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ABSTRACT: This article reviews our experience with the use of intrauterine tamponade with balloon catheters in the management of severe postpartum hemorrhage. This is a case series report of 23 patients with postpartum hemorrhage unresponsive to medical therapy managed with intrauterine balloon tamponade. We identified these patients by International Classification of Diseases (ICD-9) codes and by reviewing labor and delivery logs. Balloon tamponade was attempted in 23 patients. When properly placed, catheters controlled postpartum hemorrhage in 18 of 20 cases (90%). In two cases, hysterectomy was required despite successful placement of the catheter. For hemorrhage due to uterine atony, our success rate was 100% (11/11 cases). In three cases, technical difficulties led to placement failure. For bleeding due to retained placenta, our success rate was 80% (4/5; failure with placenta percreta). Vaginal bleeding was stopped with the catheter in two of three cases of amniotic fluid embolus and in one case after dilation and curettage for postpartum septic shock. Thus balloon tamponade is an effective adjunct in the treatment of severe postpartum hemorrhage, especially when due to uterine atony when medical therapy fails.
American Journal of Perinatology 07/2007; 24(6):359-64. · 1.32 Impact Factor
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ABSTRACT: The prevalence of gestational diabetes mellitus (GDM) varies in direct proportion with the prevalence of type 2 diabetes in a given population or ethnic group. Given that the number of people with diabetes worldwide is expected to increase at record levels through 2030, we examined temporal trends in GDM among diverse ethnic groups.
Kaiser Permanente of Colorado (KPCO) has used a standard protocol to universally screen for GDM since 1994. This report is based on 36,403 KPCO singleton pregnancies occurring between 1994 and 2002 and examines trends in GDM prevalence among women with diverse ethnic backgrounds.
The prevalence of GDM among KPCO members doubled from 1994 to 2002 (2.1-4.1%, P < 0.001), with significant increases in all racial/ethnic groups. In logistic regression, year of diagnosis (odds ratio [OR] and 95% CI per 1 year = 1.12 [1.09-1.14]), mother's age (OR per 5 years = 1.7 [1.6-1.8]) and ethnicity other than non-Hispanic white (OR = 2.1 [1.9-2.4]) were all significantly associated with GDM. Birth year remained significant (OR = 1.06, P = 0.006), even after adjusting for prior GDM history.
This study shows that the prevalence of GDM is increasing in a universally screened multiethnic population. The increasing GDM prevalence suggests that the vicious cycle of diabetes in pregnancy initially described among Pima Indians may also be occurring among other U.S. ethnic groups.
Diabetes Care 04/2005; 28(3):579-84. · 8.09 Impact Factor
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ABSTRACT: The objective of this study was to test whether maternal age at delivery, child's birth order, cesarean section, complicated delivery, maternal smoking during pregnancy, or neonatal jaundice predict islet autoimmunity in children at genetically increased risk of type 1 diabetes in a birth cohort with blood draws at ages 9, 15, and 24 months and yearly thereafter. Newborns with diabetes-associated human leukocyte antigen genotypes (n = 938) and offspring or siblings of persons with type 1 diabetes (n = 428) from the Denver, Colorado, metropolitan area were examined from January 1994 to February 2003. Information on perinatal factors was collected by using questionnaires soon after the birth. Islet autoimmunity was defined as positivity for > or = 1 autoantibody to glutamic acid decarboxylase65, insulin, or protein tyrosine phosphatase-2/ICA512 at > or = 2 consecutive visits (n = 52; mean follow-up, 3.9 years). Complicated delivery (breech, forceps, vacuum extraction) predicted a higher risk of islet autoimmunity (hazard ratio = 2.10, 95% confidence interval: 1.09, 4.05). Increasing maternal age was related to risk of islet autoimmunity among first-degree relatives of persons with type 1 diabetes (hazard ratios = 3.96 and 8.88 for maternal ages 25-34 and > or = 35 years, respectively, compared with < 25 years; p for trend = 0.008. Other factors evaluated were not related to risk of islet autoimmunity. In conclusion, influences in utero or during delivery may affect the fetal immune system.
American Journal of Epidemiology 07/2004; 160(1):3-10. · 5.22 Impact Factor
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ABSTRACT: The purpose of this study was to develop a model of chronic intrauterine and fetal infection with Prevotella bivia, an anaerobe of the lower genital tract that is associated often with bacterial vaginosis.
Thirty timed pregnant New Zealand White rabbits on gestational day 21 were inoculated with P bivia or saline solution in a planned ratio of 4:1 (24 P bivia: 6 saline solution). Rabbits were inoculated 6 cm transcervically with 10(5) to 10(8) colony-forming units/uterine horn of P bivia or with saline solution. Necropsy was scheduled on days 4, 6, or 7 after inoculation. Cultures were collected from blood, uterus, amniotic fluid and fetal brain, lung, and heart. Tissues from placenta, uterus, fetal brain, and lung were evaluated with the histologic inflammation score, with a range of 0 to 13. Amniotic fluid was assayed for tumor necrosis factor-alpha by bioassay. Animals with contamination by other organisms were excluded. Categoric data were evaluated with the use of the Fisher exact test, and continuous data were evaluated with the use of the Wilcoxon rank sum.
