Communications in brief
Volume !2i Number 2
205
Fig. I. Twelve minutes of the record of the fetal heart rate in beats per minute (upper panel) and uterine contractions (lower panel) induced by oxytocin and detected by ultrasound and external tocodynamometer, respectively. The frequency and duration of contractions demomtrate the adequacy of the challenge .
rest. An OCT was performed (Fig. 1), and this was read as negative. Subsequent estriol levels were: day of OCT, 19.7 mg. per 24 hours; two days following the test, 12.7 mg. per 24 hours. Fetal heart tones were lost on the morning of the third day, between 62 and 68 hours following the OCT. Because of the previous cesarean section, the patient had a repeat cesarean section with delivery of a 3.572 gram grossly normal infant, showing some maceration. Pathologic study of the fetus and placenta revealed no abnormalities other than those consistent with maternal diabetes. Diabetic control during the period of hospitalization was similar to that described earlier with no acetonuria.
We have reviewed II published reports of experience with the OCT. in a total of 1,245 patients, mostly in the high-risk category.* Of these patients, 157 have had positive tests and 11 of these infants were stillborn. It should be emphasized that in many cases the test result was used in management and deliveries were performed on the basis of it; at times patients were not permitted to labor following a positive test. However , in four studies, results of the OCT's were not used in patient management, and the stillbirth rate was 22 per cent (9/40). Among I ,036 patients with negative tests, only two babies died in utero within a week of the negative test. One infant had a tight nuchal cord at delivery, and the other was born hydropic, with the placenta showing thrombosis of the chorionic vessels. Whether the patients were diabetic was not noted . The excellent outcome of this group is all the more imposing when it is noted that most pregnancies were high risk, and the stillbirth rate would be expected to be far greater than the 0.2 per cent actually observed. The survival rate *A list of the references reviewed may be obtained from the senior author.
was no doubt also improved by the application of ancillary methods of fetal surveillance such as urinary estriol determinations, cephalometry, more intensive observation, and early delivery . Decreasing the interval between OCT's may have saved one or both of the two previously reported infants , though there is no way to be sure of this. The infant in the present report would have been lost even with biweekly OCT's, because fetal heart tones were lost less than 68 hours after the final negative test. In view of the great logistic problems involved in decreasing the OCT interval and lack of evidence that it would improve fetal outcome, there appears to be no reason at this stage to alter timing on a weekly basis when the tests are clearly negative .
Pentazocine withdrawal syndrome in the newborn infant ODED PREIS, M . D. SOOK ]. CHOI, M.D. NATHAN RUDOLPH, M . B.B.CH. Department of Pediatrics, St~te Univrrsity of N ew York, Downstate M edical Center, Brooklyn, New York
THE NARCOTIC WITHDRAWAL syndrome in newborn infants of mothers addicted to heroin, as well as those maintained on methadone, is a well-recognized Reprint requests: Dr. 0. Preis, Department of Pediatrics, Box 49, State University of New York, Downstate Medical Center. 450 Clarkson Ave., Brooklyn , New York 11203.
206 Communications in brief
January 15. I 977 Am.
entity. Recently, at least two reports 1 • 2 have indicated that repeated use of pentazocine by the pregnant mother may also result in withdrawal symptoms in her baby. We report an additional case of neonatal pentazocine withdrawal, verified by demonstration of this agent in the urine of both mother and infant. A male infant was delivered to a 29-year-old black woman, para 1-0-1-1, with negative serology after 3\12 hours of uncomplicated labor, with a one-minute Apgar score of 9. The mother had a history of nonspecific mild abdominal pain predating the present pregnam:y. During the last trimester, she had increasing abdominal pain for which the obstetrician prescribed pentazocine, 50 mg. three times per day, which she used on a regular basis during the last six weeks of pregnancy. On examination the infant had a birth weight of 2.400 grams with a head circumference of 32 em., and the gestational age was estimated at 38 weeks. No abnormal findings were noted. At 10 hours of age, the infant became irritable and developed coarse tremors. His symptoms gradually increased and by the third day he had marked tremulousness, with almost incessant crying, profuse sweating, frequent bowel movements, and a voracious appetite. At this stage, phenobarbital, 4 mg. per kilogram per day given every eight hours, was started. The infant responded rapidly to therapy, and the phenobarbital dosage was gradually reduced during the subsequent two weeks. He was discharged at three weeks of age, thriving and with no recurrence of symptoms. Routine laboratory investigations performed during the symptomatic period, including serum calcium, magnesium, electrolytes and blood sugar, were normal. Urine samples collected approximately 12 to 14 hours after delivery showed a strongly positive reaction for pentazocine in the mother and a trace positive reaction in the newborn infant.
