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Porreco R, Garite TJ, Combs CA, Maurel K, Huls CK, Baker S, Fortner KB, Longo SA, Nageotte M, Lewis D, Tran L. Booster course of antenatal corticosteroids after preterm prelabor rupture of membranes: a double-blind randomized trial. Am J Obstet Gynecol MFM 2023; 5:100896. [PMID: 36796641 DOI: 10.1016/j.ajogmf.2023.100896] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 01/31/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND Preterm prelabor rupture of membranes is a leading cause of preterm birth and is responsible for 18% to 20% of perinatal deaths in the United States. An initial course of antenatal corticosteroids has been shown to reduce morbidity and mortality in patients with preterm prelabor rupture of membranes. For patients who remain undelivered for 7 days or more after the initial course of antenatal corticosteroids, it is uncertain whether a booster course of antenatal corticosteroids reduces neonatal morbidity or increases the infection risk. The American College of Obstetricians and Gynecologists has concluded that the current evidence is insufficient to make a recommendation. OBJECTIVE This study aimed to evaluate if a single booster course of antenatal corticosteroids improves neonatal outcomes after preterm prelabor rupture of membranes. STUDY DESIGN We conducted a multicenter, placebo-controlled randomized clinical trial. The inclusion criteria were preterm prelabor rupture of membranes, gestational age of 24.0 to 32.9 weeks, singleton, initial antenatal corticosteroid course administered at least 7 days before randomization, and planned expectant management. Consenting patients were randomized in gestational age blocks to either receive booster antenatal corticosteroids (12 mg betamethasone every 24 hours for 2 days) or a saline placebo. The primary outcome was composite neonatal morbidity or death. A sample size of 194 patients was calculated to yield 80% power at P<.05 to detect a reduction in primary outcome from 60% in placebo group to 40% in antenatal corticosteroids group. RESULTS From April 2016 through August 2022, 194 patients consented and were randomized (47% of 411 eligible patients). Intent-to-treat analysis was performed on 192 patients (2 placebo patients left hospital, outcomes unknown). The groups had similar baseline characteristics. The primary outcome occurred in 64% of patients who received booster antenatal corticosteroids vs in 66% of patients who received the placebo (odds ratio, 0.82; 95% confidence interval, 0.43-1.57; gestational age-stratified Cochran-Mantel-Haenszel test). Individual components of the primary outcome and secondary neonatal and maternal outcomes were not significantly different between the antenatal corticosteroids and placebo groups. Specifically, chorioamnionitis (22% vs 20%), postpartum endometritis (1% vs 2%), wound infections (2% vs 0%), and proven neonatal sepsis (5% vs 3%) were not different between the groups. CONCLUSION A booster course of antenatal corticosteroids at least 7 days after the first antenatal corticosteroids course in patients with preterm prelabor rupture of membranes did not improve neonatal morbidity or any other outcome in this adequately-powered, double-blind randomized clinical trial. Booster antenatal corticosteroids did not increase maternal or neonatal infection.
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Affiliation(s)
- Richard Porreco
- Obstetrix Medical Group of Colorado, Presbyterian St. Luke's Medical Center, Denver, CO (Dr Porreco).
