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Atrial septal aneurysm is an increasingly recognized cardiac abnormality. It represents a marked bulging of the interatrial septum into one atrium or the other. A consistent association between this structure and embolic stroke has been demonstrated. Because of the high prevalence of patent foramen ovale or atrial septal defect associated with this structure, paradoxical embolism has been suggested as a mechanism for embolic events. An alternate explanation is the local association of the aneurysm with thrombus. Few data have been found to support this mechanism, however. We report a young woman with multiple strokes during pregnancy in whom transesophageal echocardiography allowed the in vivo demonstration of atrial-septal-aneurysm-associated thrombus. This observation lends further support to the "local thrombus" mechanism of embolie events. It also underscores the potential utility of transesophageal echocardiography in evaluating patients with stroke of uncertain etiology., (Copyright © 1991 Demos Publications. Published by Elsevier Inc. All rights reserved.)

Eighty-eight neonates born to mothers with a history of cocaine use during pregnancy were divided into two groups based upon the detection of cocaine metabolites in the first neonatal urine. Forty neonatal urine samples were positive for cocaine and 46 were negative. Preterm labor, premature rupture of membranes, and meconium-stained amniotic fluid were significantly more frequent in those mothers whose neonates tested positive for cocaine metabolites than in those whose infants were negative (P less than .05). Neonates testing positive were more likely to exhibit signs and symptoms of acute cocaine intoxication. Low birth weight, growth retardation, and abruptio placentae were also more frequent than would be expected in the general population, but were not statistically different between the groups. These findings suggest that the differences noted in the cocaine-positive group may represent acute and chronic exposure, whereas the negative group reflects the problems associated with chronic usage alone.

Red blood cell 2,3-diphosphoglycerate (2,3-DPG) levels were studied in 227 normal gravid women in all stages of pregnancy, active labor, and early post partum. An increase to peak levels was observed at 19 to 22 weeks followed by a gradual fall toward normal. During labor and early post partum, 2,3-DPG again rose significantly above levels observed at term. Serial 2,3-DPG values through the third trimester, labor, and postpartum period in 11 hypertensive mothers and 20 normal gravid control subjects and their newborn infants were studied. Maternal 2,3-DPG levels were significantly higher in the hypertensive mothers when compared to control mothers at similar gestational stages. However, no difference in 2,3-DPG levels was observed when newborn infants of hypertensive mothers were compared with those of normal control subjects.

Oral contraceptive users have been reported to have a higher incidence of viral, bacterial and fungal infections. This study was undertaken to try to elucidate some of the mechanisms responsible for this increased susceptibility to infection. Peripheral blood lymphocytes were labelled with murine monoclonal antibodies directed against T cells and the various lymphocyte subsets: helper cells, suppressor/cytotoxic cells, or natural killer cells. The lymphocytes were then analyzed on a Coulter Electronics Epics V fluorescent activated cell sorter (FACS). A total of 27 control and 33 oral contraceptive users were studied. In comparison to the control group, there was no significant difference between the two groups in percentage or absolute numbers of total T cells, helper cells, suppressor/cytotoxic cells or natural killer cells. This study suggests that the increase in herpes virus, C. trachomonas, candida, and other infections in women taking oral contraceptives is not related to alterations in the numbers of T lymphocyte subsets or in levels of NK cells.

Neonatal mortality, idiopathic respiratory distress syndrome, and early periventricular/intraventricular hemorrhage in the neonate weighing 2000 g or less were correlated with umbilical artery acid-base status. Neonatal mortality and, to a lesser extent, idiopathic respiratory distress syndrome correlated with umbilical artery acidosis. Early periventricular/intraventricular hemorrhage was associated with low Apgar scores, but showed no correlation with umbilical artery acid-base status.

bradycardia lasting more than 21/2 minutes with a decrease in FHR of more than 30 b.p.m. were observed in the course of 15 monitored labors. The mean fetal pH during the 20 minutes following the bradycardia (early recovery) was significantly less than the mean pH obtained 30 minutes or more after the bradycardia (late recovery). Various types of periodic heart rate changes were observed during the early recovery period but few persisted into late recovery. Vaginal delivery occurred in 13 of 15 patients. Two cesarean sections were performed for indications unrelated to the prolonged bradycardia. The 5 minute Apgar score of all 15 neonates was 7 or greater.

