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Hyperemesis gravidarum is an infrequent, yet significant, maternal complication of pregnancy. Beginning with the frequently experienced nausea and vomiting of pregnancy, symptoms can progress to hyperemesis, a debilitating condition affecting maternal and fetal well-being. A basic understanding of the pathophysiology of the disease process and an awareness of the therapeutic interventions that are available will facilitate midwifery planning for either the collaborative care or the potential referral to medical management, both of which may be required with this clinical entity. The diagnosis and initial management of hyperemesis is within the purview of midwifery care. As certain critical features of duration and severity evolve, medical collaboration and ultimate hospitalization may be required. For those few individuals requiring the most intense level of care, the critical support and encouragement afforded by midwifery participation will contribute to timely resolution of this debilitating condition. This article discusses the continuum from differential diagnosis to ultimate care of the woman who has excessive nausea and vomiting of pregnancy. Collaboration among health care providers will allow all to exercise their respective skills in achieving the optimum in safe therapy and support for their patients. [ABSTRACT FROM AUTHOR]

Prenatal smoke exposure has been shown to change cochlear echo response amplitudes and auditory brainstem response (ABR) wave latencies in newborns. Since gene expression changes are often synchronized in different tissue types, the goal of the present work was to determine the relationships between prenatal smoke exposure induced changes in hearing responses with changes in placental gene expression. Results showed significant cotinine level elevations in mothers who smoked ≥10cigarettes/day during their pregnancy compared to no detectable cotinine in nonsmoking mothers. Cochlear echo response amplitudes in the 2-8kHz range and ABR wave latencies, specifically wave V and interpeak interval I-V, were also significantly reduced in newborns of smoking mothers. Functional pathway analysis of upregulated placental genes using the Database for Annotation, Visualization and Integrated Discovery (DAVID) online software showed significant enrichment of terms associated with neurodevelopmental processes including glutamatergic and cholinergic systems and a number of wingless type proteins in the top two tiers with corrected enrichment p-values of ≤0.05. Other relevant functional pathways were significant at unadjusted enrichment p-values of 0.001-0.11 and included calcium signaling, neurotransmission/neurological processes and oxidative stress. The neurological process clusters included 7 genes (EML2, OTOR, SLC26A5, TBL1X, TECTA, USH1C and USH1G) known to modulate cochlear outer hair cell motility. We localized proteins encoded by the top two regulated genes, TBL1X and USH1C, using immunohistochemistry to placental stem and anchoring villi associated with active contractile function. These placental genes may mediate active contraction and relaxation in the placental villi, for example, during maternal-fetal perfusion matching, similar to the active lengthening and shortening of the cochlear outer hair cells during sensory transduction. Thus, the functional consequence of their alteration in the cochlea would be reflected as a decline in cochlear echoes as shown in this study. Such parallel changes suggest the potential utility of placental gene expression as a surrogate for evaluating changes in the developing cochlea related to potential aberrant cochlear function in newborns with prenatal smoke exposure., (Copyright © 2013 Elsevier Inc. All rights reserved.)

The placenta is a marker of biologic events that occur during pregnancy. Placental pathologic examination gives insight to pregnancy-related insults, which affect the newborn at and after birth. Clinicians and risk managers can use this information to identify the cause of newborn complications in cases suggested to be birth-related injuries.

Severe trauma to an obstetric patient is truly an injury of double magnitude. While being cognizant of the fetus and its well-being, all expediency must be employed to accomplish a thorough evaluation of the injured patient and allow for the prompt employment of appropriate therapeutic measures. The best key to fetal survival is successful maternal therapy.

This study examined levels of tryptase, a specific mast cell product, in synovial fluid. Samples of synovial fluid from eight patients with rheumatoid arthritis and ten with other arthritides were measured in solid-phase immunoradiometric assays. Elevated concentrations of tryptase were present in samples from three patients with rheumatoid arthritis, one with psoriasis, and one with Reiter's syndrome. The data support the theory that mast cell activation is involved in the pathogenesis in some inflammatory joint diseases, but activation does not appear to be disease specific.