Pentazocine originally was marketed as a drug with little abuse potential. However, with more widespread use of the drug, addiction has been observed. Both human and animal studies have indicated that pentazocine crosses the placenta rapidly and is readily detectable in fetal blood. In our patient, as well as in the two cases reported previously, 1 • 2 the onset of symptoms of drug withdrawal commenced during the first 24 hours after birth ( 10, 20, and four hours, respectively). These time intervals appear to correlate well with both the time that the mother last ingested the drug as well as the short half life (two hours) of pentazocine. It is apparent that pentazocine is not a harmless agent in the pregnant woman. On the contrary. although no withdrawal effects have been reported in the adult after therapeutic use, it is possible that such use during late pregnancy might result in withdrawal symptoms in the offspring. Therefore, we suggest extreme caution in prescribing this drug as a therapeutic agent during pregnancy. REFERENCES I. Goetz, R. L., and Bain, R. V.: Neonatal withdrawal
symptoms associated with maternal use of pentazocine,]. Pediatr. 84: 887. 1974.
f.
Obstet. Gvnecol.
2. Scanlon, J. W.: Pentazocine and neonatal withdl·awal symptoms. J. Pediatr. 85: 73.'i, 1974.
Hemodynamic and metabolic studies of a case of toxemia of pregnancy URI FREUND, M.D. WILLIAM f'RENCH, M.D. RICHARD W. CARLSON, M.D., PH.D. MAX HARRY WElL, M.D., PH.D. HERBERT SHUBIN. M.D.t The Shock Research Unit and thf Department of Medicine, University of Southern California School of Medicine, the Los Angele~. County/USC Medical Center, and the Center for the Critically Ill, Hollywood Presbvterian Medical Center, Los Angeles, California
SEvERE To x EM 1 A of pregnancy is a life-threatening crisis in which hypertension, congestive heart failure, hypoproteinemia, and edema may be seen. Opportunity was provided for detailed study of the hemodynamic, volume, and related metabolic defects in a patient immediately after delivery by cesarean section. Hypertension and pulmonary edema were associated with hypovolemia. Volume repletion proved beneficial. A 22-year-old white woman, gravida I, para 0, of 34 weeks' gestation, was admitted because of toxemia. She complained of headache, vomiting, and generalized swelling. On a clinic visit I week prior to admission, hypertension, peripheral edema, and edema of the abdominal wall were observed. The blood pressure was 180/140 mm. Hg and the heart rate was 140 beats per minute. The fetal heart rate was !50 beats per minute. No uterine contractions were detected and the cervix was closed and not effaced. Laboratory data at the time of admission are shown in Table I. Treatment with magnesium sulfate, hydralazine, and phenobarbital was followed by reduction of the blood pressure to 110/90 mm. Hg. A cesarean section was performed 7 hours later, and a female infant, weighing 3.1 kilograms with an Apgar score of 9, was delivered. Abruptio placentae and 3,500 mi. of ascitic fluid were discovered at operation. No cardiac murmurs or gallop rhythm were detected and the lungs were clear on auscultation, The chest. x-ray revealed perihilar congestion and interstitial edema. An 8 inch Teflon catheter was inserted into the femoral
This study was supported by United States Public Health Service Research Grants HL-05570 from the National Heart, Lung, and Blood Institute, GM-16462 from the National Institute of General Medical Sciences, and ROI HS 01474 from Health Resources Administration. Reprint requests: Richard W. Carlson, M.D., Ph.D., Center for the Critically Ill, University of Southern California Sc.hool of Medicine, 1300 North Vermont Ave., Los Angeles, California 90027. tDeceasedJune 29, 1975.
