Thirty-eighth Week Research Articles

The influence of body mass on foot dimensions during pregnancy

In this study, a time-series approach was used to measure women's feet to accurately analyze changes in foot size and body mass during pregnancy. One-hundred women who were pregnant for the first time were asked to respond to questions on subjective complaints of foot discomfort listed in a questionnaire. Among these 100 women, a sample of 30 was obtained and used to measure the women's feet from the twentieth week of the gestation period until labor. The data (from 5 of the 30 women) were used to establish a prediction model for the influence of body mass on changes in foot size during pregnancy. The results indicate that the women subjectively complained that their shoes were too tight, resulting in foot discomfort. From the twentieth to the thirty-eighth week of pregnancy, the average increase in foot length, width, and back foot surface was 0.86 cm (3.6%), 0.25 cm (2.6%), and 18.36 cm2 (11.9%), respectively. The height of the arch decreased by an average of 0.52 cm (−24.2%). Body mass accounted for more than 90% of the variation (R2) in foot dimensions during pregnancy and, thus indicated satisfactory predictive ability. The prediction model developed in this study can serve as a reference for clinical applications and shoe design to prevent women from experiencing extreme discomfort in their feet during pregnancy.

Pregnancy complicated with a giant splenic cyst: a case report and review of the literature

Splenic cysts or masses in pregnancy are extremely rare and only five cases were described in the literature. We present the first case of splenic cyst in pregnancy treated laparoscopically with fenestration and preservation of the spleen. A 23-year-old primigravida at 9 weeks of gestation presented for her prenatal follow-up with a 3 weeks history of epigastric pain and early satiety. A magnetic resonance imaging of the abdomen and pelvis demonstrated a gigantic splenic cyst measuring 17 x 13 x 15 cm. Aspiration of the cyst was performed under ultrasound guidance for diagnostic purposes as well as for relief of patient's symptoms. The patient was followed by bi-weekly sonographic scan until the second trimester. A second aspiration of the cyst was complicated with sepsis, and laparoscopic fenestration and omentopexy were performed. The patient's remaining antepartum course was uncomplicated and she had a normal spontaneous delivery at thirty-eighth week. The most feared complication of a splenic cyst in pregnancy is spontaneous rupture, which in the third trimester is associated with a perinatal mortality rate as high as 70%. Surgical therapy should therefore be provided in the second trimester. Laparoscopic fenestration with omentopexy is a minimally invasive, effective and safe procedure for this condition.

Rapid clearance of fetal cells from maternal circulation after delivery.

We previously reported increased apoptosis in the maternal circulation during pregnancy, partly accounting for the presence of cell-free fetal DNA in maternal plasma. In the current study, apoptosis was quantitated in 60 peripheral blood samples obtained from 15 women sequentially tested postpartum using the binding of annexin V. FISH with X/Y probes was performed on annexin V-positive cells isolated by MACS in patients with male fetuses to estimate the proportion of fetal cells among the apoptotic cell population. Twenty-four women at the thirty-seventh to thirty-eighth week of gestation and 35 nonpregnant females were used as controls. Apoptosis rate in the thirty-seventh to thirty-eighth week was 12.5% (9.2-14.7%). At 30 minutes, 12 hours, 24 hours, and 48 hours postpartum, it was 25.1% (16.8-28.5%), 12.5% (10.9-14.1%), 6.1% (4.8-7.1%), and 2.3% (1.3-3.0%), respectively. Male apoptotic cells were identified in all cases with male fetuses at 37 to 38 weeks of gestation, and the mean proportion was 9.9% (5.9-13.2%). The proportion of fetal cells 30 minutes after delivery was 14.8% (12.5-25.5%) and 12 hours postpartum 2.1% (0.8-4.1%). Male fetal apoptotic cells were detected in three of eight samples collected 24 hours after delivery from women who delivered males, at frequencies of 0.10%, 0.15%, and 0.25% (mean 0.16%). There were no fetal apoptotic cells 48 hours after delivery. Apoptosis partly accounts for the clearance of fetal cells from the maternal circulation. Because it is a rapid reaction, completed within 2-3 hours, persistence of fetal cells is possibly due to apoptosis-resistant progenitors or to defective regulation of apoptosis, leading to fetal cell microchimerism associated with autoimmune diseases.