The feasibility of prolonging the delivery interval of the fetus or fetuses in multiple gestations after the preterm delivery of one fetus has been demonstrated. Five clinical reports and a literature review served as the database for this study. Pregnancy was extended in each of five patients with multiple gestations after the extreme preterm delivery of one fetus. Four of the six remaining infants survived. The literature reviewed shows successful survival in 42 of 52 (81%) such asynchronously delivered infants. Use of tocolytic therapy, broad-spectrum antibiotics and cerclage allows pregnancy extension when delivery occurs asynchronously in multiple gestations. The patient's strong desire and full understanding of the potential risks are mandatory before such an endeavor is attempted.

After a patient with a history of systemic lupus erythematosus in remission was given salsalate, all of her hematologic elements, especially leukocytes, profoundly decreased within hours, although the patient was receiving steroids. She had been challenged with salsalate at an earlier date, with a similar but less impressive drop in blood counts. Granulocytotoxic antibodies persisted during this episode in contrast to declining lymphocytotoxic and anti-native DNA antibodies that accompanied a remission of systemic lupus. This is the first case of this kind occurring with salsalate therapy and may have represented preformed antibodies induced by salsalate.

In a case of monoamniotic twinning, amniography was used to confirm the diagnosis. This modality, old but now employed infrequently, helps establish the absence of a dividing membrane and complements currently used ultrasound diagnostic methods. A successful outcome resulted. Amniography should be considered a useful diagnostic modality in the management of twin gestations and not be relegated to the past.

A placenta previa, whether found fortuitously by ultrasound or with the clinical emergency of maternal hemorrhage, carries significant maternal and fetal risk. Accurate diagnosis, judicious expectant management with transfusion as required, and delivery at the time of fetal lung maturation can lead to the most favorable outcome. Anticipation of the clinical complication of placenta accreta may avoid some serious consequences. Clinical judgement and skill in the performance of cesarean sections, dilatation and curettage, and other forms of uterine invasive techniques may help to keep subsequent incidence of placenta previa at a reasonably low rate.

A study of chorioamniotic membranes was undertaken in 2 term populations. One group of women delivered vaginally after normal labor (N = 41), the other by elective cesarean section (N = 41). Rheologic properties were measured in an experimental environment. The membranes in each group responded similarly while intact. Those membranes subject to labor, however, ruptured earlier in cyclic testing. They also required more time to dissipate applied stress. This stress response pattern is similar to that seen with rupture of amorphous materials in which multiple flaws or cracks are aggravated by stress testing. The clinical problem of premature rupture of the membranes may occur by a phenomenon that produces flaws in their structure. The data suggest that these flaws may be aggravated by labor-like uterine activity.

Of 3,918 obstetric patients who underwent scanning during the first 20 weeks of gestation, 94 had sonolucent adnexal masses identified. These represented predominantly the corpus luteum of pregnancy. The incidence of such a mass significantly declined after the tenth gestational week. This pattern of degeneration is physiologic and represents the normal course of events for the ovary in the first half of pregnancy. Characteristics of these masses and indications for operative intervention are discussed. The obstetric outcome for eight patients who underwent surgical treatment was uncomplicated. Guidelines for management of significant adnexal masses in pregnancy is similar to that of the nonpregnant state.

A malpractice suit can have a devastating impact on a practitioner's professional and personal life. The physician's reaction to this event is profound, affecting his own life-style and that of family, colleagues, and patients. This commentary presents an analogy between the physician's reaction to a malpractice suit and the stages of grief described by Elisabeth Kübler-Ross: the sequence of denial, anger, bargaining, depression, and acceptance. Understanding the psychodynamics of this reaction can help physicians to cope with the problems inherent in a malpractice suit and to maintain a greater stability in their personal lives. Adverse effects on medical practice and private life-style, and on the legal proceedings, can be minimized.

Steroid therapy remains the treatment of choice for immunologic thrombocytopenia in pregnancy. However, for cases refractory to steroid therapy, alternate forms of treatment must be used. This case report and review discusses a successful technique for acute, short-term correction of thrombocytopenia. In limited experience the administration of high-dose immunoglobulin appears to be effective for antepartum use in patients with immunologic thrombocytopenia. The concomitant or subsequent performance of splenectomy appears to be a valuable adjunct in long-term treatment of this condition.

