RESUMEN
OBJECTIVE: To examine whether alcohol abuse (ALC) continued to be a health hazard to pregnant women in the 1990s. STUDY DESIGN: Analysis of a perinatal data base comprising 170,258 women with singleton pregnancies. Univariate cross table analysis and logistic regression were conducted to examine the association between alcohol abuse and congenital malformations coded according to the International Classification of Diseases (ICD). RESULTS: 14,727/170,258 mothers (8.6%) admitted to ALC during pregnancy and 36,705/170,258 (21.6%) to smoking. Anomaly rates for ALC (365/14,092, 4.3%) vs. Non-ALC (6187/149,344, 4.0%) differed significantly (p<0.001). The rates of specific anomalies varied between <0.1% and 1.1%. Odds ratios for 16 ICD 9 anomaly categories were >1 in 14 instances overall (Sign test, p=0.004), in 12 instances in women <30 years (p=0.08), and in 13 instances in women over 30 years (p=0.02). Congenital anomalies of the "respiratory system" (ICD9 748), of "genital organs" (ICD9 752.1), of the "integument" (ICD9 757), and "other anomalies of limbs/other musculoskeletal anomalies" (ICD 755/756) were statistically significantly associated with ALC, especially in women>30 years. CONCLUSION: ALC in pregnancy continued to be an important factor independently associated with an increased incidence of a broader range of congenital anomalies than previously recognized. Risk for anatomic anomalies was increased in offspring of ALC women over age 30, consistent with previous reports of increased risk of neurobehavioral abnormality in offspring of women over 30.
Asunto(s)
Anomalías Inducidas por Medicamentos/etiología , Alcoholismo/complicaciones , Trastornos del Espectro Alcohólico Fetal/epidemiología , Anomalías Inducidas por Medicamentos/epidemiología , Adulto , Femenino , Alemania/epidemiología , Humanos , Modelos Logísticos , Paridad , Embarazo , Factores de Riesgo , Fumar/epidemiologíaRESUMEN
OBJECTIVE: To determine the effects of fetal hypoxia and hyperoxia on placental vascular tone and production of interleukin-6 and tumor necrosis factor-alpha. STUDY DESIGN: The maternal and fetal circulation of 2 cotyledons from 5 human placentas were perfused for 4 hours. The fetal circulation of 1 cotyledon was perfused with hypoxic Hanks' balanced salt solution; the other was perfused with hyperoxic Hanks' balanced salt solution. Fetal vascular pressures were recorded every 10 minutes, and fetal vein effluents were collected hourly. RESULTS: Fetal-placental vascular perfusion pressure was reduced from baseline during hypoxic conditions. Cytokine concentrations were elevated during hyperoxic conditions compared with hypoxic conditions, with significant differences achieved at 2, 3, and 4 hours for interleukin-6 and at 4 hours for tumor necrosis factor-alpha. CONCLUSION: Fetal-placental vasodilation may be a compensatory mechanism to improve hypoxic conditions. Supraphysiologic oxygenation may contribute to the fetal inflammatory response syndrome and to the development of cerebral palsy.
Asunto(s)
Enfermedades Fetales/fisiopatología , Feto/irrigación sanguínea , Hiperoxia/fisiopatología , Hipoxia/fisiopatología , Mediadores de Inflamación/metabolismo , Placenta/irrigación sanguínea , Sistema Vasomotor/fisiopatología , Humanos , Interleucina-6/metabolismo , Factor de Necrosis Tumoral alfa/metabolismoRESUMEN
OBJECTIVE: To determine whether current methods of detecting Down syndrome based on fetal femur length calculations are influenced by gestational age or maternal height. METHODS: Four formulas were used to calculate expected femur length (FL) based on the fetal biparietal diameter (BPD) between 15 0/7 weeks' gestation and 19 6/7 weeks' gestation. For each gestational age, the BPD:FL ratio for women shorter than one standard deviation (SD) below the mean height was compared with the ratio for women taller than one SD above the mean height. A measured:expected FL ratio of 0.91 or less and a BPD:FL ratio greater than 1.5 SD above the mean was considered abnormal. RESULTS: The four formulas used to calculate measured:expected FL ratios were significantly more likely to be abnormal at 15--16 weeks' gestation, compared with 18-19 weeks' gestation (P <.05). Maternal height correlated with femur lengths at 18 and 19 weeks' gestation (P <.05) but not at earlier gestational ages. At 18 and 19 weeks' gestation, women shorter than one SD below the mean were twice as likely to have an abnormal BPD:FL ratio compared with women taller than one SD above the mean (relative risk 2.38; 95% confidence interval 1.21, 4.69). CONCLUSION: Early gestational age increases a woman's risk of having an abnormal measured:expected FL ratio, whereas short stature increases a woman's risk of having an abnormal BPD:FL ratio at later gestational ages. These findings indicate that risk assessment for fetal Down syndrome for such patients might be inaccurate. (Obstet Gynecol 2001;97:742-6.
