RESUMEN
OBJECTIVE: The aim of the study was to determine whether use of the fetal fibronectin assay would decrease the number of admissions to labor and delivery for diagnosis and treatment of preterm labor. STUDY DESIGN: A prospective cohort design was used to compare preterm labor admissions during a 12-month period of fetal fibronectin assay use (study) against a baseline period before fetal fibronectin assay was implemented as standard protocol. Patients coming to the physician's office or hospital with signs and symptoms of preterm labor had a sample obtained for fetal fibronectin assay per labeling criteria. Comparisons were made with the Mann-Whitney U test, independent Student t test, chi2 test, and Fisher exact test. P <.05 was considered significant. RESULTS: There was no difference noted in the number of deliveries between the baseline and study years. During the study year 251 of 330 patients evaluated for preterm labor met study criteria and had the fetal fibronectin assay completed. Eight patients did not have fetal fibronectin assay results available because of specimen handling errors, leaving 243 subjects available for study. Compared with the baseline year, the study year had significantly fewer admissions for preterm labor, preterm labor admissions per patient, and prescriptions written for tocolytic agents. In addition, the length of stay per admitted patient was significantly reduced. The study population had no differences in neonatal outcomes from the baseline population in terms of deliveries at <35.0 weeks' gestation, number of admissions to the neonatal intensive care unit, neonatal intensive care unit length of stay, or days of ventilatory support per patient admitted to the neonatal intensive care unit. CONCLUSIONS: Use of the fetal fibronectin assay resulted in significantly reduced preterm labor admissions, length of stay, and prescriptions for tocolytic agents. No negative impact on neonatal outcomes was observed. Reductions in admissions for preterm labor and in charges per admission resulted in approximately $486,000 saved during the study period. A trend toward increased corticosteroid administration (for neonates ultimately admitted to the neonatal intensive care unit) was noted.
Asunto(s)
Proteínas Fetales/análisis , Fibronectinas/análisis , Trabajo de Parto Prematuro/diagnóstico , Admisión del Paciente/estadística & datos numéricos , Complicaciones Infecciosas del Embarazo/diagnóstico , Adolescente , Adulto , Betametasona/uso terapéutico , Estudios de Cohortes , Femenino , Proteínas Fetales/metabolismo , Fibronectinas/metabolismo , Glucocorticoides/uso terapéutico , Humanos , New Mexico/epidemiología , Trabajo de Parto Prematuro/tratamiento farmacológico , Trabajo de Parto Prematuro/epidemiología , Embarazo , Complicaciones Infecciosas del Embarazo/tratamiento farmacológico , Complicaciones Infecciosas del Embarazo/epidemiología , Estudios Prospectivos , Sensibilidad y Especificidad , Infecciones Estreptocócicas/diagnóstico , Infecciones Estreptocócicas/tratamiento farmacológico , Infecciones Estreptocócicas/epidemiología , Streptococcus agalactiaeRESUMEN
OBJECTIVE: The study's aim was to determine whether healthy nulliparous women with abnormal glucose tolerance during pregnancy are at increased risk for development of pregnancy-associated hypertension or preeclampsia. STUDY DESIGN: A series of 4589 healthy nulliparous women from 5 university centers were evaluated prospectively to determine whether calcium supplementation would prevent preeclampsia. Pregnancy-associated hypertension was a diastolic blood pressure > or = 90 mm Hg on 2 occasions 4 hours to 1 week apart. Pregnancy-associated proteinuria was proteinuria > or = 1+ by dipstick testing on 2 occasions 4 hours to 1 week apart, proteinuria > or = 300 mg/24 h, a protein to creatinine ratio of > or = 0.35, or a single dipstick measurement of > or = 2+. Preeclampsia was defined as pregnancy-associated hypertension and pregnancy-associated proteinuria documented within 7 days of each other. Normal glucose tolerance was a plasma glucose level < 140 mg/dL 1 hour after a 50-g oral glucose challenge. Abnormal glucose tolerance was a plasma glucose level > or = 140 mg/dL 1 hour after a 50-g oral glucose challenge followed by a 3-hour 100-g oral glucose tolerance test yielding < 2 abnormal values. Gestational diabetes mellitus was a plasma glucose level > or = 200 mg/dL 1 hour after a 50-g oral glucose challenge in the absence of an oral glucose tolerance test or > or = 2 abnormal plasma glucose values in a 3-hour 100-g oral glucose tolerance test (> or = 105 mg/dL fasting, > or = 190 mg/dL at 1 hour, > or = 165 mg/dL at 2 hours, or > or = 145 mg/dL at 3 hours). For purposes of this study women with preeclampsia were excluded from the category of pregnancy-associated hypertension. RESULTS: Calcium supplementation did not prevent pregnancy-associated hypertension or preeclampsia. Of 3689 women with complete glucose testing data, 227 (6%) had abnormal glucose tolerance and 81 (2%) had gestational diabetes mellitus. Compared with women with normal glucose tolerance, women with abnormal glucose tolerance were significantly older, had greater body mass index, and were more likely to be white non-Hispanic, to smoke, and to have private medical insurance. Among women with gestational diabetes mellitus, after adjustment for clinical center the relative risks of preeclampsia and of all hypertensive disorders were increased (relative risk 1.67, 95% confidence interval 0.92-3.05, and relative risk 1.54, 95% confidence interval 1.28-2.11, respectively). Risk ratios were not substantially reduced after further adjustment for race and body mass index (odds ratios 1.41 and 1.48, respectively). Even within the normal range, multivariate analysis demonstrated that the level of plasma glucose 1 hour after a 50-g oral glucose challenge was an important predictor of preeclampsia. CONCLUSION: Even within the normal range, the level of plasma glucose 1 hour after a 50-g oral glucose challenge was positively correlated with the likelihood of preeclampsia. Women with gestational diabetes mellitus were at increased risk for hypertensive disorders during pregnancy after adjustment for clinical center, race, and body mass index, although the increase was not statistically significant. These findings suggest that insulin resistance may play a role in the pathogenesis of the hypertensive disorders of pregnancy.
