Search

Personal observation suggested that blood loss increased among patients with preeclampsia who received magnesium sulfate infusions. Bleeding time (modified Ivy) was checked before infusion of magnesium and at the completion of infusion for nine patients with preeclampsia and three who did not receive magnesium. Bleeding time more than doubled among patients who needed magnesium and did not change among controls. [ABSTRACT FROM AUTHOR]

Introduction: Cerebral venous sinus thrombosis (CVST) is a well-known, although underestimated, cause of stroke in childhood. Its diagnosis requires a high index of suspicion, a correct interpretation of neuroimaging studies and an interrelation between clinicians and radiologists. The clinical features, risk factors and neuroimaging of children under 15 years of age with CVST were analyzed., Methods: multicenter, retrospective, descriptive, study of a consecutive series of cases of children under 15 years of age, who were admitted due to CVST between January 1st, 2010, and March 1st, 2022., Results: The study included 51 patients: 39% with acute symptoms and 59% with subacute symptoms. Newborns predominantly presented encephalopathic symptoms and seizures, while children exhibited signs of intracranial hypertension (ICH). Risk factors were identified in 90% of the cases. Magnetic resonance with angiography in venous time confirmed the diagnosis in 80% of the patients, with the straight sinus being the most affected in newborns and the lateral sinus in children. Hemorrhagic complications were found in 30.5%, being more frequent in newborns. Anticoagulation was initiated in 82% without complications. Sequelae were present in 44.4% of newborns and 37.9% of children, being more frequent and severe in newborns., Conclusions: To make an early diagnosis, it is essential to consider CVST in newborns with encephalopathic symptoms and/or seizures, and in children with signs of ICH in the presence of predisposing or triggering conditions.

The SPATA5 gene encodes a 892 amino-acids long protein that has a putative mitochondrial targeting sequence and has been proposed to function in maintenance of mitochondrial function and integrity during mouse spermatogenesis. Several studies have associated homozygous or compound heterozygous mutations in SPATA5 gene to microcephaly, intellectual disability, seizures and hearing loss. This suggests a role of the SPATA5 gene also in neuronal development. Recently, our group presented results validating the use of blood cells for the assessment of mitochondrial function for diagnosis and follow-up of mitochondrial disease, minimizing the need for invasive procedures such as muscle biopsy. In this study, we were able to diagnose a patient with epileptogenic encephalopathy using next generation sequencing. We found two novel compound heterozygous variants in SPATA5 that are most likely causative. To analyze the impact of SPATA5 mutations on mitochondrial functional studies directly on the patients' mononuclear cells and platelets were undertaken. Oxygen consumption rates in platelets and PBMCs were impaired in the patient when compared to a healthy control. Also, a decrease in mitochondrial mass was observed in the patient monocytes with respect to the control. This suggests a true pathogenic effect of the mutations in mitochondrial function, especially in energy production and possibly biogenesis, leading to the observed phenotype., (© 2023. The Author(s).)

A febrile seizure occurs in association with fever in a child aged 6 to 60 months, without central nervous system infection or other known cause of acute seizures in a child without a prior history of afebrile seizures. Febrile seizures occur in about 2-5% of children. Central nervous system infections should be considered in patients with febrile seizures, even though the frequency of this possibility is low, especially when patients do not return to baseline. Simple febrile seizures are considered benign events and there are clear guidelines about evaluation and management, but the evaluation of complex febrile seizures is controversial. They are associated with a small increased risk of epilepsy which cannot be prevented. The role of electroencephalography is controversial. We analyzed the data of many studies and concluded that epileptiform discharges have poor positive predictive value. Neuroimaging is recommended to look for acute or pre-existing hippocampal abnormalities following febrile status or focal febrile seizures that could be associated to the risk of developing mesial temporal sclerosis and temporal lobe epilepsy. The relationship between these disorders and febrile seizures remains a controversial issue. An abnormal electroencephalography or magnetic resonance imaging studies will not change the clinical management and could contribute to overdiagnosis.