Asunto(s)
Estatura , Síndrome de Down/diagnóstico por imagen , Fémur/embriología , Fémur/crecimiento & desarrollo , Edad Gestacional , Ultrasonografía Prenatal/métodos , Adulto , Estudios de Cohortes , Intervalos de Confianza , Síndrome de Down/epidemiología , Desarrollo Embrionario y Fetal , Femenino , Humanos , Valor Predictivo de las Pruebas , Embarazo , Prevalencia , Probabilidad , Medición de Riesgo , Sensibilidad y EspecificidadRESUMEN
Constitutional mosaic trisomy 8 has been associated with syndromic dysmorphology, corneal opacities, leukemias, and trophoblastic disease. However, abnormal maternal serum alpha-fetoprotein (MSAFP) has not been reported in association with mosaic trisomy 8. Our case first presented for evaluation of an extremely elevated MSAFP with mild elevation of MShCG in an otherwise normal pregnancy: MSAFP 13.89 MoM, MShCG 3.57 MoM, and MSuE3 1.04 MoM. Fetal dysmorphism was limited to bilateral pyelectasis and a prominent third ventricle. Spontaneous labor at 38 weeks resulted in the birth of a 3,570-gram AGA male with APGARs 7(1)/8(5). The neonate had facial asymmetry, 5th finger clinodactyly, 2-3 toe syndactyly, undescended testicle, abnormal prepuce, and mild pyelectasis. CT scan revealed hypoplasia of the corpus callosum, while echocardiography demonstrated bicuspid aortic valve, and the neonatal karyotype (blood) returned 46,XY/47,XY+8. Evaluation at 3 months revealed more prominent facial asymmetry, plagiocephaly, plantar creases, descent of the testis, and mild developmental delay. Review of the literature does not include any previously reported maternal serum alpha-fetoprotein aberrations in mosaic trisomy 8.
Asunto(s)
Cromosomas Humanos Par 8 , Mosaicismo , Trisomía , alfa-Fetoproteínas/análisis , Adulto , Agenesia del Cuerpo Calloso , Válvula Aórtica/anomalías , Criptorquidismo/genética , Asimetría Facial/genética , Femenino , Dedos/anomalías , Edad Gestacional , Humanos , Recién Nacido , Masculino , Embarazo , Resultado del Embarazo , Sindactilia/genética , Dedos del Pie/anomalíasRESUMEN
BACKGROUND: Does the prenatal ascertainment of isolated mild ventriculomegaly increase the a priori risk for aneuploidy when isolated or not associated with advanced maternal age? Does isolated mild ventriculomegaly increase the risk for pediatric developmental delay? METHODS: The Wayne State University (WSU) Reproductive Genetics abnormal case data base and the Madigan Army Medical Center (MAMC) experience were reviewed to compare the rates of aneuploidy for cases with fetal ventriculomegaly. Cases were classified by maternal age and associated sonographic markers of aneuploidy. Aneuploidy rates were compared between the isolated ventriculomegaly, ventriculomegaly with advanced maternal age (AMA), and ventriculomegaly associated with multiple anomalies. Rates of aneuploidy were compared to identify association. RESULTS: A total of 118 cases with ventriculomegaly were identified for comparison. Ninety-four cases were identified in the WSU cohort; 46 demonstrated isolated ventriculomegaly alone, and aneuploidy was present in 3/25 (12%) with invasive fetal testing, 0/24 (0%) cases in the MAMC cohort demonstrated aneuploidy. Isolated mild ventriculomegaly cases at MAMC were identified for further tests. DISCUSSION: Although the two study populations vary in age and risk distributions, the attributable risk for isolated mild ventriculomegaly poses a counseling conundrum due to the neurodevelopmental implication of this minor dysmorphism more so than its association with aneuploidy.
