[Show abstract][Hide abstract] ABSTRACT: To analyze the effect of gestational age, delivery mode, and maternal-fetal risk factors on rates of respiratory problems among infants born 34 or more weeks of gestation over a 9-year period.
Retrospective analysis of prospectively collected maternal and neonatal data on all inborn births at 34 or more weeks of gestation at a single tertiary care center for the years 1990-1998. Specific diagnostic criteria were concurrently applied by a single investigator.
Over the 9-year period, late-preterm births increased by 37%, whereas births at more than 40 weeks decreased by 39%, resulting in a decrease in median age at delivery from 40 weeks to 39 weeks (P<.001). Respiratory problems occurred in 705 term or late-preterm infants (4.9%), with clinically significant morbidity (respiratory distress syndrome, meconium aspiration syndrome, or pneumonia) least common at 39-40 weeks of gestation. Respiratory morbidity was greater among infants born by cesarean delivery or complicated vaginal delivery compared with uncomplicated cephalic vaginal delivery. The rate of respiratory morbidity did not change over time (1990-1992 1.3%, 1993-1995 1.5%, 1996-1998 1.4%, P=.746). The etiologic fraction for respiratory morbidity did not change over time for infants 34-36 weeks but decreased twofold for infants born after 40 weeks.
Over the 9-year study period, reduced respiratory morbidity associated with decreased births after 40 weeks were offset by the adverse respiratory effect of increased cesarean delivery rates and increased late-preterm birth rates.
Obstetrics and Gynecology 05/2008; 111(4):814-22. DOI:10.1097/AOG.0b013e31816499f4 · 4.37 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The purpose of this study was to estimate the incidence of adhesions after cesarean deliveries and to determine their impact on delivery and infant well-being.
This was a retrospective cohort analysis with chart review. The charts of 542 women who had undergone primary (265 women) or repeat cesarean (277 women) deliveries were reviewed. The incidence, severity, and locations of adhesions; delivery time; cord blood pH, and Apgar scores were noted.
After the first cesarean delivery, 100 of 217 women (46%) had pelvic adhesive disease; 48 of 64 women (75%) who underwent a third cesarean delivery and 5 of 6 women (83%) who underwent a fourth cesarean delivery had formed pelvic adhesive disease. Compared with primary cesarean section, delivery of the infant was delayed 5.6 minutes (52%) with 1 previous cesarean birth, 8.5 minutes (79%) after 2 cesarean birth, and 18.1 (169%) during the fourth cesarean birth (P < 0.001 for all comparisons).
A high percentage of cesarean deliveries result in adhesive disease, which delays repeat cesarean delivery of the fetus. The potential for adhesive disease should be included in counseling regarding primary elective cesarean births.
American journal of obstetrics and gynecology 06/2007; 196(5):461.e1-6. DOI:10.1016/j.ajog.2006.12.017 · 3.97 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The null hypothesis is that local anesthesia does not decrease pain perception during amniocentesis.
We performed a prospective randomized study comparing local anesthesia (1% lidocaine) with no anesthesia before amniocentesis in a racially diverse population. Immediately after the procedure, subjects were asked to assess their pain using both a Visual Analogue Scale and a 101-point Numerical Rating Scale.
Two hundred four women were enrolled; 101 women received local, 102 women received no local, and 1 woman declined the amniocentesis after randomization. There was no difference in pain perception between the 2 groups as measured by either the visual analogue scale or the numeric rating scale (P = .28 and .18 respectively). The correlation coefficient between the 2 pain scales was strong with 0.86 for the local group and 0.92 for the no local group, (P < .001).
Administration of local anesthesia before amniocentesis does not decrease maternal pain perception.
American journal of obstetrics and gynecology 02/2007; 196(1):55.e1-4. DOI:10.1016/j.ajog.2006.08.025 · 3.97 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Pregnancies complicated by Rh isoimmunization have decreased significantly since the widespread use of Rh immune globulin. Uncommon red blood cell antigens have therefore become more clinically evident. We report a case of anti-Cw immunization that resulted in severe fetal anemia that required multiple transfusions.
A 28-year-old multigravida presented to our service at 18 weeks of gestation with her fourth pregnancy. Her pregnancy was complicated by anti-Cw isoimmunization that resulted in severe fetal anemia requiring in utero fetal blood transfusions.
While previous reports recommend only postpartum surveillance when Cw isoimmunization is present, we report a case resulting in severe fetal anemia.
[Show abstract][Hide abstract] ABSTRACT: The objective of the study was to estimate the risks of third-trimester amniocentesis with continuous ultrasound guidance.
