ISSN:0029-7828    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Platelets have been implicated in the development of preeclampsia and may be activated weeks before clinical symptoms appear. Even in normal pregnancy a hypercoagulable state exists, and the risk of thrombosis is even higher in the puerperal period. Because of past difficulty in obtaining blood samples from discharged patients, researchers collected blood samples at home from 11 preeclamptic women whose blood pressures averaged 170/108 mm Hg. Seven were nulliparas, and gestational age at delivery averaged about 36 weeks. Eleven normotensive parturients formed a control group. Seven women in each group had cesarean delivery.Preeclamptic women had a significant rise in the number of platelet from 6 to 14 days postpartum, with an average increase from 240 to 621 × 109/liter. Earlier postpartum counts did not differ significantly from antepartum counts. Control women also had a significant increase in platelet counts, reaching a mean peak of 351 × 109/liter, 6 to 14 days after delivery. Peak counts were significantly higher in the preeclamptic group at this stage, as was the increase from antepartum to postpartum values. Platelet volumes were significantly higher in preeclamptic than in control women before delivery. A postpartum decline in both groups eliminated any group difference. In neither group did estimated blood loss correlate with the postpartum platelet count, and women in the two groups lost comparable amounts of blood.Platelet counts increased 2- to 3-fold in preeclamptic women in the second postpartum week compared with women who remained normotensive during pregnancy. The authors suggest that it may be helpful to estimate platelet numbers in high-risk patients after they are discharged. High-risk patients include those with severe preeclampsia and the hemolysis, elevated liver enzymes, low platelets syndrome, especially those who had a cesarean delivery or have other risk factors, such as obesity, older age, or postpartum infection. Measures intended to prevent thrombosis should be considered when such patients exhibit delayed rebound thrombocytosis in the postpartum period.Acta Obstet Gynecol Scand 1999;78:866–870

ISSN:0029-7828    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Glycemic control, maternal complications, and perinatal outcomes were evaluated in a randomized, controlled, open-label study of 138 women with gestational diabetes and 58 others diagnosed as having pregestational diabetes mellitus. Criteria for gestational diabetes were two or more serum glucose levels of at least 5.9, 10.6, 9.2, or 8.1 mmol/liter at baseline and 1, 2, and 3 hours, respectively, after a 100-gm oral glucose load. Participants received insulin either twice a day, with two-thirds of the total daily dose given in the morning and one-third in the afternoon (both mixtures of regular and intermediate insulins), or four times a day, with the first three doses of regular insulin given by insulin pen 30 minutes before each main meal and the fourth dose of intermediate insulin given before bedtime. A 55 percent carbohydrate diet containing increased complex carbohydrates and decreased refined carbohydrates was prescribed. Glucose levels were monitored at home using a reflectance meter and by the glucose kinase method in the hospital. Levels of glycated hemoglobin A1cand fructosamine values were estimated each month.Overall glycemic control was significantly better in women given insulin four times a day than in those receiving the twice-daily regimen. The former patients received a higher average dose of insulin but were not at greater risk of severe hypoglycemia. There were no group differences in gestational age at delivery, pregnancy-induced hypertension, or cesarean delivery. Perinatal mortality rates also were similar, but overall morbidity was less frequent with the four-times-daily insulin treatment, and the difference was significant (relative risk, 0.59) in women with gestational diabetes. Among infants whose mothers had gestational diabetes, hypoglycemia and hyperbilirubinemia were less prevalent when the mother received insulin four times daily. The only significant difference in the group with pregestational diabetes was a lower risk of neonatal hypoglycemia with the four-times-daily insulin treatment (relative risk, 0.17).Four-times-daily insulin treatment is no more complicated or expensive than twice-daily treatment and provides better glycemic control and superior perinatal outcomes. In addition, this regimen may be given using a single type of insulin and “pens,” which are more convenient for both patients and staff and provide accurate dosing. Patients need not schedule their meals so rigidly, in contrast to what is required with use of intermediate insulin, and are able to adjust the insulin dose to their appetite and exercise plans.Br Med J 1999;319:1223–1227

