摘要:

ObjectiveTo determine whether maternal or fetal morbidity is increased in association with fetal pulse oximetry monitoring using an atraumatic intrapartum transcervical fetal oxisensor.MethodsIn a prospective cohort study from January 1993 to June 1996, 196 fetuses were monitored during the intrapartum period with a fetal oximetry sensor placed between the uterine wall and the presenting fetal part. The oxisensors were in position for a median duration of 134 minutes. A total of 101 monitored fetuses underwent intrapartum fetal scalp blood sampling because of nonreassuring heat rate tracings. For a control group, we selected all cases during the same period in which fetal blood sampling was performed in the intrapartum period (n= 949) without pulse oximetry monitoring. Data for maternal and fetal morbidity were evaluated and tested for significant differences by the Mann-WhitneyUtest.ResultsThere was no significant difference in gestational age, birth weight, duration of labor, fetal outcome parameters, cesarean rate, operative vaginal deliveries, episiotomy rate, or perineal injuries between the study and control groups. Similarly, the percentages of neonatal intensive care unit admissions, neonatal resuscitations, and neonatal infections were not statistically different in the two groups. A rare complication in the group with pulse oximetry monitoring was a transient impression of the oxisensor probe on the fetal cheek. The rates of postpartum maternal infections, anemia, or secondary would disruptions were identical in both groups.ConclusionThere was no increased fetal or maternal morbidity associated with the use of an atraumatic intrapartum fetal pulse oxisensor.

ISSN:0029-7844    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

ObjectiveTo determine patterns of use of cord blood gas analysis in two institutions in Portland, Maine; to determine which factors, if any, predicted use of the test; and to evaluate compliance with ACOG guidelines.MethodsBilling data were used from 3166 deliveries during 1994 in the two hospitals to find deliveries in which the test was performed. We merged billing data with birth certificate data to examine factors associated with the test's use. Finally, we compared its use in our community with recently updated COG guidelines.ResultsThere was a 20-fold difference in the test's use between institutions (P< .001). The test was performed in 49% of all births at the tertiary care center and 2.5% of births at the community hospital. Many maternal and neonatal factors were linked to use of the test, but delivery system factors, in particular, the institution, were the strongest predictors of the test's use, even controlling for confounding factors between hospitals. There was little adherence to ACOG guidelines with 97% of the tests being performed in situations in which ACOG's recommendations did not support use of the analysis.ConclusionCurrent use of cord blood gas analysis in our community is not consistent with guidelines or cost-effective use of resources; the institutional factors that determine excess use should be examined and modified.

ISSN:0029-7844    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

ObjectiveTo test the hypothesis that a range of severity of placental vascular lesions underlies preeclampsia and that the likelihood of its clinical diagnosis increases with the extent and severity of uteroplacental vascular lesions.Methodsfour hundred sixty-five consecutive placentas of singleton, nonanomalous, live-born infants born before 32 weeks' gestation were examined prospectively, and uteroplacental vascular and related villous lesions were assigned a semiquantitative lesion score based on severity and extent of lesions. The summed scores of individual lesions yielded a total uteroplacental vascular lesion score, ranging from 0 to 21, that was correlated with the odds of a clinical diagnosis of preeclampsia, as well as with potential confounders, including maternal age, race, gestational age at delivery, and birth weight centile. Statistical analysis was performed using contingency tables, one-way analysis of variance, multiple logistic regression, and receiver operating characteristic curve.P< .05 was considered significant.ResultsA clinical diagnosis of preeclampsia was present in 78 of 465 (17%) cases. Logistic regression demonstrated that the total uteroplacental vascular lesion score related significantly to the diagnosis of preeclampsia (odds ratio 1.43, 95% confidence interval 1.31, 1.57) and this association was independent of gestational age at delivery and birth weight centile. Preeclampsia was diagnosed in 12 of 284 (4%) cases with no or minimal histologic evidence of placental vascular injury (total score less than 4). Conversely, the diagnosis was not made in 4% of cases despite the presence of extensive placental vascular injury (total score at least 14).ConclusionThe likelihood of clinical diagnosis of pre-eclampsia before 32 weeks increases with progressive impairment of the uteroplacental circulation. Histopathologic examination of the placenta can be used to confirm the diagnosis of preeclampsia.

ISSN:0029-7844    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

ObjectiveThis study was designed to estimate the predictive value of the first neonatal platelet count for the second neonate in women with immune thrombocytopenic purpura (ITP).MethodsData of 34 patients, repeatedly pregnant while they had ITP, were prospectively collected in two study centers between 1984 and 1995. The main outcome measure was neonatal thrombocytopenia.ResultsEarly neonatal platelet counts (ie, umbilical cord count or count during the first 24 hours of life) between siblings were correlated (r= .73; 95% confidence interval (CI) for the correlation coefficient 0.52, 0.86). Severe thrombocytopenia (less than 50 × 109/L) at birth did not occur in any of the 27 siblings of infants with birth platelet levels above 50 × 109/L. Also the second sibling's nadir neonatal platelet counts during the first 2 weeks of life were correlated with those of the first sibling (r= .76; 95% CI for the correlation coefficient 0.58, 0.88). In those cases in which the first sibling had a lowest platelet count above 100 × 109/L (n= 19), the second sibling never became thrombocytopenic.ConclusionThe platelet count of the first sibling can be used to counsel women with ITP, and may be helpful in their management.