Asunto(s)
Aneuploidia , Ventrículos Cerebrales/anomalías , Enfermedades Fetales/genética , Estudios de Cohortes , Femenino , Enfermedades Fetales/epidemiología , Enfermedades Fetales/patología , Humanos , Embarazo , Diagnóstico Prenatal , Factores de RiesgoRESUMEN
OBJECTIVE: We evaluated the medical-sociological implications of parental perception of risk and decision-making choices for prenatally ascertained choroid plexus cysts (CPCs) between two obstetric populations with similar clinical situations. METHODS: The Wayne State University (WSU) Reproductive Genetics database and the Madigan Army Medical Center (MAMC) experience were reviewed to compare the rates of aneuploidy and invasive testing for cases with CPC. Aneuploidy rates were compared between those with isolated CPC, CPC with advanced maternal age (AMA), and CPC associated with multiple anomalies. RESULTS: 186 cases were identified in the WSU cohort, of whom 27 (15%) declined invasive fetal testing. In the remaining 159 cases, aneuploidy was present in 2/132 (1.5%) isolated CPCs, 3/11 (27%) CPCs with AMA, and 15/16 (93%) CPCs with multiple anomalies. 107 cases were identified in the MAMC cohort, of whom 99 (92%) declined invasive fetal testing. No cases of aneuploidy were found in the 3/12 AMA cases or 5/95 non-AMA cases who underwent amniocentesis. CONCLUSIONS: The 2 cases of aneuploidy with isolated CPC cannot be ignored, and provide an estimated attributable risk of at least 0.8%, a higher risk than 38 years of age. However, the parental sociologic context may be as important as the genetic-prognostic risk for decision-making.
Asunto(s)
Plexo Coroideo/anomalías , Quistes/diagnóstico , Toma de Decisiones , Asesoramiento Genético/psicología , Padres/psicología , Centros Médicos Académicos , Aneuploidia , Estudios de Cohortes , Quistes/epidemiología , Quistes/genética , Femenino , Hospitales Militares , Humanos , Incidencia , Embarazo , Complicaciones del Embarazo/diagnóstico , Complicaciones del Embarazo/epidemiología , Complicaciones del Embarazo/psicologíaRESUMEN
OBJECTIVE: This study was undertaken to determine whether adrenomedullin, a hypotensive peptide, decreases vasomotor tone in fetoplacental vasculature that has been constricted with the thromboxane sympathomimetic U46619. STUDY DESIGN: The fetoplacental vascular beds of 20 perfused human placental cotyledons were vasoconstricted with a continuous infusion of U46619 (10(-8) mol/L). The vasculature was then sequentially injected with deionized water, 30 ng adrenomedullin, 300 ng adrenomedullin, and 3000 ng adrenomedullin. Any change in perfusion pressure was noted after each dose. In a separate experiment the fetoplacental vasculature in 2 perfused cotyledons from each of 10 placentas was vasoconstricted with U46619 (10(-8) mol/L). Adrenomedullin was infused continuously at either 200 ng/min (n = 5) or 2000 ng/min (n = 5) for 40 minutes. A corresponding control cotyledon from each placenta had isotonic sodium chloride solution added to its perfusion. Perfusion pressures were recorded every minute during the infusion and for 40 minutes afterward. Analysis of variance was used to compare pressure changes in the cotyledons that received bolus doses of adrenomedullin. Paired t tests of mean percentage pressure changes were used to compare the study and control groups that received the continuous infusions. RESULTS: In the cotyledons that received bolus doses of adrenomedullin, the mean (+/-SEM) percentage perfusion pressure changes from the baseline were -6.7 +/- 0.5 for 30 ng adrenomedullin (P =.0039), -8.5+/- 0.7 for 300 ng adrenomedullin (P <.0001), and -13.1 +/- 1.0 for 3000 ng adrenomedullin (P <.0001). With the continuous adrenomedullin infusion of 200 ng/min, there was no significant difference in the mean percentage pressure change from baseline between the study and control groups (-0.57%). At 2000 ng/min there was a significant difference (-15.34%; P <.0001). CONCLUSION: Adrenomedullin caused vasodilatation of fetoplacental vasculature previously constricted with the thromboxane sympathomimetic U46619 in the isolated perfused placental cotyledon. This vasodilatation occurred in a dose-dependent manner.