ISSN:0029-7828    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

It now is feasible to close exposed spinal cord tissuein uterowith the goal of preventing secondary neurological compromise in animals with a surgical spinal defect. The present study was conducted to determine whether clinical intrauterine repair of myelomeningocele enhances the neurological outcome in infants with spina bifida. A nonrandomized observational study was undertaken of 29 infants with isolated fetal myelomeningocele who were seen at a tertiary-care center and underwent repair between 24 and 30 weeks’ gestation. The 23 control infants, having repair within 48 hours after delivery, were matched with study cases for level of the lesion, practice parameters, and calendar time. The infants were followed up for at least 6 months. Surgery was performed after anesthetic was administered to the mother and under extended-spectrum antibiotic coverage. Intrauterine access was gained using electrocautery or a special hollow trocar. An 8-cm hysterotomy was made with an autostapling device, and the defect was repaired in the same way as in postnatal life. After the neural placode was dissected from arachnoidal tissue, the dura was freed, reflected over the placode, and closed. At present, no drain is left in place.Half of the study mothers and only 9 percent of control women were admitted with preterm uterine contractions, despite the lack of significant group differences in preexisting obstetrical risk factors. Nearly 40 percent of study women gave birth while still receiving tocolysis, compared with 4 percent of control women. The estimated gestational age at delivery was 33 weeks for the study group and 37 weeks for the control group, a difference significant at the .001 level. Five study infants were born before 30 weeks’ gestation. Birth weights were significantly lower in the study group because of earlier gestational age at delivery. Ventriculoperitoneal shunt placement was necessary to decompress hydrocephalus in 59 percent of study infants, compared with 91 percent of infants who underwent repair after delivery. The long-term rates of shunt placement were 62 percent and 91 percent, respectively, still a significant difference. Only 2 of 29 study infants, compared with 10 of 22 control infants having postdelivery repair, had significant cerebellar herniation through the foramen magnum. Study infants less often had talipes (28 percent vs. 70 percent). One study infant required mechanical ventilation for longer than 72 hours. The average Bayley Scale developmental score in 26 study infants, assessed at ages 2 to 18 months, was 100. Although intrauterine repair of myelomeningocele makes premature delivery more likely, it does lessen the risk of both hindbrain herniation and shunt-dependent hydrocephalus.JAMA 1999;282:1819–1825

ISSN:0029-7828    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

The estimated risk of fetal anemia secondary to maternal alloimmunization in the United States is 35 per 10,000 live births. About 10 percent of affected fetuses will require transfusion before 34 weeks’ gestation. Previous observations showed that peak systolic blood flow velocity in the middle cerebral artery (MCA), measured by Doppler ultrasonography, is increased in anemic fetuses. This multicenter prospective study examined the value of this measurement for detecting anemia in 111 fetuses at risk because of maternal red blood cell alloimmunization. If valid, the method might replace invasive methods, such as amniocentesis and cordocentesis. Peak systolic velocity was estimated by Doppler velocimetry, and hemoglobin values were compared with those in 265 normal fetuses. At-risk status was based on severe fetal anemia in a previous pregnancy, a maternal serum red blood cell antibody titer of 1:16 or greater, or increasing bilirubin in the amniotic fluid.Mild anemia (hemoglobin of 0.84–0.65 the median for gestational age) was found in 32 percent of the fetuses evaluated; moderate anemia (0.65–0.55 times the median), in 4 percent; severe anemia (<0.55 times the median) without hydrops, in 17 percent; and severe anemia with hydrops, in 11 percent. The best threshold values for peak systolic velocity in the MCA were 1.29, 1.5, and 1.55 times the median for mild, moderate, and severe anemia, respectively. Changes in threshold values according to gestational are shown inFigure 1. Peak systolic velocity predicted moderate or severe anemia (without hydrops) with 100 percent sensitivity, with a false-positive rate of 12 percent. The positive and negative predictive values were 65 percent and 100 percent, respectively. Doppler estimates of peak systolic blood flow velocity in the MCA are an accurate noninvasive means of estimating the degree of anemia in fetuses at risk because of maternal red blood cell alloimmunization.Fig. 1. Peak velocity of systolic blood flow in the middle cerebral artery in 111 fetuses at risk for anemia due to maternal red-cell alloimmunization. Open circles indicate fetuses with either no anemia or mild anemia (≥0.65 multiples of the median hemoglobin concentration). Triangles indicate fetuses with moderate or severe anemia (<0.65 multiples of the median hemoglobin concentration). The solid circles indicate the fetuses with hydrops. The solid curve indicates the median peak systolic velocity in the middle cerebral artery, and the dotted curve indicates 1.5 multiples of the median. Copyright© 2000 Massachusetts Medical Society. All rights reserved.N Engl J Med 2000;342:9–14