Trypanosoma cruzi is the etiologic agent of Chagas' disease, an infection that affects several million people in Latin America. With no immediate prospect of a vaccine and problems associated with current chemotherapies, the development of new treatments is an urgent priority. Several aspects of the redox metabolism of this parasite differ enough from those in the mammalian host to be considered targets for drug development. Here, we review the information about a trypanosomatid-specific molecule centrally involved in redox metabolism, the dithiol trypanothione, and the main effectors of cellular antioxidant defense. We focus mainly on data from T. cruzi, making comparisons with other trypanosomatids whenever possible. In these parasites trypanothione participates in crucial thiol-disulfide exchange reactions and serves as electron donor in different metabolic pathways, from synthesis of DNA precursors to oxidant detoxification. Interestingly, the levels of several enzymes involved in trypanothione metabolism and oxidant detoxification increase during the transformation of T. cruzi to its mammalian-infective form and the overexpression of some of them has been associated with increased resistance to macrophage-dependent oxidative killing. Together, the evidence suggests a central role of the trypanothione-dependent antioxidant systems in the infection process.

Objectives: Our purpose was to evaluate the perinatal mortality and morbidity of deliveries with fetuses presenting by the breech comparing outcomes of two groups according to mode of delivery: vaginal and cesarean section., Results: Of 756 fetuses studied, 271 were delivered vaginally and 485 by cesarean section. In infants weighing > or = 1500 grams, "further corrected" mortality and morbidity rates were low and similar for both delivery routes: one neonatal death (NNM) in each. Among very low birth weight (VLBW) infants (< 1500 grams) the "further corrected" mortality rate was higher in the vaginal group: 57.4%, and 18.0% in abdominal deliveries (odds ratio [OR] = 6.1, 95% CI: 3.1 to 12.1). Likewise, rate of depression at five minutes were higher in the vaginal group (p < 0.001). However, the average fetal weight among the vaginal deliveries VLBW (787 grams) was 250 grams less than in the cesarean section group (1040 grams). After adjustment for fetal weight, gestational age, and other prognostic variables the odds ratio for neonatal death was no longer statistically significant (adjusted OR = 2.1, 95% CI: 0.9 to 5.2, p = 0.105). Comparison of planned vaginal delivery with elective cesarean section yielded smaller differences (adjusted OR for neonatal death = 1.3, 95% CI: 0.6 to 2.9, p = 0.525)., Conclusion: The poor perinatal outcomes of breech delivered infants are due primarily to VLBW, congenital malformations, and premature labor. Although abdominal delivery had a lower NNM rate than vaginal delivery, the difference was not significant after adjustment for confounding factors. The results confirm the findings of a previously analyzed similar series delivered at our institution between 1980 and 1987. They suggest that, with appropriate technique, abdominal delivery is not mandatory in breech presentation.

The objectives of this study were to evaluate the possible mechanisms involved in prolongation of bleeding time in pre-eclamptic patients receiving a magnesium sulfate infusion to prevent convulsions. Eighteen pre-eclamptic patients near term or at term (4 cases 33 to 35 weeks; the remainder > 36 weeks) were studied. Fifteen of them received magnesium sulfate infusion; 3 did not and served as controls. Bleeding time (modified Ivy method with Surgicutt), platelet count, platelet aggregation pattern, as well as serum arachidonic acid metabolites [thromboxane B2 (TxB2) and 6-Keto-prostaglandin F1 alpha (6-Keto-PGF1 alpha)] werde done on admission to the labor floor (before magnesium infusion) and repeated at discontinuation of the infusion, 12-24 hours postpartum; the controls received the second test 24 hours postpartum. Thirteen of 15 patients receiving magnesium sulfate had an increase in bleeding time from an average of 6 minutes 31 seconds to 11 minutes 56 seconds, an 82% rise (p < 0.004). In 2 there was a decrease. Among the 3 controls the averages were 6 minutes 38 seconds and 6 minutes 3 seconds. The total magnesium given ranged from 52.5 to 145 grams. Platelet counts averaged 251,000/mm3 (range 145,000-519,000). Platelet aggregation pattern done in 11 patients and was normal and unchanged after magnesium in 10 of the patients with increased bleeding time and one control. TxB2 and 6-Keto-PGF1 alpha levels did not change significantly either after magnesium administration (688 and 135 pgm/ml, to 654 and 117) or in controls (695 and 230 pgm/ml, to 445 and 225). Likewise, the ratio of these 2 substances did not change in either group (6.3 to 6.6, and 4.2 to 2.2). There was no correlation between duration of infusion or total magnesium given and directions of small changes observed. This study confirms a prior preliminary observation that magnesium sulfate infusion, as currently used to prevent eclamptic convulsions, induces a significant prolongation of bleeding time. This effect is mediated neither by changes in platelets count or aggregation pattern, nor by changing the level or ratios of serum arachidonic acid metabolites (TxB2 and 6-Keto-PGF1 alpha). Further studies are needed to clarify the mechanism of this clinically important observation of increased bleeding following magnesium sulfate infusion.