Asunto(s)
Ácido 15-Hidroxi-11 alfa,9 alfa-(epoximetano)prosta-5,13-dienoico/farmacología , Vasos Sanguíneos/efectos de los fármacos , Vasos Sanguíneos/embriología , Péptidos/farmacología , Placenta/irrigación sanguínea , Simpatomiméticos/farmacología , Vasoconstricción/efectos de los fármacos , Vasoconstrictores/farmacología , Vasodilatación , Vasodilatadores/farmacología , Adrenomedulina , Femenino , Feto/fisiología , Humanos , Técnicas In Vitro , Embarazo , Tromboxano A2/análogos & derivadosRESUMEN
OBJECTIVE: The purpose of this work was to demonstrate the approach to developing an integrated curriculum for obstetric ultrasound training by utilizing an accredited American Institute of Ultrasound in Medicine teaching platform. METHODS: During the 1996-98 academic years, the American College of Obstetricians and Gynecologists and American Institute of Ultrasound in Medicine guidelines for ultrasound performance and training were integrated into a multifaceted training program for obstetric and radiological residents and maternal-fetal medicine fellows consisting of a structured reading program, self study of a 35-mm slide program of normal/abnormal anatomy, a basic ultrasound and fetal echocardiography interactive CD program, hands-on supervised scanning program and practical and certificate-bearing fetal echocardiography courses for fellows. All obstetric residents were given pretests and post-tests to measure learning performance in the program. The results from these tests were analyzed for statistical significance. RESULTS: Thirteen obstetric residents completed the training program. The locally developed pretest showed a mean of 16/40 correct questions with an SD of 1.85. After completing the training, the mean obstetric resident scores on the post-test were 32/40 with an SD of 5.9. This difference was statistically significantly different, P < 0.009. Radiology residents showed an improvement from no residents passing the obstetric ultrasound portion on the 1996 Radiology Boards to 100% pass rate in 1997 (four residents per year) after completing the course. Maternal-fetal medicine fellows progressed from inability to perform acceptable fetal echocardiography to full ability to perform fetal echocardiographic examinations. CONCLUSION: An integrated approach to obstetric ultrasound training for obstetric and radiologic residents and maternal-fetal medicine fellows with multifaceted learning methods is easily achieved with available guidance from the American College of Obstetricians and Gynecologists and American Institute of Ultrasound in Medicine.
Asunto(s)
Curriculum , Ginecología/educación , Internado y Residencia , Obstetricia/educación , Ultrasonografía , DC-I , Evaluación Educacional , Becas , Radiología/educación , Sociedades Médicas , Ultrasonografía Prenatal , Estados UnidosRESUMEN
OBJECTIVE: The purpose of this study was to identify the placental expression of adrenomedullin and adrenomedullin receptor messenger ribonucleic acid and compare them between placentas from pregnancies associated with oligohydramnios as a result of uteroplacental insufficiency and placentas from normal pregnancies. STUDY DESIGN: Total ribonucleic acid was extracted from the amnion, chorion, cotyledon, umbilical vein, and umbilical artery in 5 normal placentas and 3 placentas from pregnancies complicated by oligohydramnios. A cell line known to express messenger ribonucleic acid of adrenomedullin and its receptor was used to optimize the polymerase chain reaction and served as a positive control preparation in all experiments. Semiquantitative reverse transcriptase-polymerase chain reaction results for adrenomedullin and adrenomedullin receptor were compared between tissues as densitometric ratios of adrenomedullin or adrenomedullin receptor messenger ribonucleic acid to beta(2)-microglobulin messenger ribonucleic acid. Results were analyzed with a Kruskal-Wallis 1-way analysis of variance. Immunohistochemical staining with an antibody to human adrenomedullin was used to localize adrenomedullin in all tissue types. RESULTS: Messenger ribonucleic acid sequences for adrenomedullin and adrenomedullin receptor genes were identified in all tested placental tissue components. Within the normal placentas the expressions of adrenomedullin and adrenomedullin receptor messenger ribonucleic acid sequences did not differ statistically between the tissue components. Within placentas from patients with oligohydramnios the expressions of adrenomedullin and adrenomedullin receptor messenger ribonucleic acid did not differ statistically between the tissue components. When normal placentas were compared with placentas from pregnancies complicated by oligohydramnios, however, a 5-fold increase in adrenomedullin messenger ribonucleic acid and a 3-fold increase in adrenomedullin receptor messenger ribonucleic acid were seen in placentas from patients with oligohydramnios. Adrenomedullin immunoreactivity was present in all tissues studied. CONCLUSION: The expression of messenger ribonucleic acid for both adrenomedullin and its receptor in these tissue components implies that placental tissues function in both synthesis and action of adrenomedullin. The increased adrenomedullin messenger ribonucleic acid expression in the umbilical artery and the elevated adrenomedullin receptor messenger ribonucleic acid expression in the cotyledons of placentas from patients with oligohydramnios may represent a local fetoplacental physiologic adaptive response to vascular compromise.