| | - Thomas J Garite
- Pediatrix Center for Research, Education, Quality and Safety, Sunrise, FL (Drs Garite and Combs and Ms Maurel); Department of Obstetrics and Gynecology, University of California, Irvine, Irvine, CA (Dr Garite); Sera Prognostics, Salt Lake City, UT (Dr Garite)
| | - C Andrew Combs
- Pediatrix Center for Research, Education, Quality and Safety, Sunrise, FL (Drs Garite and Combs and Ms Maurel); Obstetrix of San Jose, Campbell, CA (Dr Combs)
| | - Kimberley Maurel
- Pediatrix Center for Research, Education, Quality and Safety, Sunrise, FL (Drs Garite and Combs and Ms Maurel)
| | - Christopher Kevin Huls
- Phoenix Perinatal Associates, Mesa, AZ (Dr Huls); College of Medicine, Banner - University Medical Center, The University of Arizona, Phoenix, AZ (Dr Huls)
| | - Susan Baker
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of South Alabama, Mobile, AL (Dr Baker)
| | - Kimberley B Fortner
- University of Tennessee Graduate School of Medicine, Knoxville, TN (Dr Fortner)
| | - Sherri A Longo
- Maternal-Fetal Medicine, Ochsner Health, New Orleans, LA (Dr Longo)
| | - Michael Nageotte
- Maternal-Fetal Medicine Specialists of Southern California, Women's Miller Children's and Women's Hospital, Long Beach, CA (Dr Nageotte)
| | - David Lewis
- Department of Obstetrics and Gynecology, Louisiana State University Health Science Center, Shreveport, LA (Dr Lewis)
| | - Lan Tran
- Maternal-Fetal-Medicine Specialists of Puget Sound, Seattle, WA (Dr Tran)
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Stafford IA, Garite TJ, Maurel K, Combs CA, Heyborne K, Porreco R, Nageotte M, Baker S, Gopalani S, Dola C, How H, Das AF. Cervical Pessary versus Expectant Management for the Prevention of Delivery Prior to 36 Weeks in Women with Placenta Previa: A Randomized Controlled Trial. AJP Rep 2019; 9:e160-e166. [PMID: 31044098 PMCID: PMC6491366 DOI: 10.1055/s-0039-1687871] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 02/21/2019] [Indexed: 02/06/2023] Open
Abstract
Objective This multicenter randomized controlled trial compared cervical pessary (CP) versus expectant management (EM) in women with placenta previa between 22.0 and 32.0 in prolonging gestation until ≥ 36.0 weeks' gestation. Study Design This study took place from November 2016 to June 2018. Women were randomized to receive either the Bioteque CP or EM. The pessary was removed at ≥ 36.0 weeks unless indicated. The primary outcome was gestational age (GA) at delivery, with secondary outcomes including need for transfusion, number and duration of antepartum admissions, type of delivery, and neonatal outcomes. A total of 140 patients were needed to show a 3-week prolongation of pregnancy in the pessary group; however, the trial was stopped early due to budgetary issues. Results Of the 33 eligible women, 17 were enrolled. Although not statistically significant, the mean GA at delivery in the CP group was greater than women in the EM group (36.5 ± 1.23 vs. 36.0 ± 2.0; p = 0.1673). The number and duration of antepartum admissions was greater in the EM group (2.7 ± 0.58 vs. 16.0 ± 22.76 days; p = 0.1264) as well. Conclusion Although the study was underpowered to determine the primary outcome, safety and feasibility of CP in pregnancies complicated with previa were demonstrated.
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Affiliation(s)
- Irene A Stafford
- Department of Obstetrics and Gynecology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas.,Touro Infirmary, Louisiana State University Health Science Center, New Orleans, Louisiana
| | - Thomas J Garite
- University of California, Irvine, Orange, California.,The Center for Research, Education, Quality and Safety, Mednax, Inc., Sunrise, Florida
| | - Kimberly Maurel
- The Center for Research, Education, Quality and Safety, Mednax, Inc., Sunrise, Florida
| | - C Andrew Combs
- The Center for Research, Education, Quality and Safety, Mednax, Inc., Sunrise, Florida.,Obstetrix Medical Group, San Jose, California
| | - Kent Heyborne
- Denver Health and Hospital Authority, Denver, Colorado
| | | | | | - Susan Baker
- University of South Alabama Children's and Women's Hospital, Mobile, Alabama
| | | | - Chi Dola
- Tulane Lakeside Hospital for Women and Children, New Orleans, Louisiana
| | - Helen How
- Norton Hospital, Louisville, Kentucky
| | - Anita F Das
- Das Consulting Group, San Francisco, California
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Garite TJ, Combs CA, Maurel K, Das A, Huls K, Porreco R, Reisner D, Lu G, Bush M, Morris B, Bleich A, Mallory K, Bono J, Artis D, Weis G, Rael J, Lech J, Swearingen K, Braescu A, Games M, Mullen G, Engelke C, Yeoman J, Rigdon J, Tyler W, Garza F. A multicenter prospective study of neonatal outcomes at less than 32 weeks associated with indications for maternal admission and delivery. Am J Obstet Gynecol 2017; 217:72.e1-72.e9. [PMID: 28267444 DOI: 10.1016/j.ajog.2017.02.043] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 02/17/2017] [Accepted: 02/24/2017] [Indexed: 01/03/2023]
Abstract