Congenital complete heart block in utero has become diagnosed more frequently with the clinical use of fetal echocardiography. The fetus with complete heart block may remain asymptomatic or may develop congestive heart failure. Congenital complete heart block is more frequently seen in infants of mothers with systemic lupus erythematosus, both clinically manifested and subclinical systemic lupus erythematosus with positive antibodies (SS-A and SS-B antibodies). At birth, the neonate with complete heart block may remain asymptomatic and may not require a pacemaker to increase the heart rate. The indications for a pacemaker in neonates with complete heart block have been discussed. Both in-utero and neonatal management of congenital complete heart block are discussed to manage congestive heart failure in a fetus. Four patients with congenital complete heart block are presented covering a broad spectrum of clinical presentation, diagnosis, and management both in the fetal and neonatal period.

The currently advised conduct for intrapartum surveillance of the fetus is either intermittent auscultation of continuous electronic monitoring, depending on the physician's preference. This applies to all, normal or high-risk, conditions. The bases for this recommendation, a number of controlled studies comparing the two methods, showed no better neonatal outcomes and increased cesarean section rates with electronic fetal monitoring. A review of the works pertaining to fetal development of cardiovascular and central nervous systems and their response to various pathophysiologic conditions (in animals and humans) was carried out in an effort to find an explanation for this apparently uncongruous position. It was found that fetal responses to seemingly comparable conditions are radically different depending on age of gestation. Many authors have pointed this out for the human fetus. However, for interpretation of electronic fetal monitoring in labor, various standard, nondescriptive, confusing words are used to imply the need for rapid intervention. The complete lack of uniform interpretation has been shown in studies comparing interobserver and intraobserver variations. This may be the consequence of poor or superficial teaching of a tool that requires much study and hard work for useful application. The inescapable conclusion is unpleasant but inevitable: to use electronic fetal monitoring properly it is necessary to start a new learning of the physiology of the fetus, its changing evolution as pregnancy advances, its different responses under stress or distress, and the various ways these are represented in electronic fetal monitoring tracings. These efforts take dedication and time spent in labor suites collating tracings with neonatal condition. Only by doing this will it be possible to assist the laboring patients with a useful tool that, so far, has not been adequately applied because of insufficient understanding.