Asunto(s)
Oligohidramnios/metabolismo , Péptidos/genética , Placenta/metabolismo , ARN Mensajero/metabolismo , Adrenomedulina , Western Blotting , Femenino , Humanos , Inmunohistoquímica , Péptidos/metabolismo , Embarazo , Estudios Prospectivos , Receptores de Adrenomedulina , Receptores de Péptidos/genética , Receptores de Péptidos/metabolismo , Valores de Referencia , Reacción en Cadena de la Polimerasa de Transcriptasa Inversa , Distribución TisularRESUMEN
OBJECTIVE: Our purpose was to determine whether exposure of the isolated, perfused human placental cotyledon to different fetal circuit perfusion rates, and to concomitant pressure differences, alters placental production of interleukin 6 and tumor necrosis factor alpha. STUDY DESIGN: The maternal and fetal circulations of 2 cotyledons from 5 placentas were perfused for 4 hours. The fetal circulation of 1 cotyledon was perfused at a low rate of 1 mL/min, and the other at a high rate of 10 mL/min. The maternal circulation of each cotyledon was perfused at 10 mL/min. Effluents from the fetal circulation were collected at hourly intervals, and concentrations of interleukin 6 and tumor necrosis factor alpha were determined by enzyme-linked immunosorbent assay. Concentrations of interleukin 6, obtained from a prior study with an estimated physiologic fetal circulation rate of 4 mL/min, were compared with the low and high perfusion rate results. RESULTS: Concentrations of interleukin 6 and tumor necrosis factor alpha were greater at the perfusion rate of 1 mL/min, in comparison with the perfusion rate of 10 mL/min, with statistically significant differences achieved at 2 and 4 hours for interleukin 6 and at 4 hours for tumor necrosis factor alpha. Concentrations of both cytokines increased exponentially with time. Placental perfusion pressures were significantly greater at the perfusion rate of 10 mL/min. CONCLUSION: Placental hypoperfusion results in an increased production of both interleukin 6 and tumor necrosis factor alpha. This finding links placental perfusion abnormalities to the myriad of disorders associated with elevated concentrations of inflammatory cytokines, including cerebral palsy.
Asunto(s)
Interleucina-6/metabolismo , Perfusión , Placenta/irrigación sanguínea , Factor de Necrosis Tumoral alfa/biosíntesis , Circulación Sanguínea , Femenino , Feto/fisiología , Humanos , Técnicas In Vitro , Concentración Osmolar , Perfusión/métodos , Embarazo , Presión , Factores de TiempoRESUMEN
OBJECTIVE: To evaluate the cost consequence of the elimination of routine Group B streptococcus (GBS) cultures in pregnancy utilizing risk factor assessment management recommendations of the Center for Disease Control. METHODS: This retrospective study cohort population included all delivering patients from June 1, 1996, to May 31, 1997, managed by the Morbidity Mortality Weekly Report (MMWR) guidelines May 31, 1996, for GBS in pregnancy compared to the previous 29 months cohort from January 1, 1994, to May 31, 1996, managed with routine GBS cultures done at 35-37 weeks. RESULTS: Of the 7,681 culture management control cohort patients, there were four neonates with culture-positive GBS sepsis (1/1,900). The cost for detection of a single positive culture in an affected neonate was $8,627 ($34,509/4) and there were 2,875 personnel hours expended. In contrast, of the 2,011 patients in the risk factor management cohort, there were two cases of neonatal GBS sepsis ($111,005). The cost for detection of a positive culture in an affected neonate was $1,579 ($3,159/2) and there were 263 personnel hours expended in the risk factor management group. In spite of these significant laboratory savings, we noted a concurrent increase in the total cost in the newborn nursery for septic work-ups and treatment from $2.4 million to $3.1 million. CONCLUSION: Risk assessment management of GBS provided a savings of both money ($7,048/positive neonatal culture) and laboratory time (586 personnel hours/positive neonatal culture). However, these savings were more than offset by cost increases occurring in the newborn nursery ($400,000), demonstrating the necessity of practice patterns to undergo concurrent evaluation to verify cost savings and prevent shifting of expenses.