ISSN:0029-7844    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

ObjectiveTo evaluate the etiology, management, and maternal and perinatal outcome in patients with septic shock during pregnancy.MethodsIn 18 patients with spetic shock during pregnancy, the criteria for the diagnosis were sepsis-induced hypotension unresponsive to adequate fluid resuscitation and requirement for vasopressors.ResultsCauses of shock were pyelonephritis (n= 6), choriomnionitis (n= 3), postpartum endometritis (n= 2), toxic shock (n= 2), and one each of septic abortion, ruptured appendix, ruptured ovarian abscess, necrotizing fasciitis, and bacterial endocarditis. Five women (28%) died. Comparing medians of the initial laboratory data for the 13 survivors with those of the five nonsurvivors revealed significant differences for hematocrit (26 compared with 35%;Z= −2.267,P= .023), aspartate aminotransferase (30 compared with 287 U/L;Z= −2.068,P= .042), total bilirubin (1.6 compared with 5.8 mg/dL;Z= 2.046,P= .045), arterial carbon dioxide pressure (30 compared with 19 mmHg;Z= −2.384,P= .013), and arterial oxygen pressure (62 compared with 104 mmHg;Z= −2.004,P= .048). Comparing medians of the hemodynamic data showed differences in blood pressure (88 compared with 70 mmHg;Z= −2.439,P= .013), stroke volume (74 compared with 52 mL;Z= −2.041,P= .038), and left ventricular stroke work index (42 compared with 12 g · m · m2;Z= −1.929,P= .052). Sixty-four percent of survivors and 80% of nonsurvivors had depressed left ventricular function (Fisher exact test,P> .99). Locating the source of infection was difficult and delayed in eight patients.ConclusionIn women with septic shock, progression to death can be dramatically rapid. Because vascular permeability is increased, it may be appropriate to administer vasopressors early during resuscitation. An initial low cardiac output is a poor prognostic sign.

ISSN:0029-7844    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

ObjectiveTo measure platelet activation in normal pregnancy, before and after stimulation with agonists, with a whole blood flow cytometric technique.MethodsIn a cross-sectional study, 5 mL of whole blood was collected from healthy volunteers (nine in the first trimester, ten in the second trimester, 35 in the third trimester, and 32 nonpregnant controls). Platelets were treated with an agonist (thrombin or U-46619, a thromboxane A2 analogue) or buffer and were exposed to saturating concentrations of monoclonal antibodies directed against platelet membrane glycoproteins (GPs): 7E3 (fibrinogen receptor GPIIb/IIIa), S12 (alpha granule marker P-selectin), and 6D1 (von Willebrand factor receptor GPIb). Mean fluorescence intensity was determined for 5000 platelets per sample by using a flow cytometer.ResultsIn the absence of agonist, no significant difference between groups was found in antibody binding. At no stage of pregnancy were circulating activated platelets detected. Platelets from third-trimester subjects bound significantly less 7E3 than platelets of controls or of first- or second-trimester subjects after stimulation with high-dose thrombin (P< .05 for all comparisons). Down-regulation of 6D1 on platelets after stimulation with high-dose U-46619 was significantly greater in third-trimester gravidas than in controls or first-trimester subjects (P< .05).ConclusionPregnancy does not increase the percentage of activated platelets in the circulation. Platelet reactivity is altered in the third trimester, as evidenced by decreased antibody binding to a fibrinogen receptor epitope and enhanced down-regulation of a von Willebrand factor receptor epitope.

ISSN:0029-7844    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

ObjectiveTo compare nicotine concentrations and fetal middle cerebral artery resistance indices (RIs) during 21-mg transdermal nicotine use with these values during maternal smoking.MethodsIn this randomized, crossover study, participants smoked approximately 20 cigarettes daily and were between 24 and 36 weeks' gestation. Subjects were randomized to transdermal nicotine or to smoking ad libitum for 8 hours. One week later, they crossed over to the other condition. Maternal plasma nicotine concentrations and hemodynamic measurements were obtained before and after the onset of smoking or patch placement.ResultsArea under the plasma nicotine concentration-time curve during patch use was similar to continued smoking (93 versus 89 ng-hour/mL, respectively)P= .77). The mean (standard error [SE] change in the middle cerebral artery RI from baseline to 4 hours later was similar during patch use and smoking: −.002 (0.008) versus −.02 (0.015), respectively (P= .3). The study had greater than 80% power to detect a 25% difference in nicotine concentrations and a change of 2 standard deviations in the middle cerebral artery RI between conditions. An unexpected finding was that of a loss of fetal heart rate (FHR) reactivity in 5/8 tracings after patch placement versus 1/6 tracings after smoking (P= .12). The baseline FHR increased by a mean (SE) of 8(4) beats per minute with loss of reactivity in the patch condition, compared with a decrease of 3 (3) beats per minute without loss of reactivity (P= .05).ConclusionEight-hour use of 21-mg transdermal nicotine yields nicotine concentrations and middle cerebral artery RIs similar to those produced by hourly smoking in pregnant smokers.