BACKGROUND Counseling for patients with impending premature delivery traditionally has been based primarily on the projected gestational age at delivery. There are limited data regarding how the indications for the preterm birth affect the neonatal outcome and whether this issue should be taken into account in decisions regarding management and patient counseling. OBJECTIVE We performed a prospective study of pregnancies resulting in premature delivery at less than 32 weeks to determine the influence of both the indications for admission and their associated indications for delivery on neonatal mortality and complications of prematurity. STUDY DESIGN This is a multicenter, prospective study in 10 hospitals where all data from the neonatal intensive care unit routinely was imported to a deidentified data warehouse. Maternal data were collected prospectively at or near the time of delivery. Eligible subjects included singleton deliveries in these hospitals between 23 0/7 and 31 6/7 weeks. The primary hypothesis of the study was to determine whether there was a difference in the primary outcome, which was defined as neonatal composite morbidity, between those neonates delivered after admission for premature labor vs premature rupture of membranes, because these were expected to be the 2 most frequent diagnoses leading to premature birth. The sample size was calculated based on a 10% difference in outcomes for these 2 entities. We based this hypothesis on the knowledge that premature rupture of membranes has a greater incidence of intra-amniotic infection and inflammation than premature labor and that outcomes for premature neonates are worse when delivery is associated with intra-amniotic infection. Additional outcomes were analyzed for all other indications for admission and delivery. Composite morbidity was defined as ≥1 of the following: respiratory distress syndrome (oxygen requirement, clinical diagnosis, and consistent chest radiograph), bronchopulmonary dysplasia (requirement for oxygen support at 28 days of life), severe intraventricular hemorrhage (grades 3 or 4), periventricular leukomalacia, blood culture-proven sepsis present within 72 hours of birth, necrotizing enterocolitis, or neonatal death before discharge from the hospital. A secondary composite of serious neonatal morbidity also was defined prospectively. RESULTS The study included 1089 mother/baby pairs. Composite morbidity between those with premature labor (77.2%) and premature rupture of membranes (73.2%) was not significantly different (P = .29). A few neonatal complications were associated with indications for admission and delivery, but on logistic regression adjusting for gestational age and other confounders, suspected intrauterine growth restriction was the only indication for admission or delivery associated with an increase in serious morbidity (odds ratio 4.5, [2.1 to 9.8], P < .003). Other factors not related to the indications for admission including cesarean delivery, and low 5-minute Apgar were associated with an increase in morbidity. CONCLUSION Studies of many single factors related to the indications for preterm delivery have been shown to be associated with adverse neonatal outcome. In this study evaluating all of the most frequent indications, however, we found only suspected intrauterine growth restriction as an indication for admission and delivery was found to be so. Thus, it seems that in almost all situations counseling patients can be based primarily on gestational age along with other factors including estimated fetal weight, sex, race, plurality, and completion of a course of antenatal corticosteroids.
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Combs CA, Garite TJ, Maurel K, Abril D, Das A, Clewell W, Heyborne K, How H, Huang W, Lewis D, Lu G, Miller H, Nageotte M, Porreco R, Sheikh A, Tran L. 17-hydroxyprogesterone caproate for preterm rupture of the membranes: a multicenter, randomized, double-blind, placebo-controlled trial. Am J Obstet Gynecol 2015; 213:364.e1-12. [PMID: 25979614 DOI: 10.1016/j.ajog.2015.05.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Accepted: 05/05/2015] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Preterm rupture of membranes (PROM) is associated with an increased risk of preterm birth and neonatal morbidity. Prophylactic 17-hydroxyprogesterone caproate (17OHP-C) reduces the risk of preterm birth in some women who are at risk for preterm birth. We sought to test whether 17OHP-C would prolong pregnancy or improve perinatal outcome when given to mothers with preterm rupture of the membranes. STUDY DESIGN This is a multicenter, double-blind, placebo-controlled, randomized clinical trial. The study included singleton pregnancies with gestational ages from 23(0/7) to 30(6/7) weeks at enrollment, documented PROM, and no contraindication to expectant management. Consenting women were assigned randomly to receive weekly intramuscular injections of 17OHP-C (250 mg) or placebo. The primary outcome was continuation of pregnancy until a favorable gestational age, which was defined as either 34(0/7) weeks of gestation or documentation of fetal lung maturity at 32(0/7) to 33(6/7) weeks of gestation. The 2 prespecified secondary outcomes were interval from randomization to delivery and composite adverse perinatal outcome. The planned sample size was 222 total women. RESULTS From October 2011 to April 2014, 152 women were enrolled; 74 women were allocated randomly to 17OHP-C, and 78 were allocated randomly to placebo. The trial was stopped when results of a planned interim analysis suggested that continuation was futile. The primary outcome was achieved in 3% of the 17OHP-C group and 8% of the placebo group (P = .18). There was no significant between-group difference in the prespecified secondary outcomes, randomization-to-delivery interval (17.1 ± 16.1 vs 17.0 ± 15.8 days, respectively; P = .76) or composite adverse perinatal outcome (63% vs 61%, respectively; P = .93). No significant differences were found in other outcomes, which included rates of chorioamnionitis, postpartum endometritis, cesarean delivery, individual components of the composite outcome, or prolonged neonatal length of stay. CONCLUSION Compared with placebo, weekly 17OHP-C injections did not prolong pregnancy or reduce perinatal morbidity in patients with PROM in this trial.