Cohort study. We reviewed the medical records of women who had an amniocentesis with continuous ultrasound guidance after 30 weeks' gestation at a single institution from January 1991 through December 1994. For procedures performed from January 1991 to February 1994, we obtained information from a chart review. From March 1994 to December 1994, we collected data prospectively. The primary outcome was whether or not there were any complications within 48 hours of the procedure. We also sought to determine any risk factors associated with complications.
Complete records and data were available for 562 amniocenteses during the study period. The mean gestational age at the time of amniocentesis was 34.9 weeks. Of the 562 procedures, five (0.8%) were unsuccessful and 50 (9%) required more than one needle stick. The complication rate was 0.7% (95% confidence level (CI) = 0.02%, 1.9%). These included spontaneous labor in a preterm gestation (1), premature rupture of the membranes (1), placental abruption (1), and fetal-maternal hemorrhage (1). No patient required an emergency cesarean delivery and none suffered a perinatal death (95% CI 0, 0.8%). Complications were not associated with the number of needle sticks, the presence of bloody amniotic fluid, or the level of operator experience.
Third-trimester amniocentesis performed with continuous ultrasound guidance has a high success rate and low risk for complications.
Obstetrics and Gynecology 03/2002; 99(2):255-9. DOI:10.1016/S0029-7844(01)01715-X · 4.37 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVE:The objective of the study was to estimate the risks of third-trimester amniocentesis with continuous ultrasound guidance.METHODS:Cohort study. We reviewed the medical records of women who had an amniocentesis with continuous ultrasound guidance after 30 weeks’ gestation at a single institution from January 1991 through December 1994. For procedures performed from January 1991 to February 1994, we obtained information from a chart review. From March 1994 to December 1994, we collected data prospectively. The primary outcome was whether or not there were any complications within 48 hours of the procedure. We also sought to determine any risk factors associated with complications.RESULTS:Complete records and data were available for 562 amniocenteses during the study period. The mean gestational age at the time of amniocentesis was 34.9 weeks. Of the 562 procedures, five (0.8%) were unsuccessful and 50 (9%) required more than one needle stick. The complication rate was 0.7% (95% confidence level (CI) = 0.02%, 1.9%). These included spontaneous labor in a preterm gestation (1), premature rupture of the membranes (1), placental abruption (1), and fetal-maternal hemorrhage (1). No patient required an emergency cesarean delivery and none suffered a perinatal death (95% CI 0, 0.8%). Complications were not associated with the number of needle sticks, the presence of bloody amniotic fluid, or the level of operator experience.CONCLUSIONS:Third-trimester amniocentesis performed with continuous ultrasound guidance has a high success rate and low risk for complications.
Obstetrics and Gynecology 01/2002; 99(2):255-259. · 4.37 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVE:To describe changes in neonatal and obstetric practices that may have contributed to the decreasing incidence of meconium aspiration syndrome in our population during this time.METHODS:We compared neonatal and obstetric characteristics of 61 infants diagnosed with meconium aspiration syndrome with 1365 infants born through moderate or thick meconium-stained amniotic fluid at more than 37 weeks’ completed gestation. Data were prospectively collected, and all respiratory diagnoses were concurrently made. Three distinct birth year groups were analyzed based on changing obstetric practice paradigms.RESULTS:Meconium aspiration syndrome decreased nearly four-fold from 1990–1992 to 1997–1998 (5.8% to 1.5% of meconium-stained infants more than 37 weeks; P < .003). The only change in neonatal characteristics was a 33% decrease in births more than 41 weeks with a reciprocal 33% increase in births 38–39 weeks during 1997–1998. Significant changes in obstetric practice included more frequent diagnosis of nonreassuring fetal heart rate patterns, greater use of amnioinfusion, and increased cesarean delivery rate in 1997–1998. By logistic regression analysis, the only consistent risk factor for meconium aspiration syndrome across all three epochs was the presence of tracheal meconium.CONCLUSION:Reduction in post-term delivery was the most important factor in reducing meconium aspiration syndrome.
[Show abstract][Hide abstract] ABSTRACT: The objectives of this study are to compare the neonatal risks and benefits of antenatal single-course versus repeated-course corticosteroids in singleton and multiple-gestation pregnancies. A comprehensive analysis was performed of the inpatient records of all neonates admitted to our center from 1 January 1994 through 31 May 1999. The primary outcome measure was survival without chronic lung disease (CLD). Secondary outcome measures included birth weight; head circumference; interval weight ratios; respiratory disease severity; intraventricular hemorrhage rate and severity; severe retinopathy of prematurity; early infection; and hospital days. All singletons 27-32 completed weeks' gestation, and multiples 26-32 weeks' gestation, whose mothers had received betamethasone before delivery, were included. One hundred and fifteen singleton and 53 multiple-gestation infants (total 168) were stratified by multiplicity, gestational-age (< or =29 or > or =30 weeks), and number of steroid courses. Repeated courses of antenatal betamethasone were not associated with greater survival without CLD, in either singleton- or multiple-gestation infants. In singletons there was no difference in any outcome measure between groups. In multiples, the only difference was greater postnatal weight gain in the lower gestation group. Mean birth head circumference was smaller in repetitively-treated singletons < or =29 weeks. There are no clinically significant neonatal benefits of repeated-course antenatal steroids in singletons > or =27 weeks estimated gestational age (EGA) or multiple-gestation infants > or =26 weeks EGA. Prospective randomized trials of single-course versus repetitive antenatal corticosteroid therapy are warranted.