Objectives: Our purpose was to evaluate factors that may influence perinatal outcomes in the very-low-birth-weight infant with breech presentation., Study Design: An observational study that included all consecutive singletons and twins with the first fetus with breech presentation weighing between 500 and 1500 gm delivered at Chicago Lying-In Hospital from July 1980 to December 1987 was performed. Uncorrected and corrected perinatal mortality and morbidity were calculated. After correction, the effect of mode of delivery (vaginal versus cesarean section) was studied. A further correction was made by excluding cesarean sections performed for fetal distress. Statistical methods included chi 2 and Fisher exact tests and logistic regression analyses to calculate unadjusted and adjusted odds ratios., Results: Of the 262 fetuses studied, nearly 60% were delivered vaginally and were of younger gestational age and lower fetal weight (300 gm) than those delivered abdominally. Forty-four percent weighed < or = 800 gm, and the perinatal mortality rate was 64.5% (53.3% after correction). Vaginal delivery had higher rates of depression, respiratory distress syndrome, and death. Prematurity was the most frequent cause of neonatal death. The corrected neonatal mortality was similar to the total inborn population of our neonatal intensive care unit for the same years. Logistic regression analyses revealed that the differences in outcomes between the two groups were primarily related to effects of gestational age, fetal weight, and year of delivery. After these factors were adjusted for, the odds of neonatal death for vaginal delivery compared with cesarean delivery were not significantly different (odds ratio 1.4, 95% confidence interval 0.6 to 3.5, p = 0.48). However, in the subgroup in footling attitude the differences were much greater, with an adjusted odds ratio of 3.2 (95% confidence interval 0.7 to 14.9, p = 0.13)., Conclusion: The exceedingly poor perinatal outcomes of very-low-birth-weight breech infants are mainly related to antenatal deaths (22%), extremely low birth weight (44%), congenital malformations, and premature labor, not to the breech presentation. The route of delivery did not significantly influence outcome among complete and frank attitudes; abdominal delivery may offer some benefit for footlings. Prematurity is the primary cause of death of normal very-low-birth-weight breech-delivered infants.

Objectives: Our purpose was to evaluate the outcome of deliveries with fetuses in breech presentation at labor and to compare the results by route of delivery. Specially reviewed were fetuses weighing > or = 1500 gm., Study Design: An observational study of consecutive cases of all singleton pregnancies and twin pregnancies with the first fetus presenting in breech delivered at Chicago Lying-In Hospital from July 1980 to December 1987 was performed. Crude perinatal mortality and effect of mode of delivery (cesarean vs vaginal) by weight were compared after correction for nonpreventable causes. A further correction was made for fetuses weighing > or = 1500 gm by excluding all cases of fetal distress from the cesarean section group. All clinically relevant factors were evaluated. Statistical methods included comparison of frequencies in the two groups by chi 2 and Fisher exact tests and comparison of means by two-sample t tests., Results: Of 21,380 deliveries, 843 (3.9%) presented by the breech. Forty-four percent were delivered vaginally; 8.4% were first twins. There were 51% preterm infants, and 24% had clinical distress. Crude perinatal mortality was 24%; 8% stillborns, 10% from prematurity, and 6% from other causes, including lethal congenital malformations. The corrected perinatal mortality was 15%. Vaginal deliveries had a higher 5-minute depression rate (32% vs 24%) and corrected perinatal mortality (23% vs 9.6%); however, fetal weights were significantly lower. There were no differences in outcomes for newborns weighing > or = 1500 gm by route of delivery; all five neonatal deaths in this subgroup occurred among the abdominal deliveries., Conclusions: The very poor perinatal outcomes in breeches are primarily related to factors other than breech presentation. Route of delivery for infants weighing > or = 1500 gm does not influence neonatal outcome; thus cesarean section solely for breech presentation in this subgroup does not appear to be justified.

Objectives: We assessed perinatal morbidity and mortality of prolonged pregnancies (> or = 294 days) compared with those of term gestations. We also evaluated the impact of induction of labor compared with spontaneous onset of labor., Study Design: This observational study included consecutive cases treated at Chicago Lying-In Hospital from July 1980 to December 1984. Complications, presence of meconium, indications for cesarean section, mode of delivery, perinatal morbidity (and mortality), meconium aspiration, and duration of labor were compared with those in the total hospital population, in infants weighing > or = 2500 gm, and within prolonged gestation groups; spontaneous onset and induced ("active management") labors were also compared. The chi 2 analysis was used., Results: Of 12,930 deliveries there were 707 prolonged gestations (5.5%) and 10,698 with infants > or = 2500 gm. Among the prolonged gestations 67% were in multiparous women and 33% in primiparous women. Labor started spontaneously in 62%, and 38% underwent induction; the overall cesarean section rate was 17% with similar indications in both spontaneous onset and induction groups. Meconium was present in 34%; it was present in 23% of inductions, which is fewer (p < 0.01) than among those with spontaneous onset of labor (40%). Also there were fewer depressed neonates at 5 minutes (p = 0.03) among inductions. Meconium aspiration was seen in 24, with nine deaths. The perinatal mortality was 14 per 1000 (corrected 12.7/1000), significantly more than in the general population. Among those with spontaneous onset of labor it was 20.5 per 1000; there were no deaths among inductions. Postpartum maternal morbidity was 16% among cesarean sections and 4% among vaginal deliveries., Conclusions: Prolonged gestation has a high perinatal morbidity and mortality rate. All perinatal deaths were observed among patients whose labor started spontaneously. "Active management" (induction at 42 weeks) did increase the primary cesarean section rate compared with that of the general obstetric population; it did not do so among prolonged gestations and prevented perinatal deaths in this group. From this experience an active approach seems justified.