ISSN:0029-7844    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

ObjectiveTo determine which fetal echocardiography views are essential to detect the majority of cardiac defects in fetuses of women with diabetes mellitus.MethodsFetal echocardiograms performed from February 1990 through May 1996 on insulin-requiring women with diabetes were reviewed. Individual component views of the examination were analyzed for the detection of fetal congenital heart defects. Sensitivity, specificity, positive predictive value, and negative predictive value were calculated. Multiple gestations and patients with additional risk factors for congenital heart defects were excluded.ResultsA total of 223 patients were included in the study. There were 11 (4.9%) congenital heart defects, eight of which were conotruncal. When the four-chamber view and outflow tracts appeared normal, additional views such as the ductal and aortic arches did not detect a cardiac defect. The sensitivity of the four-chamber view for detecting an abnormal heart increased from 73% to 82% with the addition of the aortic outflow tract. There were two false-negative and no false-positive diagnoses.Conclusionthe four-chamber and outflow tracts are the essential views that will detect most cardiac defects in fetuses of women with insulin-requiring diabetes mellitus.

ISSN:0029-7844    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

ObjectiveTo determine whether there is a gender discrepancy in severe twin-twin transfusion syndrome.MethodsAll cases of twin-twin transfusion syndrome evaluated between 1989 and 1996 were reviewed retrospectively. The following sonographic criteria were used: a single placenta, a thin membrane, the same gender, a combination of polyhydramnios-oligohydramnios, a stuck twin, and an estimated weight discordance exceeding 20%. At least five of six sonographic criteria were required for inclusion in the study. Only severe cases, which were defined as early onset (before 30 weeks' gestation), a combination of polyhydramnios and oligohydramnios, a stuck twin, fetal hydrops, fetal death, or the requirement of medical or invasive treatment, were included. Chorionicity was confirmed by placental examination when available.ResultsThirty-seven twin pregnancies met the above criteria, of which 33 (89%) twin pairs were female. The median gestational age at presentation was 19 weeks (range, 15–29; standard deviation, 5.6). A single placenta, thin membrane, same gender, and polyhydramnios-oligohydramnios were present in every case. A stuck twin was noted in 34 of 37 cases (92%), and a growth discordance exceeding 20% was present in 26 of 36 (72%). Placental pathology, which was available in 31 (84%) cases, confirmed a monochorionic placentation in 29. Twenty-five (68%) cases had reduction amniocentesis, two were treated with indomethacin, one underwent a cord ligation, and in four cases, fetal death occurred before treatment was instituted.ConclusionThere is a significant female preponderance in pregnancies complicated by severe twin-twin transfusion syndrome. The reasons for this are unclear, but they may be related to either placental or fetal gender-specific differences affecting a subset of monochorionic twin pregnancies.

ISSN:0029-7844    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

ObjectiveTo compare biopsychologic profiles of women with dyspareunia with a matched no-pain control sample, and to determine whether dyspareunia subtypes based on physical findings have different psychosocial profiles from matched controls.MethodsOne hundred and five women with dyspareunia and 105 matched no-pain control women underwent standard gynecologic examination, endovaginal ultrasound, and colposcopy. They also completed a structured interview inquiring about pain other than dyspareunia, sexual function, and history of abuse, the Brief Symptom Inventory, the Sexual Opinion survey, and the Locke-Wallace Marital Adjustment Scale.ResultsIn comparison with women who do not experience pain with intercourse, the dyspareunia sample was found to have more physical pathology on examination, and they reported more psychologic symptomatology, more negative attitudes toward sexuality, higher levels of impairment in sexual function, and lower levels of marital adjustment. They did not report more current or past physical or sexual abuse. However, when the undifferentiated dyspareunia sample was divided into subtypes based on physical findings from the gynecologic examinations, the pattern of significant differences from controls varied according to dyspareunia subtype. Elevated psychologic symptomatology and relationship maladjustment were confined to the subtype with no discernible physical findings who reported levels of sexual function not significantly different from matched controls. The vulvar vestibulitis subtype suffered the highest levels of sexual impairment although this subtype was not characterized by higher levels of psychologic symptoms than controls.ConclusionAs an undifferentiated group, women with dyspareunia have more physical pathology, psychologic distress, sexual dysfunction, and relationship problems. However, this pattern of differences appears to vary depending on the presence and type of physical findings evident on examination. Dyspareunia is a heterogeneous disorder requiring comprehensive gynecologic and psychosocial assessment to determine differentiated treatment strategies.

ISSN:0029-7844    

出版商:OVID    

年代:1997

数据来源: OVID