American Journal of Perinatology 09/2001; 18(5):267-7. DOI:10.1055/s-2001-16989 · 1.60 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objective: To determine whether betamethasone administered to women at risk of preterm delivery causes adrenal suppression.Methods: Ten women at risk of preterm delivery had three weekly low-dose (1 μg) ACTH stimulation tests with the first one between 24 and 25 weeks’ gestation. Immediately after the first and second ACTH stimulation tests, we gave each woman a 12-mg betamethasone dose intramuscularly and repeated it 24 hours later. The third ACTH stimulation test was 1 week after the second course of betamethasone. Serum cortisol levels were measured before (baseline) and 30 minutes after ACTH administration.Results: All subjects had normal baseline and stimulated cortisol levels for the first ACTH stimulation test. Mean baseline serum cortisol levels decreased with each ACTH stimulation test, from 25.4 ± 4.8 μg/dL (before betamethasone) to 4.3 ± 4.0 μg/dL (1 week after the second course of betamethasone) (P < .001). The mean stimulated cortisol levels also decreased from 33.0 ± 4.3 μg/dL (before betamethasone) to 11.8 ± 6.4 μg/dL (1 week after the second course of betamethasone) (P < .001). Compared with initial ACTH stimulation tests, laboratory evidence of adrenal suppression occurred in four patients 1 week after the first course of betamethasone and in seven patients after the second course. No signs or symptoms of Addisonian crisis occurred antepartum or intrapartum.Conclusion: Antenatal administration of betamethasone produced measurable adrenal suppression in women at risk of preterm delivery. The number of women with adrenal suppression increased each week that antenatal betamethasone was repeated. (Obstet Gynecol 2000;96:287–90.)
[Show abstract][Hide abstract] ABSTRACT: The objective of this study was to evaluate the hypothesis that ketoacids (acetoacetic acid and beta-hydroxybutyrate) diminish glucose transport in trophoblasts cultured from first-trimester chorionic villi.
First-trimester trophoblasts were obtained by transabdominal chorionic villus sampling for subsequent cytogenetic analysis. The cells were established as a continuous line exhibiting trophoblast characteristics. Trophoblasts were cultured in Ham's F12/Dulbecco's modified Eagle's medium (1:1) supplemented with 15% fetal bovine serum. Experiments were initiated by a 24-hour preincubation in serum-free Ham's F12/Dulbecco's modified Eagle's medium followed by incubation with ketoacids (acetoacetic acid and beta-hydroxybutyrate, 0 to 10 mmol/L) in the presence or absence of insulin-like growth factor-I (100 ng/ml). The cells were challenged with 2-deoxy-[1,2-3H]D-glucose (0.1 mmol/L) for 5 minutes and then cell-associated radioactivity was measured. Total ribonucleic acid was extracted from cells incubated with ketoacids in the presence or absence of insulin-like growth factor-I, and Northern blots were probed with a phosphorus 32-labeled complementary deoxyribonucleic acid fragment encoding the rat GLUT 1.
Ketoacids caused a dose-dependent inhibition of glucose transport. At 5 mmol/L acetoacetic acid there was a > 50% reduction in the rate of glucose transport in both control and insulin-like growth factor-I-treated cells. The diminution in glucose uptake by trophoblasts was not due to cellular toxicity of the ketoacids because there was no significant difference in trypan blue exclusion or lactate dehydrogenase release between control and ketoacid-treated cells. Northern analysis revealed that the steady-state expression of GLUT1 messenger ribonucleic acid was diminished in ketone-treated cells, but this effect was overcome by coincubation of cultures with insulin or insulin-like growth factor-I.
These results indicate that ketoacids can suppress the uptake of glucose into first-trimester human trophoblasts. Because ketoacidosis in pregnant women with diabetes mellitus is a frequent clinical consequence of poor metabolic control, it is possible that elevated levels of acetoacetic acid and beta-hydroxybutyrate may impair the transport of glucose across the placental trophoblast and into the fetal circulation.