Rapid and simultaneous measurement of estrone, estradiol, estriol and estetrol in serum by high performance liquid chromatography with electrochemical detection.

A high performance liquid chromatographic (HPLC) method with electrochemical detection (ECD) was developed for the simultaneous measurement of estrone, estradiol, estriol and estetrol in serum. These hormones were extracted with diethylether, chromatographed on an silica-octadecyl silane (ODS) column with an eluent of phosphate buffer solution-acetonitrile-methanol (volume ratio 152:85:40), and detected by ECD at +1.0V vs. Ag/AgCl. In comparisons between the values measured by this method and radioimmunoassay, significant correlations were noted for estrone (r = 0.759, p less than 0.01), estradiol (r = 0.816, p less than 0.001) and estriol (r = 0.830, p less than 0.001). In clinical applications of this method, differences between cases of the normal and the anencephalic pregnancy in the thirty-eighth week of gestation were distinct not only in the individual estrogen, but also in the profile analysis of estrogens. With this method, all 4 serum estrogens above approximately 500 pg/ml could be measured within 2 h, and the method seemed to be clinically applicable.

Comparative urodynamic studies of continent and stress incontinent women in pregnancy and in the puerperium

Twelve pregnant women were examined by urethral pressure profile measurement and simultaneous urethrocystometry early in pregnancy (weeks 12 to 16), in the thirty-eighth week, and 5 to 7 days after delivery. All patients reported symptoms of stress incontinence starting at an early gestational age. It was found that the stress incontinent women, compared to 14 continent, healthy women from whom measurements were obtained earlier, had shorter urethral lengths. Furthermore, no increase in urethral length during pregnancy was registered among the stress incontinent women, whereas such an increase did occur in the continent women. In contrast to the continent women, the incontinent patients had a low urethral closure pressure at rest and this pressure did not appear to increase sufficiently to compensate for the progressive increase in bladder pressure during pregnancy. As a result the urethral closure pressure in the stress incontinent women, therefore, decreased more and more during stress situations as pregnancy progressed, resulting in an increased leakage of urine.

Urodynamic studies in normal pregnancy andin puerperium

Fourteen primiparas (11 pregnant for the first time, and three with a history of one abortion) were examined during pregnancy to elucidate changes in parameters of importance of maintenance of urinary continence. Urethral pressure profile measurements and simultaneous urethrocystometry were carried out in the beginning of pregnancy (weeks 12 to 16), in the thirty-eighth week, and 5 to 7 days after delivery. Both the absolute and functional lengths of the urethra were found to increase throughout pregnancy by median values of 6.7 and 4.8 mm, respectively. Also, the maximum urethral pressure increased gradually during pregnancy, returning within 1 week after delivery to almost the same value as at the beginning of pregnancy. The urethral closure pressure also increased throughout pregnancy. Thus, the results of the investigation revealed that the physiologic changes which took place within the urethra during pregnancy were to advantage from standpoint of maintaining continence.