The intrapartum FHR and UC were recorded in a population of 707 consecutive cases of prolonged gestation looking for a characteristic pattern. There is no typical pattern for prolonged pregnancy. However, there are differences from preterm and term populations. There is a very high incidence of variable (55%) and late (17%) decelerations. These were seen more frequently among cases receiving oxytocin. Nearly 50% of C-sections had lates. Baseline alterations (tachycardia 26%, fixed 8%, and saltatory 17%) were often associated. Apgar scores < or = 6 at 1 minute were correlated with variable and late decelerations. However, acidemia (UA pH < or = 7.20) could not be predicted from FHR patterns because there was no correlation between low pH and clinical depression. Alarmingly a few fetuses in agonal state presented normal appearing tracings, or deteriorated rapidly without the usual indicative changes by FHR. All intrapartum or NND had this misleading pattern. In view of this unpredictable aberrant pattern as the only certain means to prevent these deaths, it is suggested that no pregnancy should be allowed to reach 294 days post LMP.

The effect of severity of hypertension on fetal heart rate tracing changes and neonatal outcomes was evaluated on all patients with hypertension seen in 1980 and 1981 (666 cases, 10% of the pregnant population) in the Chicago-Lying In Hospital. The patients were grouped according to severity of hypertension, and the fetal heart rate monitoring, drugs administered, mode of delivery, and neonatal outcome were analyzed. Half of the patients (326) had mild hypertension and 13% (87) had severe hypertension; the remainder (253) had moderate hypertension. There were 49% primiparous and 51% multiparous women. The diagnosis of preeclampsia was made in 76% of cases, and chronic hypertension in 19%. Only 12% of the total were premature by dates, but 47% of this group were among the severe group. Oxytocin was given to 50%, whereas delivery was spontaneous in 56% of cases, and by cesarean section in 22%. This was higher among the severe hypertension group (37%), and the prematurity rate was 47%. Nonstress testing was done in one third of cases and only nonreactivity was associated with neonatal death. Neonatal depression (Apgar score less than 6 at 5 minutes) was significantly associated with intrapartum fixed baseline and late decelerations; these were the best predictors of fetal outcome. The administration of magnesium sulfate, hydralazine, meperidine, or morphine did not predictably affect the fetal heart rate pattern. The perinatal mortality was 21% in the mild group and 36% and 138%, respectively, among moderate and severe cases of hypertension. Close antepartum and intrapartum surveillance, including proper fetal monitoring, should help to reduce risks for mother and fetus through timely intervention.

The fetal intrapartum condition as well as maternal and immediate neonatal outcome of 274 consecutive midforceps rotations (head in transverse or posterior position and below + 1 station but without reaching the perineum) were compared with 106 cesarean sections done for arrest of progress for more than two hours and cervical dilatation of at lest 7 cm. It was found that there were more nulliparous among cesarean section patients, that their fetuses weighed near 400 gm more on the average, and that their time in labor was 200 minutes longer. On the other hand, the midforceps group had a higher incidence of spontaneous labor, conduction anesthesia, and intraprtum fetal distress (37%). There were no differences in fetal outcome, other than admission to NIC and/or NIM among C-section infants. This latter group had a higher postdelivery maternal complication rate (hemorrhage and infection), as well as longer than expected hospital stay. These findings are discussed. It appears that midforceps rotation, properly indicated and executed, offers a safe alternative to C-section for delivery of the infant.