A new method of partial erythrocyte exchange for pregnancies complicated by a major hemoglobinopathy is described. The Haemonetics 30 Cell Separator allows efficient withdrawal and discard of the patient's erythrocytes. The patient's leukocytes, platelets, and plasma are conserved and returned with washed, compatible donor red cells which contain Hb AA. Three pregnant black women with significant hemoglobinopathies were treated by this modality during their pregnancies. Vaginal term deliveries were accomplished in each case. The method offers advantages in the efficiency of blood quantity displacement, patient comfort, adaptability to the patient with severe anemia, and the use of outpatient facilities. The method is suggested for use whenever a patient with an obstetrically significant hemoglobin variant needs transfusions of erythocytes.

A population of 1320 patients was reviewed to assess the clinical significance of antepartum meconium staining on the occurrence of premature rupture of the membranes. Specimens of amniotic membranes were studied by tensile strength testing from 2 population groups. The results of the retrospective review showed no difference in the incidence of premature rupture of the membranes between the populations with clear amniotic fluid and those with meconium-stained fluid at time of amniorrhexis. The tensile strength testing demonstrated that the study population with antepartum meconium-stained fluid had significantly lower stress tolerance. This investigation demonstrated a significant decrease in stress tolerance of human chorioamniotic membranes associated with a meconium-stained fluid environment, but this loss of stress tolerance is not apparently significant in clinical practice.

This study establishes the viscoelastic nature of the human chorioamniotic membrane. Membrane tissue taken from term pregnancies was placed in a state of biaxial stress consistent with the condition in which membranes rupture in normal healthy patients. The phenomena of creep, stress relaxation, elastic recovery, and time-dependent load deformation relations were demonstrated. The experiments needed to produce these phenomena are described. The results are graphically reported. The experiments were performed using samples of fetal membranes and compared to gum rubber which is a known elastic material. From the results, one can conclude that fetal membranes are viscoelastic. The flow freely under applied stress, and they have elastic and viscous properties which are time dependent.

This paper presents a review of physical principles involved in deformation and creep in the human chorioamniotic membrane. These are definable rheological properties found in many materials. Experimental data are presented on 66 human fetal membranes. A difference in the stress tolerance between preterm and term membranes is demonstrated. A computer model has been devised which allows for the calculation of changes in thickness of the membrane at the point of fracture. This computer model allows for the study of the physical property of the tissue in ways which have not previously been suggested. The model suggests that the pathophysiology related to rupture of the membrane is based on changes in the thickness of this tissue occurring secondary to acute and chronic stress applications. The data derived in these experiments suggest a possible physical model for rupture of the membranes; they also introduce questions regarding the anatomic and biochemical makeup of the chorion and the amnion and the respective role that each plays in maintaining the integrity of the human chorioamniotic sac.

Lead represents a significant environmental hazard to pregnant women and their offspring. Exposure to high environmental levels of lead has been associated with spontaneous abortion, premature rupture of fetal membranes (PROM), and preterm delivery. The relationship between lower exposures and obstetric complications is unknown. The concentration of lead in the blood was measured in 635 specimens of umbilical cord blood collected at delivery. No relationship was found between concentrations of lead in cord blood and the incidence of PROM, preterm delivery, preeclampsia, or meconium staining. Maternal and infant capillary blood was collected 24 hours post partum from 154 of these deliveries. The concentrations of lead in the blood did not vary significantly among cord, infant, and maternal samples, and the three measurements were highly correlated. Levels of zinc protoporphyrin (ZnP) were increased in cord blood as compared with mothers' blood, but no concentration-response relationships between the ratio of cord ZnP to maternal ZnP and lead were found.

Cholecystosonography was performed on 338 obstetric patients, and the gallbladder was successfully visualized in 93% of them. Gallbladder volume increased with duration of pregnancy. Three and one-half percent of the patients had obvious cholelithiasis, and a total of 4.2% had abnormalities. These findings suggest that cholecystosonography should become part of the routine obstetric ultrasound examination.

Presented is the case of a triplet pregnancy with conjoined twins diagnosed antenatally with sonography. Prenatal diagnosis has the potential to improve outcome for the normal infant.