Amniotic fluid glucose concentration

The results of glucose estimations in 350 specimens of amniotic fluid in 278 pregnancies are presented. In the control group of normal pregnancies, a gradual decrease from 65.25 ± 12.10 mg. per cent (mean ± 2 S.E.) at 7 to 12 weeks to 28.01 ± 4.41 mg. per cent at 17 to 20 weeks was established. After 20 weeks, the same values persisted up to 32 weeks (23.50 mg. per cent), when these began to decrease to 13.28 ± 4.37 mg. per cent in the thirty-eighth week. In the last weeks of pregnancy, the abrupt fall of the mean values, including the absence of glucose in the forty-second week, was established. In pregnancies with placental insufficiency (intrauterine fetal growth retardation, pre-eclampsia, and postmature pregnancy), significantly lower values were present (p < 0.01), while in diabetic pregnancies significantly higher mean values (p < 0.01) were observed. A significantly higher incidence (p < 0.02) of depressed infants (Apgar score ≤ 7) and infants with acidosis-preacidosis was observed in pregnancies with lowered amniotic fluid glucose concentrations. In pregnancies with decreased estriol excretion and meconium-stained liquor amnii, a significantly lower glucose mean value (p < 0.01, about < 0.02) was evident.

Pregnancy after eclampsia

A prospective study of the pregnancy immediately after convulsive eclampsia was undertaken in 110 patients, divided in three groups: 32 with early eclampsia (convulsions appearing before the thirty-fifth week of amenorrhea), 46 with intermediate eclampsia (convulsions appearing from the thirty-fifth to the thirty-eighth week), and 32 with term eclampsia (convulsions after the thirty-eighth week). Parameters studied in the eclamptic and in the subsequent pregnancy were: perinatal death, average amenorrhea, fetal weight, incidence of retarded fetal growth (RFG), frequency and severity of recurrent toxemia, weight gain during pregnancy, and method of delivery. Perinatal mortality rate in subsequent pregnancies was lower than the average for a general obstetric population in Mexico City but subsequent pregnancies tended to end before term, with 22.0 per cent of growth retarded fetuses, and repeating some degree of toxemia in 35.4 per cent of the cases. These tendencies were considerably more evident in the group of early eclampsia and the differences were highly significant statistically. These findings were commented upon and it was suggested that the most significant characteristic of prognostic consequences for the future pregnancies of eclamptic patients was the timing of convulsions in regard to the length of the pregnancy. This parameter may signal the presence of previous underlying disease and may parallel the importance of the basic defects.

Origin of the cells in the liquor amnii

The cytologic features of the amniotic fluid were studied. Four epithelial cell types are ordinarily present, namely, large eosinophilic cells, large cyanophilic cells, small round cyanophilic cells, and polygonal eosinophilic cells. The first three cell forms may be nucleate or anucleate, the fourth is always anucleate. The polygonal cells occur after the thirty-eighth week only. The origin of the cells was established by comparing them with scrapings of fetal surfaces. The cells appeared to be shed essentially by the fetal buccal mucosa, vaginal epithelium, and skin, and there is probably a contribution from the urine. The source of the small blue cells and the polygonal cells in particular is discussed.

Relationship between length of gestation and cervical dilatation, uterine contractility, and other factors during pregnancy

The relationship was examined in healthy young primigravidas between the length of gestation and several factors measured during pregnancy, including the physical and chemical state of the cervix, uterine contractility, smoking, and sexual intercourse. Cervical dilatation and effacement during pregnancy relate to the time in gestation at which labor starts. For example, at the thirty-second week the internal cervical os was one fingerbreadth dilated in all patients who subsequently were delivered before the thirty-eighth week, but in only 10 per cent of those delivered after the forty-first week. The concentration of cervical hydroxyproline did not relate to gestation at labor nor to the physical state of the cervix. There was a highly significant negative correlation between the activity of the uterus at the thirty-sixth week of pregnancy and gestation at the onset of labor. The proportion of patients delivered before the end of the thirty-ninth week was significantly greater for smokers that for nonsmokers. However, the relationship between the length of gestation and cervical dilatation and uterine contractility in pregnancy remained significant in nonsmokers. The frequency of sexual intercourse during pregnancy did not influence the time in gestation when labor began.