Volume !2i Number 2
205
Fig. I. Twelve minutes of the record of the fetal heart rate in beats per minute (upper panel) and uterine contractions (lower panel) induced by oxytocin and detected by ultrasound and external tocodynamometer, respectively. The frequency and duration of contractions demomtrate the adequacy of the challenge .
rest. An OCT was performed (Fig. 1), and this was read as negative. Subsequent estriol levels were: day of OCT, 19.7 mg. per 24 hours; two days following the test, 12.7 mg. per 24 hours. Fetal heart tones were lost on the morning of the third day, between 62 and 68 hours following the OCT. Because of the previous cesarean section, the patient had a repeat cesarean section with delivery of a 3.572 gram grossly normal infant, showing some maceration. Pathologic study of the fetus and placenta revealed no abnormalities other than those consistent with maternal diabetes. Diabetic control during the period of hospitalization was similar to that described earlier with no acetonuria.
We have reviewed II published reports of experience with the OCT. in a total of 1,245 patients, mostly in the high-risk category.* Of these patients, 157 have had positive tests and 11 of these infants were stillborn. It should be emphasized that in many cases the test result was used in management and deliveries were performed on the basis of it; at times patients were not permitted to labor following a positive test. However , in four studies, results of the OCT's were not used in patient management, and the stillbirth rate was 22 per cent (9/40). Among I ,036 patients with negative tests, only two babies died in utero within a week of the negative test. One infant had a tight nuchal cord at delivery, and the other was born hydropic, with the placenta showing thrombosis of the chorionic vessels. Whether the patients were diabetic was not noted . The excellent outcome of this group is all the more imposing when it is noted that most pregnancies were high risk, and the stillbirth rate would be expected to be far greater than the 0.2 per cent actually observed. The survival rate *A list of the references reviewed may be obtained from the senior author.
was no doubt also improved by the application of ancillary methods of fetal surveillance such as urinary estriol determinations, cephalometry, more intensive observation, and early delivery . Decreasing the interval between OCT's may have saved one or both of the two previously reported infants , though there is no way to be sure of this. The infant in the present report would have been lost even with biweekly OCT's, because fetal heart tones were lost less than 68 hours after the final negative test. In view of the great logistic problems involved in decreasing the OCT interval and lack of evidence that it would improve fetal outcome, there appears to be no reason at this stage to alter timing on a weekly basis when the tests are clearly negative .
Pentazocine withdrawal syndrome in the newborn infant ODED PREIS, M . D. SOOK ]. CHOI, M.D. NATHAN RUDOLPH, M . B.B.CH. Department of Pediatrics, St~te Univrrsity of N ew York, Downstate M edical Center, Brooklyn, New York
THE NARCOTIC WITHDRAWAL syndrome in newborn infants of mothers addicted to heroin, as well as those maintained on methadone, is a well-recognized Reprint requests: Dr. 0. Preis, Department of Pediatrics, Box 49, State University of New York, Downstate Medical Center. 450 Clarkson Ave., Brooklyn , New York 11203.
206 Communications in brief
January 15. I 977 Am.
entity. Recently, at least two reports 1 • 2 have indicated that repeated use of pentazocine by the pregnant mother may also result in withdrawal symptoms in her baby. We report an additional case of neonatal pentazocine withdrawal, verified by demonstration of this agent in the urine of both mother and infant. A male infant was delivered to a 29-year-old black woman, para 1-0-1-1, with negative serology after 3\12 hours of uncomplicated labor, with a one-minute Apgar score of 9. The mother had a history of nonspecific mild abdominal pain predating the present pregnam:y. During the last trimester, she had increasing abdominal pain for which the obstetrician prescribed pentazocine, 50 mg. three times per day, which she used on a regular basis during the last six weeks of pregnancy. On examination the infant had a birth weight of 2.400 grams with a head circumference of 32 em., and the gestational age was estimated at 38 weeks. No abnormal findings were noted. At 10 hours of age, the infant became irritable and developed coarse tremors. His symptoms gradually increased and by the third day he had marked tremulousness, with almost incessant crying, profuse sweating, frequent bowel movements, and a voracious appetite. At this stage, phenobarbital, 4 mg. per kilogram per day given every eight hours, was started. The infant responded rapidly to therapy, and the phenobarbital dosage was gradually reduced during the subsequent two weeks. He was discharged at three weeks of age, thriving and with no recurrence of symptoms. Routine laboratory investigations performed during the symptomatic period, including serum calcium, magnesium, electrolytes and blood sugar, were normal. Urine samples collected approximately 12 to 14 hours after delivery showed a strongly positive reaction for pentazocine in the mother and a trace positive reaction in the newborn infant.