ISSN:0029-7828    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Because the use of corticosteroids in women with preterm premature rupture of membranes (PPROM) remains controversial in South Africa, a double-blind, randomized trial was planned at six public hospitals serving mainly indigent women. Women with documented PPROM at 28 to 34 weeks’ gestation (or with a clinically estimated fetal weight of 1000–2000 gm if gestational age was unknown) were randomly assigned to receive 24 mg of dexamethasone intramuscularly or a saline placebo in two doses 24 hours apart. Dexamethasone was given to 102 women who delivered 105 infants, and placebo was given to 102 women with 103 infants. Clinical features were comparable in the two groups. All participants received amoxicillin and metronidazole. Obstetrical management was expectant. If contractions began within 24 hours of admission, hexoprenaline was administered.There were no differences in maternal outcome, including infection, between the steroid-treated and control groups. No woman in either group became severely septic. There was a trend toward fewer perinatal deaths in the dexamethasone group, with an odds ratio of 0.37, but no differences in respiratory distress syndrome or the need for mechanical ventilation. Definite hyaline membrane disease was diagnosed in approximately 8 percent of all infants. No intraventricular hemorrhage was encountered. Just over one-fourth of steroid-treated women and 18 percent of placebo recipients delivered within 24 hours of entry into the study. When only women who delivered after 24 hours were analyzed, there were significantly fewer (1 vs. 7) perinatal deaths in the dexamethasone group and trends toward less respiratory distress and necrotizing enterocolitis. The rate of neonatal infection was 11 percent in each group.This trial in a mostly indigent population with PPROM demonstrates improved infant survival and no increase in the risk of maternal or infant sepsis. This treatment would seem, on balance, to be advantageous to women in developing countries with preterm labor, whether elective or not. The same may be the case for developing areas if there is a relatively high rate of underlying infection. Antibiotics should be given prophylactically whenever women with PPROM receive steroids.S Afr Med J 1999;89:865–870

ISSN:0029-7828    

出版商:OVID    

年代:2000

数据来源: OVID

ISSN:0029-7828    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Both pregnant women and newborn infants are vulnerable to group B streptococcal (GBS) infection, but many cases in neonates may be preventable through intrapartum antibiotic prophylaxis. Consensus guidelines established in 1996 proposed using either a risk-based or a screening-based approach to determine who should receive prophylaxis. This study examined trends in GBS disease in the years 1993 to 1998. Population-based surveillance was conducted in designated counties of eight states, where project personnel communicated at least twice a month with contacts in participating microbiology laboratories that served acute-care hospitals. GBS infection was diagnosed when the organism was isolated from a nominally sterile site. The criterion age for late-onset neonatal disease was 7 days; for child disease, 90 days; and for adult disease, 15 years. Race-specific incidence rates were estimated using census and live-birth data, and national projections were adjusted for race.A total of 7867 cases of invasive GBS disease were identified in the surveillance areas; 84 percent of isolated were in the blood. Infants less than 3 months of age were affected in 28 percent of cases, and more than two-thirds of these were less than 1 week of age. The proportion of early onset cases identified on the day of birth decreased from 76 percent in 1993 to 71 percent in 1998, not a significant change. Four of five infants with early onset GBS disease presented with bacteremia, another 6 percent with meningitis, and 7 percent with pneumonia. The same case fatality rate of 4 percent was associated with each presentation. Preterm infants (gestational age <37 weeks) with early onset disease were likelier to die than term infants (relative risk, 6.7). Bacteremia and meningitis were the predominant forms of late-onset disease. The overall case fatality rate was 2.8 percent. Early onset neonatal disease dropped from 1993 to 1998, most markedly when the consensus guidelines were released. The reduction was most evident in black neonates. In contrast, the overall rate of late-onset disease changed very little during the period under review. Children aged 3 months to 14 years were about twice as likely to die of GBS disease as were newborn infants with early onset disease. Just over half of affected nonpregnant adults presented with bacteremia, but a wider range of disease was seen in adult than in neonates, including abscess, pericarditis, and necrotizing fasciitis. Invasive GBS disease declined significantly in pregnant girls and women. Bacteremia was most common in this group, accounting for nearly two-thirds of cases. Bacteremic chorioamnionitis and endometritis each occurred in 10 percent of cases, and septic abortion occurred in 7 percent. Adults died significantly more often than newborn infants (relative risk, 2.5).Based on data from 1993, there were an estimated 6100 cases of early onset GBS disease each year before active preventive efforts were under way. In 1998, an estimated 3900 early onset neonatal cases and 200 neonatal deaths were prevented by intrapartum antibiotic prophylaxis. It is hoped that vaccines against GBS ultimately will reduce the need for antibiotic prophylaxis and protect pregnant women.N Engl J Med 2000;342:15–20