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Affiliation(s)
- C Andrew Combs
- Center for Research, Education, and Quality, Obstetrix, Mednax National Medical Group, Sunrise, FL; Obstetrix Medical Group, San Jose, CA.
| | - Thomas J Garite
- Center for Research, Education, and Quality, Obstetrix, Mednax National Medical Group, Sunrise, FL; Department of Obstetrics and Gynecology, University of California, Irvine, School of Medicine, Irvine, CA
| | - Kimberly Maurel
- Center for Research, Education, and Quality, Obstetrix, Mednax National Medical Group, Sunrise, FL
| | - Diana Abril
- Center for Research, Education, and Quality, Obstetrix, Mednax National Medical Group, Sunrise, FL
| | | | - William Clewell
- Obstetrix Medical Group, Phoenix Perinatal Associates, Phoenix, AZ
| | | | | | | | - David Lewis
- Department of Obstetrics and Gynecology, University of South Alabama School of Medicine, Mobile, AL
| | - George Lu
- Obstetrix Medical Group, Kansas City, MO
| | | | | | | | | | - Lan Tran
- Obstetrix Medical Group, Seattle, WA
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Combs CA, Garite TJ, Lapidus JA, Lapointe JP, Gravett M, Rael J, Amon E, Baxter JK, Brady K, Clewell W, Eddleman KA, Fortunato S, Franco A, Haas DM, Heyborne K, Hickok DE, How HY, Luthy D, Miller H, Nageotte M, Pereira L, Porreco R, Robilio PA, Simhan H, Sullivan SA, Trofatter K, Westover T, Garite TJ, Maurel K, Abril D, Combs CA. Detection of microbial invasion of the amniotic cavity by analysis of cervicovaginal proteins in women with preterm labor and intact membranes. Am J Obstet Gynecol 2015; 212:482.e1-482.e12. [PMID: 25687566 DOI: 10.1016/j.ajog.2015.02.007] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Revised: 01/12/2015] [Accepted: 02/09/2015] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Microbial invasion of the amniotic cavity (MIAC) is common in early preterm labor and is associated with maternal and neonatal infectious morbidity. MIAC is usually occult and is reliably detected only with amniocentesis. We sought to develop a noninvasive test to predict MIAC based on protein biomarkers in cervicovaginal fluid (CVF) in a cohort of women with preterm labor (phase 1) and to validate the test in an independent cohort (phase 2). STUDY DESIGN This was a prospective study of women with preterm labor who had amniocentesis to screen for MIAC. MIAC was defined by positive culture and/or 16S ribosomal DNA results. Nine candidate CVF proteins were analyzed by enzyme-linked immunosorbent assay. Logistic regression was used to identify combinations of up to 3 proteins that could accurately classify the phase 1 cohort (N = 108) into those with or without MIAC. The best models, selected by area under the curve (AUC) of the receiver operating characteristic curve in phase 1, included various combinations of interleukin (IL)-6, chemokine (C-X-C motif) ligand 1 (CXCL1), alpha fetoprotein, and insulin-like growth factor binding protein-1. Model performance was then tested in the phase 2 cohort (N = 306). RESULTS MIAC was present in 15% of cases in phase 1 and 9% in phase 2. A 3-marker CVF model using IL-6 plus CXCL1 plus insulin-like growth factor binding protein-1 had AUC 0.87 in phase 1 and 0.78 in phase 2. Two-marker models using IL-6 plus CXCL1 or alpha fetoprotein plus CXCL1 performed similarly in phase 2 (AUC 0.78 and 0.75, respectively), but were not superior to CVF IL-6 alone (AUC 0.80). A cutoff value of CVF IL-6 ≥463 pg/mL (which had 81% sensitivity in phase 1) predicted MIAC in phase 2 with sensitivity 79%, specificity 78%, positive predictive value 38%, and negative predictive value 97%. CONCLUSION High levels of IL-6 in CVF are strongly associated with MIAC. If developed into a bedside test or rapid laboratory assay, cervicovaginal IL-6 might be useful in selecting patients in whom the probability of MIAC is high enough to warrant amniocentesis or transfer to a higher level of care. Such a test might also guide selection of potential subjects for treatment trials.