On routine fontanelle scanning of neonates weighing less than or equal to 2000 g within the first 24 hours of life, 21% had abnormal findings related to peri/intraventricular hemorrhage. These findings occurred almost exclusively in patients who were in labor, with one exception, and were not observed without labor. Once labor ensued, the performance of cesarean section did not prevent periventricular and intraventricular hemorrhage. Other obstetric factors including fetal heart rate monitoring and umbilical artery pH values were not related to early periventricular and intraventricular hemorrhage. The practical significance of these findings is discussed.

The small-for-gestational-age fetus continues to account for a large proportion of fetal demise in late pregnancy. Delivery at 37 to 38 weeks' gestation to preempt this is our recommended mode of management. Prenatal diagnosis was made in only 33% of cases in this study. The course of 101 growth-retarded pregnancies has been critically evaluated towards improving the rate of prenatal diagnosis.

A double-blind study evaluating two dose schedules of oral prostaglandin E2 (PGE2) was conducted in 56 normal "unripe" multiparas at term. The effect of PGE2 was evaluated by comparing the change in Bishop score of the cervix and patient's response to oxytocin induction of labor after the prostaglandin priming. In the two study groups (one group on a fixed PGE2 dosage and the other on a variable drug regimen) an average change of more than three points in the Bishop score was observed. In control group no significant change in cervical ripeness was observed. Nine of the 32 patients (28%) receiving prostaglandin delivered during the priming phase of the study, whereas only 1 control patient (4.2%) delivered during priming. Six of 24 control patients (25%) failed to deliver, wheras only 3 of 32 study patients (9%) failed. In the successfully induced patients, the response to oxytocin, as expressed by the time to active phase, total time of labor, and mean dose of oxytocin required, did not vary significantly when control and study groups were compared. It is concluded that PGE2 at either dosage schedule is effective in changing the Bishop score of the cervix and that it is not feasible to titrate the PGE2 dose in order to effectively ripen the cervix without a very high incidence of induction of labor. In those cases where priming was completed, without accidental delivery, the induction phase was successful more than 90% of the time. No adverse effect to mother or baby was observed during this study.

The significance of fetal heart rate-uterine contraction (FHR-UC) monitoring as a means of predicting the condition of the fetus during labor was studied by correlating 460 fetal pH determinations obtained from 216 patients with the analysis of the 20-minute FHR-UC record preceding the fetal scalp blood sample. Both qualitative and quantitative analyses of the FHR-UC record were performed. The results indicate a less than 10% chance of fetal pH less than or equal to 7.250 with an normal baseline FHR and no periodic changes or with periodic accelerations, early decelerations, and uncomplicated baseline bradycardia or tachycardia. Variable or delayed decelerations with a total surface area (TSA) of 1-100 for the 20-min period were associated with a fetal pH less than or equal to 7.250 in 23 and 34% of cases, respectively. Variable or delayed decelerations with a TSA greater than 100 had a 35 or 47% chance of fetal pH less than or equall to 7.250. It is concluded that FHR-UC monitoring can be used to screen the innocuous from the ominous periodic change but that fetal scalp blood pH must be obtained to identify accurately the true from the false-positive ominous pattern.

Maternal serum prolactin (PRL) levels were evaluated in patients having contraction stress tests (CST) by nipple stimulation. Of 79 CSTs, 14 failed and 65 were successful. Poststimulation PRL levels in failed cases were significantly lower than those in gestational age-matched successful cases, despite longer duration of nipple stimulation in the failed cases.

Nipple stimulation was found to be a safe alternative to oxytocin in the management of the third stage of labor.

The cerebral function monitor, a system which records integrated electroencephalograms, was used to assess neurological status of newborns who had a non-reactive non-stress test prior to delivery. Babies born within 24 h of a non-reactive tracing had a significant lack of sleep cycling and persistence of immature patterns when compared with controls matched for gestational age.

With the aid of specific monoclonal antibodies, indirect immunofluorescence, and flow cytometry, peripheral blood lymphocyte populations were studied in 12 preeclamptic mothers and compared with those of ten normal patients at term. As well, lymphocyte subsets from newborns of these preeclamptic mothers and ten normal patients at term were studied. Lymphocytes were labelled with murine monoclonal antibodies directed against T cells and subsets of helper cells, suppressor/cytotoxic cells and natural killer cells. Cord blood lymphocytes of neonates from preeclamptic mothers showed a statistically significant reduction of total T cells, helper cells, and natural killer cells as compared to control. A significant reduction in helper/suppressor ratio was also observed. It is hypothesized that the differences in the immune system of the neonates in the preeclamptic group may be due to the stress of intrauterine malnutrition secondary to uteroplacental insufficiency.