Asunto(s)
Prueba de Tolerancia a la Glucosa , Hipertensión/diagnóstico , Preeclampsia/diagnóstico , Complicaciones del Embarazo , Adulto , Glucemia/metabolismo , Índice de Masa Corporal , Calcio/administración & dosificación , Calcio/uso terapéutico , Diabetes Gestacional/diagnóstico , Método Doble Ciego , Femenino , Humanos , Hipertensión/prevención & control , Seguro de Salud , Cinética , Preeclampsia/prevención & control , Embarazo , Estudios Prospectivos , Proteinuria , Grupos Raciales , Factores de RiesgoRESUMEN
BACKGROUND: The incidence of genital herpes simplex virus (HSV) has increased in recent years, particularly among women of reproductive age. This places more neonates at risk for severe morbidity and mortality. Treatment recommendations for primary disease in pregnancy are lacking, particularly for those who acquire. HSV remote from term. CASE: A patient at 17 weeks of gestation carrying dichorionic twins developed primary herpes with subsequent vertical transmission of the virus and significant neonatal morbidity. CONCLUSION: Data regarding risks and benefits of treatments such as acyclovir and immunoprophylaxis are lacking at a time when the incidence of HSV infection is on the rise.
RESUMEN
The results of ten clinical trials suggest that supplemental calcium may prevent preeclampsia. However, methodologic problems and differences in study design limit the acceptance of the results and their relevance to other patient populations. Many of the trials were conducted in countries where, unlike the United States, the usual daily diet contained little calcium. Moreover, none of the trials has reported the outcome of systematic surveillance for urolithiasis, a potential complication of calcium supplementation. In response to the need for a thorough evaluation of the effects of calcium supplementation for the prevention of preeclampsia in the United States, the trial of Calcium for Preeclampsia Prevention (CPEP) was undertaken at five university medical centers. Healthy nulliparous patients were randomly assigned to receive either 2 g supplemental calcium daily (n = 2295) or placebo (n = 2294) in a double-blind study. Study tablets were administered beginning from 13 to 21 completed weeks of gestation and continued until the termination of pregnancy. CPEP employed detailed diagnostic criteria, standardized techniques of measurement, and systematic surveillance for the major study endpoints and for urolithiasis. The nutrient intake of each patient was assessed at randomization and at 32-33 weeks gestation. This report describes the study rationale, design, and methods.