The fetal heart rate (FHR) tracings of 302 consecutive breech presentations were analyzed to assess their potential value in clinical practice. There were 274 singleton births, 27 first twins and 1 triplet. Ten percent of the gestations were greater than or equal to 42 weeks, and 26% were less than or equal to 36 weeks. Infants premature by weight (less than 2,500 gm) made up 32%. Only 33.3% had no decelerations, and 63.0% had variable or variable-late decelerations. The latter group had a significantly higher incidence of depressed neonates and neonatal deaths. When accelerations were present, there were significantly fewer depressed infants and neonatal deaths. Overall the perinatal mortality (PNM) was 7.9%; for premature infants it was 27%, postterm 3% and term 1%. There was a 31% incidence of cesarean section. The PNM, when analyzed according to route of delivery, was no different for the very-low-birth-weight, low-birth-weight and term infants. Weight-specific mortality accounted for the apparent difference among the very-low-birth-weight infants. The high incidence and pathophysiology of cord compression (for first- and second-stage labor) may explain the higher incidence of depression in breeches as compared to cephalics. FHR monitoring should be done throughout delivery in order for the physicians to intervene on time when fetal distress is imminent.

The supernumerary ovary is a rare gynecologic anomaly; 13 cases have been reported on since 1890. Three were associated with tumors arising in the ectopic ovarian tissue. We encountered two cases of benign neoplasms discovered to have originated in supernumerary ovaries.

We report a case of fetal cystic hygroma with 45,X/46,XY mosaicism.

Among a large series of high-risk patients who had direct electronic monitoring, 330 fetuses presented "variable" decelerations and 598 had no decelerations. Among those with variable decelerations, there were 18 who presented such associated fetal heart rate (FHR) alterations as tachycardia, fixed baseline, and slow recovery ("hypoxic components"). The fetal outcome, as well as the characteristics of FHR patterns, were compared among the three groups. Baseline changes were significantly higher among pure variable decelerations and still higher among those having variable decelerations with hypoxic components. Likewise, one- and five-minute Apgar scores were significantly lower in that order. Only 4 per cent with no decelerations had clinical fetal distress while 23 per cent with variable decelerations and 78 per cent of those with variable and hypoxic components had distress. Neonatal death was higher among groups with variable decelerations. Premature rupture of membranes seemed to be the only clearly different (and probably influencing) clinical condition, being higher among the group with variable decelerations. Variable decelerations ("cord patterns") are associated with a relatively high rate of depressed infants. This problem is much worse when elements characteristic of hypoxia are identified in FHR tracings. The degree of drop in FHR frequency is not among those elements so identified. It is thus possible to prevent significant fetal deterioration by meticulous analysis of FHR tracings and active management when "late" components are identified on variable decelerations.

Because of the unresolved controversy regarding the effect of epidural anesthesia upon uterine contractility, it was decided to study its effect on a small number of patients. Intrauterine and intra-arterial continuous pressure, continuous fetal heart rate, and maternal heart rate recordings were obtained from at least 20 minutes before administration of the epidural anesthic until complete dilatation in these patients. Nineteen patients were in spontaneous labor, and 18 had labor stimulated with oxytocin. Plain lidocaine, 1 or 1.5%, was used in 12 patients (30 observations), and lidocaine with epinephrine, 1:200,000 was used in 26 patients (51 observations). Uterine contractions were calculated in Montevideo units for 60 minutes following the epidural anesthetic. The changes, if any, were compared in both groups. There was a significant decrease in uterine activity when epinephrine was added to the anesthetic solution, mainly a lessening of intensity. There were comparable decreases in systolic/diastolic blood pressure in both groups and compensatory tachycardia. In one case, severe hypertension was observed following administration of lidocaine epinephrine. It was concluded that the addition of epinephrine to the anesthetic solution predictably produces diminution of uterine activity, and it does not give "cardiovascular support" to the laboring patient.