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Combs CA, Gravett M, Garite T, Hickok D, Porreco R, Lapidus J, Grove T, Rael J, Miller H, Clewell W, Luthy D, Pereira L, Nageotte M, Robilio D, Fortunato S, Simhan H, Baxter J, Amon E, Franco A, Trofatter K, Heyborne K. 73: Intramniotic inflammation may be more important than the presence of microbes as a determinant of perinatal outcome in preterm labor. Am J Obstet Gynecol 2013. [DOI: 10.1016/j.ajog.2012.10.238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Combs CA, Garite TJ, Maurel K, Mallory K, Edwards RK, Lu G, Porreco R, Das A. 17-Hydroxyprogesterone caproate to prolong pregnancy after preterm rupture of the membranes: early termination of a double-blind, randomized clinical trial. BMC Res Notes 2011; 4:568. [PMID: 22206581 PMCID: PMC3260323 DOI: 10.1186/1756-0500-4-568] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2011] [Accepted: 12/29/2011] [Indexed: 12/03/2022] Open
Abstract
Background Progestational agents may reduce the risk of preterm birth in women with various risk factors. We sought to test the hypothesis that a weekly dose of 17-hydroxyprogesterone caproate (17P) given to women with preterm rupture of the membranes (PROM) will prolong pregnancy and thereby reduce neonatal morbidity. Methods Double-blind, placebo-controlled randomized clinical trial. Women with PROM at 23.0 to 31.9 weeks of gestation were randomly assigned to receive a weekly intramuscular injection of 17P (250 mg in 1 mL castor oil) or placebo (1 mL castor oil). The primary outcome was the rate of continuing the pregnancy until 34.0 weeks of gestation or until documentation of fetal lung maturity at 32.0 to 33.9 weeks of gestation. Planned secondary outcomes were duration of latency period and rate of composite neonatal morbidity. Enrollment of 111 participants per group, 222 total, was planned to yield 80% power to detect an increase in the primary outcome from 30% with placebo to 50% with 17P. Results Twelve women were enrolled of whom 4 were randomly assigned to receive 17P and 8 to receive placebo. The trial was terminated prematurely because of two separate issues related to the supply of 17P. No adverse events attributable to 17P were identified. Conclusion Because of premature termination, the trial does not have adequate statistical power to evaluate efficacy or safety of 17P in women with PROM. Nonetheless, ethical principles dictate that we report the results, which may contribute to possible future metaanalyses and systematic reviews. Trial Registration ClinicalTrials.gov: NCT01119963 Supported by a research grant from the Center for Research, Education, and Quality, Pediatrix Medical Group, Sunrise, FL
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Affiliation(s)
- C Andrew Combs
- Obstetrix Medical Group, Center for Research, Quality, and Education, San Jose, CA, USA.
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Combs C, Hickok D, Garite T, Porreco R, Naranatt P. 640: 16S ribosomal DNA PCR identifies a greater number and broader diversity of microorganisms associated with intraamniotic infection than culture alone. Am J Obstet Gynecol 2009. [DOI: 10.1016/j.ajog.2009.10.505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Combs C, Hickok D, Garite T, Porreco R, Hollemon D, Harden L. 442: Intraamniotic infection not reliably predicted by clinical signs and symptoms. Am J Obstet Gynecol 2009. [DOI: 10.1016/j.ajog.2009.10.608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Heyborne K, Garite T, Porreco R, Abril D, Phair K. Optimal management of monoamniotic twins. Am J Obstet Gynecol 2003. [DOI: 10.1016/j.ajog.2003.10.217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Wachtel SS, Sammons D, Manley M, Wachtel G, Twitty G, Utermohlen J, Phillips OP, Shulman LP, Taron DJ, Müller UR, Koeppen P, Ruffalo TM, Addis K, Porreco R, Murata-Collins J, Parker NB, McGavran L. Fetal cells in maternal blood: recovery by charge flow separation. Hum Genet 1996; 98:162-6. [PMID: 8698333 DOI: 10.1007/s004390050181] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Fetal blood cells can be recovered from the maternal circulation by charge flow separation (CFS), a method that obviates the risks associated with amniocentesis and chorionic villus sampling. By CFS, we processed blood samples from 13 women carrying male fetuses, 2 carrying fetuses with trisomy 21, and 1 who had delivered a stillborn infant with trisomy 18. On average more than 2000 fetal nucleated red blood cells were recovered per 20-ml sample of maternal blood. Recovery of fetal cells was confirmed by fluorescence in situ hybridization with probes for chromosomes Y, 18 and 21. After culturing of CFS-processed cells, amplification by the polymerase chain reaction revealed Y-chromosomal DNA in clones from four of six women bearing male fetuses, but not in clones from three women bearing female fetuses.