After the exclusion of 8 animals because of contamination with other organisms, 22 animals were evaluated. Of 3 rabbits with an inoculum of 10(8) P bivia colony-forming units/horn, 2 animals (67%) had fever within 24 hours. These results were not compatible with chronic, subclinical infection. Therefore, 14 does had inocula of 10(5-6) P bivia colony-forming units/horn, with necropsy planned at day 4 (n=5 animals), day 6 (n=3 animals), and day 7 (n=6 animals), and 5 animals were inoculated with saline solution. Animals that had been inoculated with P bivia were significantly more likely to have a positive culture than were those animals that were inoculated with saline solution (64% vs 0%; P<.04). Preterm delivery without fever occurred in 21% of does (3/14 does) that were inoculated with P bivia overall and in 33% of the does (3/9 does) that were followed for 6 to 7 days. No saline-solution inoculated animal had preterm birth. There was an increase in amniotic fluid tumor necrosis factor-alpha levels over time in the P bivia group (P=.12). Histologic inflammation scores were not significantly different between P bivia and saline solution groups.
Inoculation with P bivia at 10(5-6) colony-forming units/horn leads to chronic intrauterine and fetal infection that are accompanied by preterm birth in up to 33% of cases. This model may serve to explore the mechanism of preterm birth that is induced by chronic infection with genital tract anaerobes.
American Journal of Obstetrics and Gynecology 05/2004; 190(4):1082-6. · 3.47 Impact Factor
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ABSTRACT: We sought to develop a model of chronic intrauterine and fetal infection with Gardnerella vaginalis.
The uterine horns of pregnant New Zealand White rabbits were inoculated on day 21 of gestation with either 10(7) colony-forming units (cfu) of G vaginalis or saline solution. At necropsy, cultures were taken from blood, uterus, amniotic fluid, and fetal tissues. Amniotic fluid was assayed for tumor necrosis factor (TNF)-alpha by bioassay. Maternal and fetal tissue samples were evaluated using the histologic index score. A P value <.05 was considered significant.
Compared with saline solution-inoculated animals, the G vaginalis group had significantly more positive cultures from uterus, amniotic fluid, and fetal brain and lung (P =.02 to <.01). For the G vaginalis group, mean TNF-alpha levels and fetal brain scores increased significantly over time (P <.001 for both).
Chronic intrauterine and fetal infection with G vaginalis is accompanied by progressive increases in amniotic fluid TNF-alpha concentrations and fetal brain histologic index scores.
American Journal of Obstetrics and Gynecology 11/2002; 187(5):1263-6. · 3.47 Impact Factor
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ABSTRACT: In a pregnant rabbit model using intracervical inoculation of Escherichia coli with delayed antibiotic therapy, we investigated the rate of positive cultures and histologic inflammation of maternal and fetal compartments and the concentration of tumor necrosis factor-alpha in the amniotic fluid for up to 5 days.
New Zealand White rabbits at 70% gestation were inoculated intracervically with 10(3) - 10(4) colony-forming units of E coli per uterine horn. At varying intervals after inoculation (0.5 - 4.0 hours), antibiotic therapy was initiated with ampicillin-sulbactam. Primary outcomes were positive cultures and histologic inflammation score. Tumor necrosis factor-alpha levels in the amniotic fluid were determined by bioassay.
A total of 60 animals were inoculated with E coli. At the endpoint, uterine cultures were positive more commonly than in the fetus or amniotic fluid (41.8% vs 27.5% vs 17.3%, respectively), which was consistent with an ascending pathway of infection. Inflammation scores were similar in uterus and placenta but lower in fetal lung and absent in fetal brain (2.8 vs 3.1 vs 0.84 vs 0.0, respectively). Comparing the durations of delay in antibiotic administration, we found a significant increase in positive uterine cultures and a significant increase in histologic inflammation score with increasing delay. The proportion of dead pups within a litter was significantly associated with the log of the tumor necrosis factor-alpha concentration in amniotic fluid and the degree of histologic inflammation in the uterus, but not with amniotic fluid or other culture positivity.
The administration of therapeutic doses of antibiotic does not consistently eradicate bacteria from the rabbit uterus nor, more importantly, from the fetus and the amniotic fluid. Obtaining a negative amniotic fluid culture does not exclude either infection in the decidua or the fetus or histologic inflammation with tumor necrosis factor-alpha elaboration.
American Journal of Obstetrics and Gynecology 03/2002; 186(2):234-9. · 3.47 Impact Factor