Asunto(s)
Hospitales de Enseñanza , Complicaciones Infecciosas del Embarazo/microbiología , Infecciones Estreptocócicas/diagnóstico , Infecciones Estreptocócicas/economía , Streptococcus agalactiae/aislamiento & purificación , Estudios de Cohortes , Femenino , Humanos , Recién Nacido , Trabajo de Parto Prematuro/microbiología , Embarazo , Complicaciones Infecciosas del Embarazo/economía , Estudios Retrospectivos , Factores de Riesgo , Infecciones Estreptocócicas/terapiaRESUMEN
We evaluated the medical-sociological implications of parental perception of risk and decision-making choices for prenatally ascertained choroid plexus cysts (CPC) between two obstetric populations. The Wayne State University (WSU) Reproductive Genetics database and the Madigan Army Medical Center (MAMC) experience were reviewed to compare the rates of aneuploidy and invasive testing for cases with CPC. Aneuploidy rates were compared between those with isolated CPC, CPC with advanced maternal age (AMA), and CPC associated with multiple anomalies. In the WSU cohort 186 cases were identified, of whom 27 (15%) declined invasive fetal testing. In the remaining 159 cases, aneuploidy was present in 2/132 (1.5%) isolated CPC, 3/11 (27%) CPC with AMA, and 15/16 (93%) CPC with multiple anomalies. In the MAMC cohort 107 cases were identified, of whom 99 (92%) declined invasive fetal testing. No aneuploidy cases were found in the 3/12 AMA cases or 5/95 non-AMA cases that underwent amniocentesis. The two cases of aneuploidy with isolated CPC cannot be ignored, and provide an estimated attributable risk of at least 0.8%, a higher risk than 38 years of age. However, the parental sociologic context may be as important for decision-making as the genetic-prognostic risk.
Asunto(s)
Anomalías Múltiples/diagnóstico , Aneuploidia , Plexo Coroideo , Quistes/complicaciones , Quistes/diagnóstico , Toma de Decisiones , Enfermedades Fetales/diagnóstico , Tamizaje Masivo/psicología , Padres/psicología , Diagnóstico Prenatal/psicología , Amniocentesis , Asesoramiento Genético , Humanos , Tamizaje Masivo/métodos , Edad Materna , Michigan , Padres/educación , Embarazo de Alto Riesgo , Diagnóstico Prenatal/métodos , Pronóstico , Estudios Retrospectivos , Factores de Riesgo , WashingtónRESUMEN
OBJECTIVE: To determine if lipopolysaccharide (LPS) alters production of interleukin-6 (IL-6) or vascular tone in perfused placental cotyledons. METHODS: Control and study cotyledons from nine placentas were perfused for 3 h. Study cotyledons received LPS in concentrations of 0.01 mcg/ml (n = 3), 0.1 mcg/ml (n = 3), or 1.0 mcg/ml (n = 3). Effluents were collected at 30, 60, 120, and 180 min following infusion with LPS. IL-6 concentrations were measured by enzyme-linked immunosorbant assay. Perfusion pressures were recorded at 10-min intervals. Data were analyzed using ANOVA for repeated measures. RESULTS: IL-6 production significantly increased over time in both the study and control cotyledons (P = 0.002). LPS treatment did not affect IL-6 production (P = 0.85) and there were no observable dose effects (P = 0.13). Perfusion pressures did not differ (P = 0.16). CONCLUSIONS: The isolated perfused placental cotyledon produces IL-6 and concentrations increase over time. LPS does not alter production of IL-6 or fetoplacental vascular tone.
Asunto(s)
Interleucina-6/biosíntesis , Lipopolisacáridos/farmacología , Placenta/irrigación sanguínea , Placenta/metabolismo , Relación Dosis-Respuesta a Droga , Femenino , Humanos , Cinética , Lipopolisacáridos/administración & dosificación , Perfusión , Placenta/efectos de los fármacos , EmbarazoRESUMEN
Military medicine has faced some big challenges in recent years. Military treatment facilities have not been exempt from these alterations, as the American public has sought to reinvent government practices with regard to medicine. Until recently, professional education consisted almost entirely of emphasis in the particular content of the chosen field. Obstetrics and gynecology was one of the first medical specialties to recognize the importance of practice management, professional growth and development, and to require exposure to it as part of the residency process. The Department of Obstetrics and Gynecology's instructional objectives dealing with professional growth and development originated as part of the military-unique curriculum for physicians implemented at Tripler Army Medical Center in Hawaii. Later, these objectives were used at Madigan Army Medical Center in Tacoma, Washington. Recent changes in the health care environment, coupled with an increasing awareness of professional liability and the newer specter of managed care, force physicians to learn the cost of each health encounter and to be more familiar with the business aspects of health care. As medicine in general is changing, the curricula have been revised and tailored to the needs of our physicians with the addition of ethics, managed care, utilization, and practice management.