Fetal heart rate and uterine activity were monitored during sexual intercourse in three otherwise normal gravid women at varying gestational ages. Increased uterine activity and a variety of fetal heart rate changes, some of which are traditionally identified as ominous, were seen in most instances immediately following orgasm. An increase in fetal activity was also commonly reported by the mothers. It is postulated that coitus is equivalent to an unmonitored contraction stress test.

This study presents 3 cases of severe soft-tissue malformations of the fetus. Prenatal diagnosis was established early in the second trimester, and the accuracy of the diagnosis was confirmed by pathological examination in each instance. A clinically oriented work-up plan for early prenatal diagnosis is proposed.

In low-birth-weight neonates, an elevation in the percentage of creatine kinase brain-band isozyme in the umbilical artery was significantly correlated with future development of neonatal grade III and grade IV periventricular-intraventricular hemorrhage, when compared with levels in those neonates who did not show periventricular-intraventricular hemorrhage or who developed grade I and grade II periventricular-intraventricular hemorrhage (p = 0.025). In these neonates the relative levels in maternal venous, umbilical arterial, and umbilical venous samples indicated that the source of the isozyme was fetal.

Twenty children who had been exposed to ritodrine in the management of preterm labor between 24 and 34 weeks' gestational age were examined at seven to nine years of life and compared with matched control subjects. No significant differences were detected in factors of growth, neurologic findings, and psychometric testing.

Four patients with severe Rh isoimmunization are presented in whom sinusoidal fetal heart rate patterns were recorded. In 2 cases in which the pattern was seen intermittently in the postintrauterine transfusion period, the perinatal outcome was good. In the 2 cases in which the pattern was seen spontaneously and continuously, the outcome was poor, confirming the ominous and possibly agonal significance of the latter pattern.

Cardiac events in 30 patients in preterm labor on ritodrine therapy were examined continuously on a Holter monitor. Unsuspected events, such as persistent severe tachycardia, premature ventricular contractions, and supraventricular premature contractions, were observed. These events did not occur more frequently in patients with cardiac symptoms. None of these changes were observed by standard monitoring methods. Continued beta-mimetic stimulation in the presence of these events may lead to the serious cardiopulmonary complications that have been reported during ritodrine infusion.

Nipple stimulation with an electric breast pump was compared with oxytocin infusion as a means of labor induction. The time from stimulation to the onset of regular uterine activity and to 200 Montevideo units of uterine activity and the time until entrance into the active phase of labor were significantly shorter in the nipple stimulation group. Once the women were in active labor, there was no difference between the groups in the length of labor or mode of delivery.

Experience with the management of 4 pairs of locked twins is described and analyzed. In view of the high morbidity figures a proposed preemptive management is suggested.

We investigated the correlation of fetal heart rate patterns and fetal acid-base findings with the occurrence of early periventricular/intraventricular hemorrhage and variants. Ninety-five consecutive singleton neonates with birthweights less than or equal to 2000 gm were investigated. One-third of them showed early periventricular/intraventricular hemorrhage or variants. Fetal heart rate scores and umbilical arterial/venous acid-base status showed no correlation with results of scanning. The implications of these findings are discussed.

The ability to tolerate an oral glucose load during convalescence from hypoxia was studied in four term and 11 premature appropriate-for-gestational-age infants by sequential measurements of the changes occurring in blood pH, bicarbonate, plasma lactic acid, and plasma glucose following an oral glucose load. All infants developed metabolic acidosis and lactic acidemia after the oral glucose load. The maximum fall in blood bicarbonate occurred at 30 minutes, and the maximum rise in plasma lactic acid concentration was attained at 60 minutes. The metabolic changes were found to be more severe in infants given the oral glucose load early in their convalescence and in those infants less than 10 days of age. The absorption of glucose was also decreased in these infants, as shown by a reduced rise in blood sugar. These observations indicate that newborn infants, term or premature, tolerate glucose loads poorly during convalescence from hypoxia.

