studies in patients with severe pregnancy-induced hypertension indicating a hyperdynamic state with large fluctuations in systemic and pulmonary vascular resistances. In addition, magnesium sulfate has been shown to have a transient hypotensive effect on mean arterial pressure, related to bolus infusion, that is not present with continuous infusion.     

Evidence for an androgen-binding component in the cytosol of the human term placenta

The present communication describes a specific, high-affinity (K_d = 1.9 ± 0.21 × 10^?9M; n = 3) binding component for dihydrotestosterone present in the high-speed, hormone-stripped cytosol fraction of the human term placenta. In order to delineate the nature of this substance, the synthetic steroids R1881 (progesterone and androgen receptor specific) and R5020 (progesterone receptor specific) were employed. Minimal binding of H³-R5020 was observed; however, H³-R1881 was found to bind with a K_d = 0.6 ± 0.18 × 10^?9M (n = 3). The relative displacing ability of R5020 for H³-R1881 was only 1.3%, substantiating the presence of an androgen binder and negating the presence of a significant level of a progesterone-binding component. Evidence that the binder is of placental origin and does not result from blood contamination includes no significant binding of H³-R1881 to pregnancy serum, binder thermolability at 45° C, and precipitation of the binder by ammonium sulfate at 30% saturation. Speculations as to the receptor or receptor-like nature of the binder are presented.     

Treatment of genital herpes simplex virus infection with photodynamic inactivation.

A double-blind randomized study to evaluate the effect of proflavine in the treatment of genital herpesvirus infection was conducted. One hundred fifty-seven women were studied, of whom 75 were treated with proflavine (treated women) and 82 were treated with placebo (control group). There were 62 women with primary disease and 95 with recurrent infection. Under the conditions by which this study was conducted, there was no apparent difference in the time of healing of lesions, development of recurrences, or virus isolation following treatment in the proflavine-treated and control groups.     

The Trend,Feasibility, and Safety of Salpingectomy as a form of Permanent Sterilization

Study ObjectiveTo assess the change in the rate of laparoscopic salpingectomy for sterilization after the release of the November 2013 Society of Gynecologic Oncology Clinical Practice Statement and the January 2015 American College of Obstetricians and Gynecologists Committee Opinion: Salpingectomy for Ovarian Cancer Prevention. We hypothesized there would be an increase in salpingectomy as a percentage of total laparoscopic sterilizations performed without an increase in complications when compared with conventional bilateral tubal ligation (BTL).DesignA retrospective cohort study.SettingFour university-affiliated hospitals in Houston, TX, and New York, NY.PatientsAll women 21 years or older who underwent interval laparoscopic permanent sterilization between April 2013 and September 2016.InterventionsSterilization by bilateral salpingectomy or conventional tubal ligation.Measurements and Main ResultsThere were 454 sterilization procedures identified; 60% were BTLs, whereas 40% were salpingectomies. The rate of use of salpingectomy significantly increased from 5% to 9% in 2013 to 2014 to 78% by 2016. There was no significant difference in intraoperative or postoperative complications or estimated blood loss. The mean procedure time was 54 minutes for salpingectomy compared with 45 minutes for BTL (p <.0001). Salpingectomy was more likely to require 3 ports compared with 2 ports for BTL (p <.0001).ConclusionsThe Society of Gynecologic Oncology and the American College of Obstetricians and Gynecologists’ support of salpingectomy for ovarian cancer prevention increased its use for sterilization. Based on this study, laparoscopic bilateral salpingectomy is a safe method of sterilization without an increase in perioperative risk compared with conventional tubal ligation. Physicians should incorporate these findings and implications when counseling patients regarding contraception and permanent sterilization.     

Ontogeny of human fetal plasma progesterone, deoxycorticosterone, and deoxycorticosterone sulfate

The concentrations of progesterone, deoxycorticosterone (DOC), and deoxycorticosterone sulfate (DOC-SO4) were determined in mixed umbilical cord plasma of abortuses and newborn infants delivered between 18 and 42 weeks' gestation. A wide range of values among individual samples was found for progesterone (224 to 2,152 ng/ml), DOC (1.6 to 10.4 ng/ml), and DOC-SO4 (17 to 154 ng/ml). Levels of progesterone and DOC in mixed umbilical cord plasma were not correlated; those of DOC and DOC-SO4 were positively correlated significantly (r = 0.3945, P less than 0.001). Whereas the mean plasma levels of DOC were similar throughout gestation, significant variation, as a function of gestational age, was found for progesterone and DOC-SO4, with levels of these steroids generally being higher near term than earlier in gestation. The administration of glucocorticosteroids to the mother resulted in a significant decrease (p less than 0.001) in plasma concentrations of DOC and DOC-SO4 in the newborn infant; levels of progesterone in umbilical cord plasma were not affected by maternal glucocorticosteroid treatment. These results suggest that the fetal adrenal glands play a direct, or possibly an indirect, role in the production of the DOC and DOC-SO4 that is present in the fetal compartment. In addition, since fetal plasma levels of progesterone are quite high throughout gestation, the potential exists for circulating progesterone to serve as a precursor for adrenal and extra-adrenal production of DOC and DOC-SO4.     

Breast milk—A natural resource

As practitioners in obstetrics, we must always concern ourselves with supplying the best care for the mother and her newborn infant. Our concern for good health for both patients must extend beyond the delivery room and the early puerperium. Currently, a large proportion of our patients are electing to bottle-feed and we are losing a valuable natural resource—breast milk. It is important that the patient be educated in the advantages and techniques of breast-feeding and that all false rumors be dispelled.     