Asunto(s)
Curriculum , Medicina Militar/educación , Gestión de la Práctica Profesional , Educación de Postgrado en Medicina , Ginecología/educación , Humanos , Obstetricia/educación , Estados UnidosRESUMEN
OBJECTIVE: To determine if decreasing the number of prenatal visits for routine obstetric patients affects pregnancy outcome. STUDY DESIGN: A historical control study was designed to include 734 deliveries from January 1 to December 31, 1991, in women who had prenatal care per American College of Obstetricians and Gynecologists Committee Opinion no. 79, January 1990, guidelines for uncomplicated obstetric care. A prospective study cohort of women with 711 deliveries from January 1 to December 31, 1994, underwent prenatal care with modified guidelines to include: first visit at 6-12 weeks to confirm dating and obtain initial laboratory data, second visit at 16-20 weeks to obtain maternal serum alpha-fetoprotein screening, third visit at 24-28 weeks for 28-week laboratory data, fourth visit at 32 weeks, fifth visit at 36 weeks, sixth visit at 38 weeks, seventh visit at 40 weeks and weekly thereafter. Pregnancy outcomes included estimated fetal weight, gestational age at delivery, preeclampsia, Apgar score at one and five minutes and delivery mode. Neonatal outcomes, including stillbirth rate, preterm delivery rate, intraventricular hemorrhage rate, bronchopulmonary dysplasia and neonatal mortality, were evaluated. RESULTS: There were no statistically significant differences in perinatal or neonatal outcomes with decreased prenatal visits from an average of 12 per pregnancy to 8. CONCLUSION: Prenatal visits can be decreased in a teaching hospital in women with uncomplicated pregnancies from the standard number, 12-14 visits, to an average of 7 or 8 per patient without adverse perinatal outcomes.
Asunto(s)
Obstetricia/normas , Resultado del Embarazo , Atención Prenatal/normas , Adulto , Femenino , Humanos , Internado y Residencia , Evaluación de Resultado en la Atención de Salud , Embarazo , Atención Prenatal/estadística & datos numéricos , Factores de RiesgoRESUMEN
OBJECTIVE: The study's objective was to determine whether there is a difference in the plasma concentration of adrenomedullin, a hypotensive peptide, between arterial and venous umbilical cord blood of uncomplicated gestations with vaginal delivery. STUDY DESIGN: Arterial and venous umbilical cord blood was obtained immediately after vaginal delivery of 44 term infants with uncomplicated antepartum and intrapartum courses. Radioimmunoassay was performed to assess adrenomedullin concentrations in the plasma. The paired t test was used to compare arterial and venous concentrations. Significance was set at P < .05. RESULTS: Mean +/- SE adrenomedullin concentrations were 178.7 +/- 4.7 pg/mL and 190.6 +/- 6.3 pg/mL for arterial and venous cord plasma, respectively. The difference between the 2 concentrations was not significant (11.8 pg/mL, P = .09). CONCLUSION: Arterial and venous umbilical plasma concentrations of adrenomedullin do not differ significantly in uncomplicated gestations terminating with uncomplicated vaginal deliveries. This suggests that in the normal state there is neither net production nor net clearance of adrenomedullin in the placenta.
Asunto(s)
Sangre Fetal/química , Péptidos/sangre , Adrenomedulina , Femenino , Humanos , Embarazo , Valores de Referencia , Arterias Umbilicales , Venas UmbilicalesRESUMEN
A case of an intracranial cavernous angioma, which presented with headaches and seizures in a pregnant patient, is described. Diagnosis was established with magnetic resonance imaging. A computer-assisted literature search uncovered no previously reported case of intracranial cavernous angioma initially presenting during pregnancy.