The primigravida in labor with high fetal station: A study of 1,209 hospital records of obstetric patients

It is generally accepted that high fetal station in primigravidas in labor near term may indicate a threat to the normal progress of labor because of fetopelvic disproportion or obstruction of the fetal passageway by tumors or the placenta. The hospital records of 1,209 obstetric patients were reviewed and 430 primigravidas were selected for detailed study by including only those with vertex presentations that entered the hospital in labor the thirty-eighth week of gestation or later. These patients were further divided into two groups, those with engaged fetal heads and those with unengaged fetal heads. When these two groups were compared, no statistical difference was found in the length of the first and second stages of labor, method of delivery, fetal head position, weight of the infant, or Apgar rating.

Fetal and maternal immunoglobulin levels during pregnancy

The passive transfer of maternal immunoglobulins to the fetus is of importance not only because of the protection it offers the child but also because active antibody synthesis is inhibited by passively transferred antibody and because the antibody may be detrimental to the child. Immunoglobulins have been measured in the paired maternal and fetal sera in 175 pregnancies ranging from the twelfth to the thirty-eighth week of gestation. Fetal IgG serum concentrations equaled the maternal values by the thirty-third week of gestation, and IgA and IgM were infrequently found in fetal serum. The significance of these findings is discussed.

Multiple repeat cesarean sections

A review of 282 patients with four or more cesarean sections over a period of 7 years (1956 through 1962) at an exclusively maternity hospital is presented.The statistical data indicate that waiting until the thirty-eighth week of gestation does not increase the danger of weakness of the previous scar and assures a mature baby.The incidence of placenta previa is more than ten times that of all deliveries.Placenta accreta seems to occur sufficiently often in cases in which the placenta overlies the previous scar to warrant serious consideration.The possibility of hysterectomy for placenta accreta or a weakened scar must be anticipated.The over-all incidence of postoperative morbidity and complications are no higher than for primary cesarean sections or any other major abdominal procedures.Repeat cesarean sections, regardless of number, can be performed without the addition of significant risk to the mother or the fetus, provided they are done by qualified physicians and with adequate hospital facilities.

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL. CASE 61-1963.

Presentation of Case First admission. A thirty-six-year-old woman entered the hospital because of dyspnea and palpitation. At the age of three years the patient had a fever and joint pains for several months, and a heart murmur was heard. Two years later chorea developed and persisted for a year. She was married at the age of twenty-four years; two years later severe dyspnea and tachycardia occurred in the thirty-eighth week of pregnancy, and cesarean section was performed and digitalis therapy instituted. Eight years before admission sodium restriction and a diuretic agent were added to the regimen because of increased dyspnea. . . .

Full-term and Low Birth Weight

It has been customary to determine prematurity by birth weight alone, even though the shortcomings of this practice have been pointed out convincingly, for instance, by McKeown and Gibson.1 The World Health Organization has recently taken cognizance of this problem, realizing that its previous recommendation of a birth weight limit of 2,500 gm is but a temporary expedient while no better method is available to define, study, and manage prematurity. The new, brief report2 points out the numerical magnitude of the problem by stating that among infants of healthy, young primigravidae receiving good obstetrical care, only two-thirds of those weighing less than 2,500 gm are born before the thirty-eighth week.

Massachusetts Medical Society

COMMITTEE ON MATERNAL WELFARE*Paralytic IleusA twenty-one-year-old gravida 2, para 1, was admitted to the hospital with painless bleeding in the thirty-eighth week. Under double-setup precautions partial premature separation of the placenta was diagnosed, but the cervix was found "unfavorable" and a lower-segment cesarean section was done. She died four days later.There had been only four prenatal visits, all with normal findings, three to seven weeks apart, the last at thirty-five weeks. Then the return appointment was set for a full calendar month later, — that is, six days before the estimated date of confinement, — but admission . . .