A randomized controlled study was carried out at three medical centers to compare the efficacy and side effects of ethanol and ritodrine in the treatment of threatened premature labor. One hundred and thirty-five patients judged to be between the twentieth and thirty-sixth week of gestation and presenting with clinical symptoms of premature labor were included. Sixty-seven patients were treated with intravenous infusion of 10 per cent ethanol. Sixty-eight patients were treated with intravenous infusion of ritodrine for 12 hours followed by oral ritodrine. If labor recurred prematurely, up to two additional courses of ethanol or ritodrine were given. Delivery was postponed for more than 72 hours in 49 of 67 patients (73 per cent) with ethanol and in 61 of 68 patients (90 per cent) with ritodrine; this difference was significant. Patients in the ethanol group gained a mean of 27.6 days while patients in the ritodrine group gained a mean of 44.0 days. Fifty-four per cent of the ethanol group and 72 per cent of the ritodrine group carried their infants to 36 weeks of gestation. Five infants in the ethanol group and one infant in the ritodrine group died from respiratory distress syndrome. The most frequent side effect of ethanol were nausea and vomiting. The most frequent side effects of ritodrine were tachycardia and blood pressure changes which were easily controlled by lowering the infusion rate. Ethanol and ritodrine were both found to be effective inhibitors of premature labor with ritodrine giving the most favorable results.

High dietary protein intake is known to increase glomerular filtration rate in the nonpregnant state. The effects of dietary protein on renal function in human pregnancy are not well known. We studied 392 patients with singleton uncomplicated pregnancies at gestational ages of 7-40 weeks. Creatinine clearance was correlated with protein intake estimated from 24-hour dietary recall during the same period. Creatinine clearances were significantly higher when dietary protein was more than 50 g than when it was less than 50 g (P less than .005). The short- or long-term significance of this finding is unclear.

Survivors of periventricular or intraventricular hemorrhage and isolated ventricular dilation showed a higher incidence of major developmental problems in the motor areas than matched control subjects in infancy. This effect is still seen, but less evident in early childhood. Problems were mainly related to grades III and IV periventricular or intraventricular hemorrhage and isolated ventricular dilation. The outcome of newborns with grades I and II hemorrhage was benign.

Ninety-two consecutive cases of breech presentation with birth weights less than or equal to 2,000 g were examined for early periventricular/intraventricular hemorrhage (PV/IVH) and neonatal demise. The total group and subgroups, based on birth weight and gestational age, showed significantly less early PV/IVH and perinatal mortality if delivered by cesarean section. There is a need for a prospective, randomized, multicentric study of this subject.

Thirty-seven consecutive patients with singleton pregnancies in "uncomplicated" preterm labor with intact membranes suitable for tocolysis were evaluated for evidence of silent chorioamnionitis by means of maternal serum C-reactive protein and amniotic fluid white blood cell count, Gram stain, and cultures. Abnormalities in these markers of infection were found to be significantly more common in cases that were refractory to tocolysis. These cases also showed both pathologic evidence of chorioamnionitis and a significantly greater neonatal early infectious morbidity. We conclude that silent chorioamnionitis is a significant cause of "uncomplicated" preterm labor refractory to conventional methods of tocolysis.

Fetal monitoring data in 200 consecutive cases was evaluated in the second hour prior to delivery to determine how neonatal outcome could be most accurately predicted. It was found that the correlation between ominous fetal heart rate-uterine contraction (FHR-UC) patterns and a depressed Apgar score at 1 minute was, at best, 37%. However, where the last fetal scalp blood pH (FSB-pH) was less than or equal to 7.2, neonatal depression occurred in 88% of cases. FSB-pH, therefore, provided a more reliable means of diagnosing fetal distress.

In 392 low birthweight neonates, acidosis as evident from umbilical artery pH 7.1 or less was strongly associated with Apgar score 6 or lower at 1 minute. However, most cases that were depressed (Apgar score 6 or lower at 1 minute) were not acidotic. Neonatal depression was most strongly and directly correlated with gestational age. Neonatal depression and birth asphyxia are distinct entities.

Two hundred eighty patients with vertex presentation who were in spontaneous labor and delivered neonates weighing 2 kg or less were examined for early ultrasound evidence of periventricular/intraventricular hemorrhage. This was correlated retrospectively with delivery route (cesarean section versus vaginal delivery) and delivery method (low forceps delivery versus normal spontaneous delivery) in the group born vaginally. No correlation was evident between early periventricular/intraventricular hemorrhage and delivery route or method.