Asunto(s)
Calcio/uso terapéutico , Estudios Multicéntricos como Asunto/métodos , Preeclampsia/prevención & control , Ensayos Clínicos Controlados Aleatorios como Asunto/métodos , Proyectos de Investigación , Calcio/efectos adversos , Método Doble Ciego , Femenino , Humanos , Hipertensión/diagnóstico , Sistemas de Información Administrativa , Estudios Multicéntricos como Asunto/estadística & datos numéricos , Evaluación Nutricional , Cooperación del Paciente , Selección de Paciente , Placebos , Preeclampsia/diagnóstico , Embarazo , Complicaciones Cardiovasculares del Embarazo/diagnóstico , Control de Calidad , Distribución Aleatoria , Ensayos Clínicos Controlados Aleatorios como Asunto/estadística & datos numéricos , Tamaño de la Muestra , Índice de Severidad de la Enfermedad , Estadística como Asunto , Estados Unidos , Cálculos Urinarios/diagnóstico , Cálculos Urinarios/etiología , Cálculos Urinarios/prevención & controlRESUMEN
OBJECTIVE: To evaluate the use of the Auto Suture Poly CS-57 disposable surgical stapler to determine if the device offers any advantages over suture closure of the uterus. METHODS: A matched case-control study design was used. Operative time, estimated blood loss, change in hematocrit, incidence of postoperative endometritis, length of stay, and total patient costs were compared. Patients were recruited from a university hospital setting and a private practice. RESULTS: There were 288 patients in the study, 144 in the staple group and 144 matched patients in the standard hysterotomy control group. Patients did not differ in age, parity, gestational age, number of primary or repeat operations, anesthesia, infant weights, or outcomes. Comparing the patients in the staple group and the control group, there was no significant difference in operative time (63.7 +/- 22.9 versus 62.0 +/- 22.3 minutes, staple group versus controls, respectively), estimated blood loss (822 +/- 338 versus 879 +/- 318 mL), change in hematocrit (-5.9 versus -6.5 volume percent), incidence of postoperative endometritis (15 versus 20%), length of stay (4.1 +/-1.3 versus 4.0 +/- 2.2 days), or total cost ($4490 +/- 1544 versus $3997 +/- 1117). Comparing patients operated upon by residents in the university to those operated upon by the private attending physicians, there were no significant differences noted in the above-mentioned variables between stapled and sutured patients. CONCLUSION: Compared with the usual suture technique for cesarean delivery, the uterine stapling device used in this study was not associated with a significant decrease in the incidence of postoperative anemia, infection, length of hospital stay, or cost. This device appears to offer no advantage over traditional hysterotomy and repair.
Asunto(s)
Cesárea , Engrapadoras Quirúrgicas , Técnicas de Sutura , Útero/cirugía , Estudios de Casos y Controles , Cesárea/métodos , Estudios de Evaluación como Asunto , Femenino , Humanos , Complicaciones Posoperatorias , Embarazo , Resultado del TratamientoRESUMEN
The null hypothesis of this study was that a prematurity prevention program that uses computerized prenatal risk assessment, educational interventions administered on a weekly basis by telephone, enhanced nutritional support, and referral to a perinatologist whenever necessary will result in no difference in the number of neonates admitted to the neonatal intensive care unit (NICU). A retrospective cohort study was designed to compare the number of admissions to the NICU for the 12 months before initiation of the prematurity prevention program with those during the first 12 months of the full working program. Compared with the year before program initiation, the prematurity prevention program resulted in a 56% reduction in the number of NICU admissions, a 49% reduction in preterm deliveries with subsequent admission of the infant to the NICU, and a 59% reduction in NICU hospital days. In addition, there was a 38% reduction in preterm deliveries caused solely by preterm labor. The null hypothesis is rejected because a comprehensive prematurity prevention program resulted in a significant reduction in NICU admissions, preterm deliveries with admission to the NICU, and NICU hospital days.
Asunto(s)
Unidades de Cuidado Intensivo Neonatal/estadística & datos numéricos , Trabajo de Parto Prematuro/prevención & control , Atención Prenatal , Estudios de Cohortes , Femenino , Humanos , Recién Nacido , Recien Nacido Prematuro , Unidades de Cuidado Intensivo Neonatal/economía , Trabajo de Parto Prematuro/economía , Trabajo de Parto Prematuro/terapia , Admisión del Paciente/economía , Admisión del Paciente/estadística & datos numéricos , Embarazo , Atención Prenatal/economía , Atención Prenatal/tendencias , Evaluación de Programas y Proyectos de Salud , Estudios RetrospectivosRESUMEN
BACKGROUND: Hepatitis C virus (HCV) is now recognized as the cause of 90% of non-A, non-B (NANB) hepatitis. This virus is responsible for a large percentage of chronic persistent and chronic active hepatitis in the United States. Parenteral and sexual transmission are well described, so a significant population of pregnant patients is at risk. Vertical transmission of the virus to the fetus is dependent upon the level of maternal viremia. CASE: The cases described in the following report demonstrate that fulminant disease may present in pregnancy. They also demonstrate the cofactors promoting the severity of illness, methods of diagnosis, potential treatment, and outcome of the infection. CONCLUSION: HCV may be encountered in pregnancy. Although most acute-phase illness will be self limiting, some patients will manifest liver failure during gestation. Because vertical transmission to the fetus is possible, the pediatrician should be informed of the maternal disease. Chronic hepatitis is almost the rule rather than the exception, so patients require close postpartum follow-up. Interferon, which may alter the course of the chronic disease, has been used on rare occasions in pregnancy.
RESUMEN
Amphetamine and methamphetamine abuse complicate a significant number of pregnancies. This case report details medical prescription of dextroamphetamine during a complicated pregnancy. A review of the literature is included regarding fetal risks of dextroamphetamine and methamphetamine exposure.