American Journal of Obstetrics and Gynecology 08/1996; 175(1):56-62. DOI:10.1016/S0002-9378(96)70251-X · 3.97 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Coronary heart disease and myocardial infarction are uncommon complications during pregnancy. Women with insulin-dependent diabetes mellitus (IDDM) have a much greater risk of serious coronary heart disease, but few cases of myocardial infarctions occurring during pregnancy have been reported. Significant maternal morbidity has been reported in half of these cases. This is a case of a myocardial infarction occurring at 21 weeks of gestation in a patient with class R/F IDDM and the subsequent pregnancy management as well as a review of the literature concerning Class H IDDM in pregnancy.
[Show abstract][Hide abstract] ABSTRACT: Since the first American report on the use of magnesium sulfate tocolysis in 1977, its popularity as a tocolytic agent has increased progressively. Primarily because of its safety and familiarity, magnesium has become the primary tocolytic agent in the majority of U.S. centers. The exact mechanism of action is unknown, and long-term effects on neonates have not been studied. Although randomized studies show similar success compared to other tocolytic agents, no placebo-controlled study has shown neonatal improvement with magnesium sulfate tocolysis. This is similar to the studies of beta-sympathomimetic tocolytics and has led some authors (e.g., Higby) to suggest that safe dosages of magnesium sulfate are ineffective in preventing preterm birth and should not be used as a tocolytic agent. Although magnesium sulfate, like other tocolytics, has not fulfilled the initial promise of preventing preterm birth, it does appear if used correctly in a well identified population of patients to at least transiently inhibit preterm labor as well as other tocolytic agents with fewer side effects and fewer contraindications.
[Show abstract][Hide abstract] ABSTRACT: Our purpose was to determine the effects of insulin and glucose on glucose transport and expression of GLUT1 glucose transporter messenger ribonucleic acid in first-trimester human trophoblast-like cells.
First-trimester human trophoblast-like cells were maintained as a continuous cell line. For 2[3H]deoxy-D-glucose uptake and messenger ribonucleic acid studies the cells were incubated in the presence or absence of insulin (10(-7) to 10(-11) mol/L) or D-glucose (0 to 50 mmol/L) for 0 to 24 hours. Glucose transport was measured by incubating cells with 0.1 mmol/L 2[3H]deoxy-D-glucose for 5 minutes. Specific uptake was determined by incubating companion cultures with 10 mumol/L cytochalasin B. The cells were then solubilized with sodium hydroxide and the radioactivity counted. Data were expressed as nanomoles of 2[3H]deoxy-D-glucose transported per milligram of protein per 5 minutes and analyzed by one-way analysis of variance with post hoc testing by the method of Tukey. GLUT1 messenger ribonucleic acid was measured by Northern blotting of total ribonucleic acid samples hybridized to a phosphorus 32-labeled complementary deoxyribonucleic encoding the rat GLUT1 glucose transporter. As a control for loading efficiency, blots were stripped and rehybridized to a 40-mer phosphorus 32-labeled beta-actin oligonucleotide probe.
Insulin treatment resulted in a dose-dependent increase in the transport of 2[3H]deoxy-D-glucose at 24 hours (p < 0.001 at 10(-7) mol/L). This change was first detected at 12 hours of incubation. These data closely paralleled the insulin-induced increase in GLUT1 messenger ribonucleic acid seen in Northern blots. In contrast to insulin, increasing concentrations of D-glucose did not change the transport of 2[3H]deoxy-D-glucose. However, when cells were incubated in low concentrations of D-glucose (0 or 1 mmol/L), an enhancement in the uptake of 2[3H]deoxy-D-glucose (p < 0.001) was observed. Kinetic studies indicated that D-glucose augmentation of 2[3H]eoxy-D-glucose uptake was significant at 9 hours (p < 0.05). The effects of D-glucose on GLUT1 messenger ribonucleic acid expression paralleled the uptake of 2[3H]deoxy-D-glucose, although the modulation of GLUT1 messenger ribonucleic acid levels by glucose was much less pronounced than in insulin-treated cells.
Although it has been assumed that the placenta has a limited role in influencing glucose transport to the fetus, our in vitro data demonstrate that both insulin and glucose can modulate glucose transport at the cellular level of the placental trophoblast. Thus maternal insulin and glycemic status may influence the expression of GLUT1, the major trophoblast glucose transporter protein, therefore directly affecting first-trimester placental glucose transport. These in vitro data may help explain the association between maternal glucose abnormalities and impaired fetal development during the first trimester when placental GLUT1 messenger ribonucleic acid expression is at its peak.
American Journal of Obstetrics and Gynecology 10/1995; 173(4):1089-97. DOI:10.1016/0002-9378(95)91332-7 · 3.97 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Anti-Js(b) has not been reported to cause severe hemolytic disease of the newborn requiring intrauterine evaluation and treatment. We now report on such a patient with high-titered anti-Js(b) causing fetal hydrops with demise in one pregnancy, followed by a pregnancy treated with multiple intrauterine fetal transfusions.