The placenta: Immunologic or hemodynamic protector of the fetus?

Complete separation of the maternal and fetal circulation during normal pregnancy has been regarded as an extremely important protective factor from the immunologic standpoint. This hypothesis was tested in outbred rabbits in which a direct maternal-fetal parabiosis was established during the last week of pregnancy by implanting an intact maternal omental pedicle subcutaneously into the fetus. A functional cross-circulation, which developed after 48 hours as evidenced by maternal⁵¹Cr-labeled erythrocytes, led to pathologic changes culminating in fetal death within 70 to 80 hours postoperatively. Hyperacute graft rejection, previously postulated as the etiology of these fetal changes, was ruled out since the same characteristic syndrome occurred in similarly treated inbred fetuses syngeneic with their mothers. This study indicates that the absence of direct vascular intercommunication between mother and fetus at the level of the placenta is clearly necessary for physiologic as well as immunologic reasons.     

Premature rupture of membranes and surface energy: possible role of surfactant

Thirty-one human placental membranes of various gestational ages (24 1/2 to 42 weeks) have been studied for their surface properties by use of a goniometer to observe drops of saline and olive oil applied at regular intervals to the amniotic and chorionic surfaces as they dried in air. Results show that the epithelial surfaces of the chorion and amnion and their interface are all appreciably hydrophobic. Surface energy decreased on the amniotic surface with fetal maturity while the surface energy of the chorion was significantly (137%) higher in those displaying premature rupture of the membranes than in others of comparable gestational age. This is explained on the basis that low-energy surfaces (for instance, Teflon) do not stick and provide boundary lubrication which facilitates movement. These properties are needed to avoid the buildup of local mechanical stress which could initiate rupture. It is speculated that the release agent-lubricant is surfactant derived from amniotic fluid and directly adsorbed onto the epithelial walls. On other tissues, the same surfactants have been shown to reduce surface energy, rendering them hydrophobic and imparting many desirable properties such as release, lubrication, and resistance to erosion.     

Asymptomatic virus shedding after herpes genitalis

Samples of cervical and vaginal secretions obtained daily from five women were studied for the presence of active virus and/or viral antigens. In women with a history of recurrent genital herpes, either infectious virus or viral antigen in exfoliated cells was repeatedly detected in the absence of overt clinical symptoms. The epidemiologic and obstetric importance of the observations is discussed.     

The use of ultrasound in the expectant management of abruptio placentae

The use of real-time ultrasound and antepartum nonstress testing in the management of abruptio placentae is discussed. In one patient, fetal distress developed when the retroplacental clot volume reached 480 ml. Two cases in which retroplacental clot was less than 480 ml were managed expectantly with the use of ultrasound and antepartum fetal testing, with excellent results.     

Moxalactam for obstetric and gynecologic infections. In vitro and dose-finding studies

Moxalactam (LY 127935), a "third-generation" beta-lactam antimicrobial, has been shown to have promising in vitro activity against a wide spectrum of pathogens similar to those isolated from women with pelvic infections. Pharmacodynamic studies have shown that its serum half life is longer than 2 hours, which permits less frequent dosing. The current investigation was carried out in two parts: In the first phase, the minimal inhibitory concentration of moxalactam against 519 clinical isolates was determined and compared to antimicrobials used in infections caused by these microbes. In vitro activity of moxalactam comparable to that of clindamycin was demonstrated against B. fragilis and other Bacteroides species. There was similar activity to penicillin G and clindamycin against anaerobic gram-positive cocci and activity superior to amikacin was demonstrated against Enterobacteriaceae. The second part of this investigation was a clinical one and 100 women with pelvic infections were given treatment with moxalactam. With an initial dose of 3 gm/day, women with posthysterectomy cellulitis and pelvic inflammatory disease did well. Women with pelvic infections following cesarean section responded less readily to this dose; however, when the initial dose was increased to 6 gm/day, a 91% cure rate was effected. The results of these investigations indicate that moxalactam is useful as a single-agent antimicrobial for treatment of polymicrobial female pelvic infection.     

Estrogen-induced refractoriness to the pressor effects of infused angiotensin II

Estrogen may be important in the hemodynamic changes that develop during pregnancy; its role in the development of vascular refractoriness to the pressor effects of infused angiotensin II is unknown. We, therefore, examined the pressor responses to six doses of angiotensin II (0.115 to 5.73 micrograms/min) in unanesthetized, nonpregnant sheep both before and after treatment with either high-dose or low-dose 17 beta-estradiol (E2) and constructed dose-response curves. Although mean arterial pressure was unchanged after the infusion of E2, cardiac output rose 28% and systemic vascular resistance fell 19% (p less than 0.001). Infused angiotensin II resulted in dose-dependent rises in mean arterial pressure before and after E2; however, the pressor response after E2 was decreased 30% to 50%. Plasma renin activity rose from 1.15 +/- 0.09 ng/ml X hr to 2.57 +/- 0.39 and 3.21 +/- 0.61 ng/ml X hr with low-dose and high-dose E2, respectively (p less than 0.05). Acutely estrogenized nonpregnant sheep develop significant alterations in both the cardiovascular and the renin-angiotensin systems in addition to decreased pressor responsiveness to infused angiotensin II. Although our findings suggest that estrogen may be important in the development of the vascular refractoriness to angiotensin II seen in pregnancy, additional studies are needed to clarify the role of each E2-induced change.