Pentazocine originally was marketed as a drug with little abuse potential. However, with more widespread use of the drug, addiction has been observed. Both human and animal studies have indicated that pentazocine crosses the placenta rapidly and is readily detectable in fetal blood. In our patient, as well as in the two cases reported previously, 1 • 2 the onset of symptoms of drug withdrawal commenced during the first 24 hours after birth ( 10, 20, and four hours, respectively). These time intervals appear to correlate well with both the time that the mother last ingested the drug as well as the short half life (two hours) of pentazocine. It is apparent that pentazocine is not a harmless agent in the pregnant woman. On the contrary. although no withdrawal effects have been reported in the adult after therapeutic use, it is possible that such use during late pregnancy might result in withdrawal symptoms in the offspring. Therefore, we suggest extreme caution in prescribing this drug as a therapeutic agent during pregnancy. REFERENCES I. Goetz, R. L., and Bain, R. V.: Neonatal withdrawal
symptoms associated with maternal use of pentazocine,]. Pediatr. 84: 887. 1974.
f.
Obstet. Gvnecol.
2. Scanlon, J. W.: Pentazocine and neonatal withdl·awal symptoms. J. Pediatr. 85: 73.'i, 1974.
Hemodynamic and metabolic studies of a case of toxemia of pregnancy URI FREUND, M.D. WILLIAM f'RENCH, M.D. RICHARD W. CARLSON, M.D., PH.D. MAX HARRY WElL, M.D., PH.D. HERBERT SHUBIN. M.D.t The Shock Research Unit and thf Department of Medicine, University of Southern California School of Medicine, the Los Angele~. County/USC Medical Center, and the Center for the Critically Ill, Hollywood Presbvterian Medical Center, Los Angeles, California
SEvERE To x EM 1 A of pregnancy is a life-threatening crisis in which hypertension, congestive heart failure, hypoproteinemia, and edema may be seen. Opportunity was provided for detailed study of the hemodynamic, volume, and related metabolic defects in a patient immediately after delivery by cesarean section. Hypertension and pulmonary edema were associated with hypovolemia. Volume repletion proved beneficial. A 22-year-old white woman, gravida I, para 0, of 34 weeks' gestation, was admitted because of toxemia. She complained of headache, vomiting, and generalized swelling. On a clinic visit I week prior to admission, hypertension, peripheral edema, and edema of the abdominal wall were observed. The blood pressure was 180/140 mm. Hg and the heart rate was 140 beats per minute. The fetal heart rate was !50 beats per minute. No uterine contractions were detected and the cervix was closed and not effaced. Laboratory data at the time of admission are shown in Table I. Treatment with magnesium sulfate, hydralazine, and phenobarbital was followed by reduction of the blood pressure to 110/90 mm. Hg. A cesarean section was performed 7 hours later, and a female infant, weighing 3.1 kilograms with an Apgar score of 9, was delivered. Abruptio placentae and 3,500 mi. of ascitic fluid were discovered at operation. No cardiac murmurs or gallop rhythm were detected and the lungs were clear on auscultation, The chest. x-ray revealed perihilar congestion and interstitial edema. An 8 inch Teflon catheter was inserted into the femoral
This study was supported by United States Public Health Service Research Grants HL-05570 from the National Heart, Lung, and Blood Institute, GM-16462 from the National Institute of General Medical Sciences, and ROI HS 01474 from Health Resources Administration. Reprint requests: Richard W. Carlson, M.D., Ph.D., Center for the Critically Ill, University of Southern California Sc.hool of Medicine, 1300 North Vermont Ave., Los Angeles, California 90027. tDeceasedJune 29, 1975.