Pregnancy complicated by spontaneous suprarenal and ovarian venous hemorrhage: A case report

An 1%year-old primigravida was hospitalized in the thirty-eighth week of pregnancy at 9:30 A.M., Sept. 30, 1956. The prenatal course had been uneventful until September 29. Then the patient experienced transitory, sharp pain in the right costovertebral angle. Since it disappeared quickly, she disregarded it. Approximately 24 hours later the excruciating pain reappeared suddenly as she sat down in a chair. Nearly two hours later, when hospitalized, the blood pressure was 110/90, the pulse 60 per minute, and the temperature 98.6” F. The skin was dry with goocl turgor. The mucous membranes were moderately pale. The head, neck, chest, heart, and lungs appeared essentially normal. The uterine fundus was soft, nontender, and within 4 cm. of the xiphoid process. The baby presented by the vertex. One observer thought the fetal heartbeat was faint for a short time. Light pressure over the right kitlney posteriorly reproducecl much discomfort. The cervix was long, uneffaced, and closed. Rectal examination added no information. There was no etlema of the extremities. The tentative diagnosis was renal colic with obstruction due to a stone, versus torsion or rupture of a viacus as a seconll choice.

Massachusetts Medical Society

COMMITTEE ON MATERNAL WELFAREReaction from Incompatible Blood TransfusionA twenty-one-year-old woman died in Massachusetts sixteen days after a cesarean section in another state during the thirty-eighth week of her third pregnancy.During her first pregnancy, at the age of eighteen, the Public Health Department laboratory of her home state reported the blood as Group A, Rh negative. During the second pregnancy she was admitted to the hospital for severe anemia and was given a transfusion. The hospital laboratory reported the Blood as Group A, Rh positive, with no agglutination in major and minor crossmatching, and there was no reaction. . . .

Double uterus with double pregnancy

1.1. A case of uterus didelphys is reported. The patient presented a problem of sterility which was presumably corrected by dividing the vaginal septum and by administration of hormonal therapy.2.2. Pregnancy took place in both uteri during the same cycle.3.3. One fetus turned spontaneously from a breech to a cephalic presentation some time during the last twenty-one days of pregnancy.4.4. Labor started spontaneously in the thirty-eighth week of gestation.5.5. Delivery of both infants was through the vaginal route, the one from the left uterus being born first and the other from the right being born fourteen hours later. Labor in the right uterus had to be initiated by rupture of the membranes and administration of intravenous Pitocin.6.6. It is suggested that one of the causes of the pregnancy occurring in only one of the uteri in cases of uterus didelphys may be the presence of the vaginal septum. A division of the septum renders each cervix equally accessible to the admission of spermatozoa with subsequent pregnancy in either one or both uteri.

A comparative study based on five hundred consecutive cases of induction of labor

This is a report of 500 consecutive inductions of labor in 430 patients all of whom were past the thirty-eighth week of pregnancy. In 338 patients the induction was successful. In 26 patients there were two inductions and in 16 patients there were three to five inductions. Six methods were tested. Pituitrin alone was successful in 26 per cent, castor oil in 53 per cent, castor oil and quinine in 63 per cent, castor oil and pituitrin in 69 per cent, castor oil with quinine and pituitrin in 73 per cent, and bag insertions in 95 per cent. Stripping the membranes markedly increases the percentage of success in each group. After the membranes were stripped, pituitrin was successful in 36 per cent, castor oil in 77 per cent, castor oil and quinine in 81 per cent, castor oil and pituitrin in 83 per cent, and castor oil with quinine and pituitrin in 94 per cent. Primiparae respond to induction methods to the same degree as do multiparae. Stripping the membranes does not hasten the onset of labor nor shorten the duration of labor. The medicinal induction of labor raises the gross and corrected morbidity from 8.6 per cent and 5.1 per cent to 10.5 per cent and 5.8 per cent respectively. When stripping is added, the morbidities increase to 11.6 per cent and 6.4 per cent respectively. The morbidity following bag inductions in this series is 33.3 per cent and 27.7 per cent respectively. There is no effect upon fetal mortality or morbidity.