Asunto(s)
Neoplasias Encefálicas/complicaciones , Hemangioma Cavernoso/complicaciones , Complicaciones Neoplásicas del Embarazo , Convulsiones/etiología , Adulto , Neoplasias Encefálicas/diagnóstico , Femenino , Hemangioma Cavernoso/diagnóstico , Humanos , Embarazo , Complicaciones Neoplásicas del Embarazo/diagnósticoRESUMEN
Multifetal pregnancy reduction (MFPR) has become a mainstay of infertility therapy as its development has allowed physicians to become more aggressive in treating patients resistant to more conservative therapies. Over the course of the past decade, MFPR has become practised in a limited number of tertiary specialty centres, which have improved its performance and very substantially lowered its risks. The majority of physicians performing MFPR employ a transabdominal needle injection of potassium chloride into the fetal thorax. Risks for pregnancy losses of patients starting with triplets and/or quadruplets reduced to twins have improved over the past decade and are not substantially different from those in patients whose pregnancy began as twins. There have been no substantiated risks of coagulopathies or damage to surviving fetuses.
Asunto(s)
Reducción de Embarazo Multifetal/métodos , Embarazo Múltiple , Ética Médica , Femenino , Humanos , Infertilidad Femenina/terapia , Selección de Paciente , Embarazo , Factores de TiempoRESUMEN
Since the advent of multiple marker screening (MMS) for Down syndrome (DS) risk calculations, limitations for twins have been apparent. Recent attempts have been made to extrapolate mathematically singleton risks to twins. Here we investigate the pattern of levels among AFP, hCG, and uE3 in twins. MMS screening data from 4,443 twin pregnancies were compared to those from 258,885 singletons from 14-21 weeks of gestational age during a 3-year period (1992-1994) in our laboratory. Medians were determined for singletons and twins, and the ratios of twins to singletons were derived. Median AFP levels for twins are approximately double those of singletons, but median increases for hCG and uE3 are less than double. The data were divided further by ethnic groups (white, African American, Asian, and Hispanic), among which there were significant variations in medians, but not in the ratios of twins to singletons. The increased serum levels of different markers in twins are not consistent across analytes, possibly reflecting independent development of different compartments. Such differences mean that a mere mathematical conversion of singleton DS risks would be imbalanced among the analytes and cannot be applied reasonably to twins. Ethnic-specific databases are as important in twins as they are in singletons.
Asunto(s)
Enfermedades en Gemelos/diagnóstico , Síndrome de Down/diagnóstico , Pruebas Genéticas/métodos , Diagnóstico Prenatal/métodos , Biomarcadores/sangre , Gonadotropina Coriónica/sangre , Estriol/sangre , Etnicidad , Femenino , Edad Gestacional , Humanos , Embarazo , Estudios Retrospectivos , alfa-Fetoproteínas/análisisRESUMEN
OBJECTIVES: Our purpose was to determine the effects of acidosis and acidosis-hypoxia on fetoplacental perfusion pressure and its response to angiotensin II. STUDY DESIGN: Perfused cotyledons from 14 placentas were studied with either an acidotic fetal circuit perfusate (n = 7) or an acidotic-hypoxic fetal circuit perfusate (n = 7). Each cotyledon's fetal vasculature was initially perfused under standard conditions and bolus injected with 1 x 10(-10) moles of angiotensin II. Fetoplacental perfusate was then replaced with either an acidotic medium (pH 6.90 to 7.00 and Po2 516 to 613 mm Hg) or an acidotic-hypoxic medium (pH 6.90 to 7.00 and Po2 20 to 25 mm Hg) followed by an angiotensin II injection. The vasculature was subsequently recovered with standard perfusate and again injected with angiotensin II. Perfusion pressures within each group were compared by one-way analysis of variance, and results were expressed as mean pressure +/- SEM. RESULTS: Resting fetoplacental perfusion pressure did not change when the fetal circuit perfusate was made acidotic (28 +/- 1 mm Hg vs 25 +/- 2 mm Hg) or acidotic-hypoxic (26 +/- 2 mm Hg vs 25 +/- 2 mm Hg). The maximal fetoplacental perfusion pressure achieved in response to angiotensin II did not differ with an acidotic perfusate (41 +/- 2 mm Hg vs 38 +/- 1 mm Hg) or with an acidotic-hypoxic perfusate (39 +/- 2 mm Hg vs 36 +/- 2 mm Hg). CONCLUSIONS: In the perfused placental cotyledon fetoplacental perfusion pressure and pressor response to angiotensin II are not affected by fetal circuit acidosis or acidosis-hypoxia. This suggests that neither fetal acidosis nor fetal acidosis combined with hypoxia has a direct effect on fetoplacental vascular tone.