ISSN:0029-7828    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

At the authors’ institution, attending physicians have managed epidural analgesia for labor and delivery for the past quarter century. At present, three obstetricians and a family practitioner provide this service 24 hours a day for women in labor. A retrospective review was made of the efficacy and complications of epidural analgesia induced by attending obstetricians during labor in the years 1993 to 1995. Typically, women requested an epidural during a prenatal visit and signed a consent form at that time. The patient determined when epidural analgesia was delivered. Following a test dose of 1.5 percent lidocaine with 1:200,000 epinephrine, 2.5 ml of 0.25 percent or 0.375 percent bupivacaine was administered via an epidural catheter and was repeated after 5 to 10 minutes. A continuous infusion followed, with 2 &mgr;g/ml of sufentanil added, at a rate of 6 or 7 ml/h as long as the patient remained stable.Epidural analgesia was administered by the attending obstetrician in 1565 of 1704 women entering labor during the period under review (92 percent). In 77 instances, the epidural failed to provide adequate pain relief and intravenous analgesia became necessary. Four other patients required general anesthesia for cesarean delivery after having received an epidural. The overall rate of inadequate relief from an epidural was 5.2 percent. Complications included 24 cases of hypotension necessitating ephedrine therapy (1.5 percent), four subarachnoid punctures requiring a blood patch for spinal headache, and three cases of unexpected spinal anesthesia. In addition, 16 women (1 percent) had analgesia above the T5 dermatome. Labor lasted 8 hours on average. An Apgar score less than 7 was recorded at 1 minute in 8.4 percent of infants and at 5 minutes in 1.6 percent. All but 5 percent of women in this series achieved adequate epidural analgesia during labor and delivery when administered by their attending obstetricians, and there were no serious complications.South Med J 1999;92:1075–1078

ISSN:0029-7828    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Fetal fibronectin (FFN), a special form of the glycoprotein present in amniotic fluid and at the chorio-decidual interface, may be distinguished from adult fibronectin using monoclonal antibody FCD-6. Levels of the fetal form reportedly correlate strongly with the Bishop score, with positive fibronectin found more often where there is a favorable cervix. This study was an attempt to determine whether the presence of FFN in cervicovaginal secretions at term predicts the cervical response to prostaglandin E2(PGE2) pessaries and successful induction of labor when the cervix is unfavorable. Secretions were tested before cervical ripening was attempted with PGE2pessaries in 58 women with a singleton term or postterm pregnancy and a modified Bishop score less than 5 who were undergoing induction. Vaginal pessaries containing 3 mg of Prostin E2were used. FFN was estimated by means of a solid-phase immunoassay using an anti-human fibronectin-gold colloid conjugate and FCD-6.Nineteen of the 58 women in the study (32 percent) had a positive result on the immunoassay for FFN. All but two of them had a modified Bishop score of 5 or greater or entered labor within 4 to 6 hours after vaginal placement of a single pessary. Two women required a second pessary but underwent cesarean delivery, one because of failed induction and the other because of failure to progress. Nearly half of the FFN-negative subjects had an improved Bishop score or entered labor after a single PGE2pessary. Seven of the other 20 women delivered vaginally after a second dose. Eight women received a third or fourth pessary, and five of them delivered vaginally. Five women received oxytocin and had the membranes ruptured, but only one of them delivered vaginally. FFN-negative women required more PGE2and had longer induction-delivery intervals than FFN-positive women, but there was no significant difference in the length of the active phase of labor. Fewer operative deliveries were performed in the FFN-positive group, but this trend was not statistically significant. These findings suggest that the FFN assay be part of assessing cervical status when labor is to be induced.Acta Obstet Gynecol Scand 1999;79:861–865

ISSN:0029-7828    

出版商:OVID    

年代:2000

数据来源: OVID