Asunto(s)
Dextroanfetamina/uso terapéutico , Metanfetamina , Complicaciones del Embarazo/rehabilitación , Trastornos Relacionados con Sustancias/rehabilitación , Adulto , Dextroanfetamina/efectos adversos , Femenino , Humanos , EmbarazoRESUMEN
We reported previously that plasma levels, urinary excretion, and metabolic production of cyclic guanosine 3',5'-monophosphate (cGMP) are increased in gravid rats, and postulated that endogenous nitric oxide (NO), a potent vasodilator and immune modulator, may mediate this change. Four lines of evidence are now presented demonstrating increased biosynthesis of NO during pregnancy in rats: 1) Urinary excretion and plasma levels of the stable NO metabolite, nitrate, are elevated in pregnant rats; urinary excretion of nitrate is increased in pseudopregnant rats. 2) The urinary excretion of cGMP also increases during pregnancy and pseudopregnancy, paralleling the rise in urinary nitrate excretion. 3) Chronic treatment with the NO synthase inhibitor, NG-nitroarginine methyl ester (NAME), inhibits the increase in urinary nitrate excretion. 4) Nitric oxide hemoglobin is detected by electron paramagnetic resonance spectroscopy in the blood of pregnant, but not in nonpregnant, rats. The results show endogenous NO production is increased in gravid rats. This finding raises the possibility that NO may contribute to maternal vasodilation and uterine immune suppression of normal pregnancy.
Asunto(s)
Óxido Nítrico/metabolismo , Preñez/metabolismo , Aminoácido Oxidorreductasas/antagonistas & inhibidores , Animales , Arginina/análogos & derivados , Arginina/farmacología , GMP Cíclico/sangre , GMP Cíclico/orina , Dieta , Femenino , Masculino , NG-Nitroarginina Metil Éster , Nitratos/administración & dosificación , Nitratos/sangre , Nitratos/orina , Óxido Nítrico Sintasa , Embarazo , RatasRESUMEN
Sixty-eight women admitted with the diagnosis of preterm premature rupture of membranes (PROM) and a latency period of at least 48 hours were followed expectantly. Fetal surveillance consisted of daily kick counts, daily nonstress test (NST), and fetal biophysical profile every 48-72 hours. Patients were delivered as a result of spontaneous labor, clinical chorioamnionitis, fetal distress, or attainment of 37 weeks' gestation. No corticosteroids, tocolytics, or prophylactic antibiotics were used. The last biophysical profile and the last NST before delivery were evaluated for each patient. There was no statistically significant association between chorioamnionitis or fetal infection and the following: 1) a low biophysical profile (score of 6 or lower), 2) a low biophysical profile that included a nonreactive NST and absent fetal breathing movements, or 3) a nonreactive NST. We conclude that the biophysical profile and the NST are poor predictors of perinatal infectious complications.
Asunto(s)
Corioamnionitis/diagnóstico , Enfermedades Fetales/diagnóstico , Rotura Prematura de Membranas Fetales/complicaciones , Monitoreo Fetal/métodos , Infecciones/diagnóstico , Adolescente , Adulto , Fenómenos Biofísicos , Biofisica , Corioamnionitis/etiología , Corioamnionitis/microbiología , Femenino , Enfermedades Fetales/etiología , Enfermedades Fetales/microbiología , Humanos , Infecciones/etiología , Valor Predictivo de las Pruebas , Embarazo , Resultado del Embarazo , Factores de TiempoRESUMEN
Fetal triploidy can be suspected but not diagnosed based on ultrasonographic findings. A patient was diagnosed with fetal triploidy in the second trimester.
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Aberraciones Cromosómicas/diagnóstico , Cariotipificación/métodos , Poliploidía , Diagnóstico Prenatal/métodos , Adulto , Amniocentesis , Aberraciones Cromosómicas/diagnóstico por imagen , Aberraciones Cromosómicas/genética , Trastornos de los Cromosomas , Femenino , Humanos , Embarazo , Ultrasonografía Prenatal/métodosRESUMEN
There are no absolute objective diagnostic criteria for cervical incompetence. Abdominal and endovaginal ultrasonographic assessment of endocervical length, both of which have been associated with technical problems, have been used to establish the diagnosis. Cervical cerclage may be useful in preventing silent cervical dilatation; however, no prospective trials with and without cerclage have been performed when endocervical shortening has been demonstrated by ultrasonography.
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Cuello del Útero/fisiología , Embarazo/fisiología , Ultrasonografía Prenatal/métodos , Incompetencia del Cuello del Útero/diagnóstico por imagen , Femenino , Humanos , Tercer Trimestre del Embarazo , Incompetencia del Cuello del Útero/terapia , VaginaRESUMEN
Fetal trauma resulting in acute anemia after maternal blunt abdominal trauma is a rare but potentially lethal condition. We recently managed such a case with the use of fetal intravascular transfusion.