Among a population of high-risk patients in labor who had continuous "direct" electronic monitoring, 147 presented late decelerations and 598 had no decelerations at the time the first stage was completed, or a cesarean section decided upon. A variety of clinical aspects of mother and fetus were analyzed, considering some alterations observed in the FHR pattern. Apgar scores were lower among decelerations, and there was a negative correlation between these two. Maternal pathology, other than PRM, was higher among decelerations and these required enhancement more often. There was very high association with tachycardia, saltatory, and fixed baseline among decelerations, and these infants were very often distressed and born depressed. Within the group of decelerations, small fetuses had lower Apgar scores. There was a negative correlation between number of decelerations and Apgar score. The small fetuses had a high incidence of tachycardia and fixed baseline, saltatory being almost absent. Their neonatal outcome was poor. A comparison of fetal response to distress was done considering age of gestation (premature, term, and postmature) and found to be different. The mechanisms involved in late deceleration are discussed, reviewing the published experimental work. When interpreting FHR patterns, age of gestation should be one of the most important considerations.

In a population of high-risk patients who had continuous "direct" monitoring during labor, 598 (46%) had no decelerations during the first stage, while 247 (19%) had presented early decelerations before completion of dilatation. The clinical characteristics, the fetal heart rate (FHR) baseline alterations, and neonatal outcome were compared between these two groups: there were no differences in any of the aspects evaluated, except that there was transient tachycardia more often among the early-decelerations group. The patients who had no decelerations were subdivided into vaginal deliveries and cesarean deliveries, and the same parameters were compared again: the cesarean section group had longer recordings and more contractions, lower Apgar 1 and 5 minute scores, and higher incidences of Apgar scores less than or equal to 6 at 1 minute, while all other aspects were similar. A possible explanation was that 82% of cesarean sections were done under general anesthesia and only 3% of vaginal deliveries. The implication of ruptured membranes in the etiology of early decelerations was extensively reviewed and discussed in view of these findings. It is concluded that amniotomy does not seem a maneuver deleterious to the fetal well-being.

A survey of results of midforceps delivery in mother and fetus was carried out, reviewing the most relevant publications of the past several years. Many discrepancies have been found from definition of what is (or should be) considered midforceps delivery to methods of gathering the material for analysis and the statistical evaluations. Specific study of some of these results was done which revealed possible flaws in the conclusions reached by the authors. Clearly maternal mortality is no longer a justifiable aspect to be studied. However, maternal morbidity should be considered and compared to that associated with vaginal and/or cesarean section deliveries. Likewise perinatal mortality and morbidity should be the standard of study and, in particular, long-term follow-up of infants delivered by the various methods. Until those observations are made from reliable data of comparable populations, it is probably not justified to condemn midforceps deliveries well conducted and judiciously indicated.

A case of pseudosarcoma botryoides of the vagina diagnosed in advanced pregnancy is described. The cellular characteristics (atypical cells and abnormal mitoses) suggested malignancy, but ultrastructural studies demonstrated the fibroblastic nature of the cells, thus confirming the diagnosis of pseudosarcoma. Local excision and subsequent cesarean section was the method of treatment. Three years later, another pregnancy was terminated by repeat cesarean section and uncontrollable hemorrhage requiring emergency hysterectomy. The histologic study of the bleeding area revealed very edematous areas and lacunaelike endothelium-lined vessels. No cellular abnormalities were observed.

The in vitro effects of local anesthetics and norepinephrine upon strips of early gestation and term pregnancy uterine arteries were studied in eight cases. In another case, the effect upon uterine veins was studied with a standard organ bath used to record isometric contractions. Histologic preparations were made to verify the type of vessel studied. An artery obtained from an eight-week gestation did not respond to either lidocaine or mepivacaine. All other arterial specimens (radial and helicoidal strips) responded with slow, rising, strong contractions to diluted concentrations of both of these substances. Likewise they responded with rapid contractions when exposed to norepinephrine. Alpha blockers were unable to prevent the contractions triggered by the local anesthetics. The vein specimens did not respond to local anesthetics but contracted when stimulated by norepinephrine. Based on these observations and after brief review of some hypotheses advanced to explain post-paracervical anesthesia fetal bradycardia, it is postulated that this bradycardia is probably due to uterine artery spasm, causing decreased intervillous space blood flow and fetal hypoxia.

Argyrophil and argentaffin cells are rarely seen in female genital tract structures. Their presence in normal, apparently healthy ovaries has not been reported until the present observation. Histochemical and ultrastructural studies demonstrated cells within the ovaries of two nonpregnant patients in the reproductive age that belong to the neuroendocrine or amine precursor uptake and decarboxylation (APUD) system. The lack of other discernible pathologic conditions suggests that these cells may be normal cellular constituents within the ovaries and lends support to the belief of a neural crest origin for primary ovarian carcinoid not associated with teratomatous or mucinous elements.

From a population of 2,774 high-risk patients monitored during labor, 1,304 single pregnancies in cephalic presentation and with direct monitoring for at least 1 hour before completion or cesarean-section were studied. The maternal and fetal clinical data and the tracings were hand reviewed, coded, and programmed for computer analysis. In the record were studied baseline, its changes (tachycardia, fixed, saltatory), the accelerations, and the decelerations (early, variable, late). Fifty-four per cent had some type of FHR deceleration. Accelerations were recorded in over 12 per cent of all cases and were associated with cord problems in 41 per cent. Subgrouping the patients by age of gestation (less than or equal to 36 weeks, 37 to 41 weeks, and greater than or equal to 42 weeks) revealed a 10 per cent prolonged gestation rate and only 6.8 per cent premature; these had a lower 5 minute Apgar score. Fetal weight and age were positively correlated with Apgar score. Baseline changes were much frequent among pre- and postmature infants, particularly tachycardia in the latter (40 per cent). The premature infants had a 25 per cent incidence of fetal distress and the postmature infants had 20 per cent. Neonatal morbidity and mortality rates were very high among premature infants and a mortality rate of 2.3 per cent was found among postmature infants. Saltatory pattern and particularly fixed baseline seem characteristic of prolonged gestation and placental insufficiency. With tachycardia, they constitute subtle symptoms of fetal distress.

A small series of 22 patients who underwent hysteroscopy cauterization is reported. The uterus was distended with CO2 and dextran. Cauterization was done with a 6 mm. long, active-tip, No. 4 electrode: There was a 27 per cent failure rate for the controlled cases, this dropping to 11 per cent after recauterization. A significant complication, small bowel perforation, was treated by resection and anastomosis with complete recovery. The uterine distention with CO2 is safe but ostium visualization is not very good; Dextran distention is more cumbersone but gives excellent visualization and exposure of the ostium because higher intrauterine pressures are developed.

The intrapartum fetal heart rate changes, type of labor, mode of delivery, and neonatal outcome were evaluated in 379 consecutive continuously monitored prolonged pregnancies (greater than 42 weeks by history and early examination). These represent only a fraction of the total prolonged gestation population. There were 56% multiparous women, 33% less than 20 years of age, and 95% with cephalic presentation. Oxytocin was given to 76% (48% induced, 28% enhanced). Delivery was by cesarean section in 13% of patients (9% of induced cases), and 15% had forceps deliveries. Fetal heart rate alterations were observed in high proportion. Cesarean section for cephalopelvic disproportion was indicated in 60% of operations, and 13% of the fetuses weighed greater than 4000 gm. Depression occurred in 15% of infants at 1 minute and in 4% at 5 minutes. Prolonged hospital stay was seen in 9%, and postmaturity syndrome in 19%. There were four perinatal deaths (two corrected). Active induction does not appear to increase the cesarean section rate. The durations of predelivery observation may be longer because the cervices are frequently unripe. There is a high incidence of fetal heart rate alterations. Induction appears justified as an active intervention to prevent some sudden unexplained deaths.