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Affiliation(s)
- S S Wachtel
- Department of Obstetrics and Gynecology, University of Tennessee, Memphis 38103, USA
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Draper D, McGregor J, Hall J, Jones W, Beutz M, Heine RP, Porreco R. Elevated protease activities in human amnion and chorion correlate with preterm premature rupture of membranes. Am J Obstet Gynecol 1995; 173:1506-12. [PMID: 7503192 DOI: 10.1016/0002-9378(95)90640-1] [Citation(s) in RCA: 72] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVES The mechanism(s) of preterm premature rupture of fetal membranes resulting in preterm birth remains unknown. Studies suggest that fetal membranes are susceptible to weakening by protease attack and that collagenases may be active at the site of rupture. In this study fetal membranes from women delivered after preterm premature rupture of membranes were compared with control membranes and analyzed qualitatively and quantitatively for protease activities. STUDY DESIGN Fourteen membranes from women with preterm premature rupture of membranes and nine membranes from women delivered preterm without premature rupture of membranes or otherwise normal women delivered at term vaginally or by cesarean section were studied. Zymogram gel electrophoresis with gelatin incorporation was used to assess the number and apparent molecular weights of protease activities. Functional and quantitative studies of protease activity were measured by fluorescent substrate cleavage. RESULTS Zymogram gel electrophoresis studies demonstrated the presence of five to seven different protease bands in preterm premature rupture of membranes samples, whereas control membranes demonstrated only one to three protease bands. Fluorescent studies of protease activity demonstrated a 10- to 40-fold increase in activity in membranes from women with preterm premature rupture of membranes compared with normal control membranes. Studies with protease inhibitors suggest that most of the activity is due to metalloproteinases. CONCLUSION In membranes from women with preterm premature rupture of membranes there appears to be a general increase in the amount of protease activity and increased numbers of putatively different proteases. Increased activity or deregulated protease control may mediate preterm premature rupture of membranes and be a potentially remediable cause of preterm birth.
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Affiliation(s)
- D Draper
- Department Obstetrics and Gynecology, University of Colorado Health Sciences Center, USA
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Schatz M, Zeiger RS, Hoffman CP, Harden K, Forsythe A, Chilingar L, Saunders B, Porreco R, Sperling W, Kagnoff M. Perinatal outcomes in the pregnancies of asthmatic women: a prospective controlled analysis. Am J Respir Crit Care Med 1995; 151:1170-4. [PMID: 7697248 DOI: 10.1164/ajrccm/151.4.1170] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Prior studies have found an increased incidence of adverse perinatal outcomes of pregnancies in asthmatic mothers, but these studies have been poorly controlled for asthma therapy and other confounding factors. The purpose of this study was to assess perinatal outcomes in actively managed pregnant asthmatic women as compared with matched nonasthmatic controls. Using an inception cohort design, we studied a volunteer sample of 486 pregnant (< 28 wk) women with documented asthma and 486 pregnant nonasthmatic controls with normal pulmonary function. Cases and controls were matched for age, smoking status, parity, and year of delivery. Asthma was managed with step therapy to prevent acute asthmatic episodes and asthma symptoms that interfered with sleep or normal activity. Chronic hypertension was significantly more common (p = 0.007) in asthmatic subjects (3.7%) than in matched controls (1.0%). However, no significant differences in incidences of preeclampsia, perinatal mortality, preterm births, low-birth-weight infants, intrauterine growth retardation, or congenital malformations were observed in the pregnancies of the asthmatic women as compared with the matched controls. Trends were observed toward relationships between more severe asthma requiring emergency therapy or corticosteroids and increased incidences of preeclampsia and low-birth-weight infants, but these associations were not statistically significant. These data suggest that the overall perinatal prognosis for women with actively managed asthma during pregnancy is comparable to that for the nonasthmatic population.
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Affiliation(s)
- M Schatz
- Department of Allergy and Obstetrics, Kaiser-Permanente Medical Center, San Diego, California
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Schatz M, Zeiger RS, Hoffman CP, Harden K, Forsythe A, Chilingar L, Saunders B, Porreco R, Sperling W, Kagnoff M. Perinatal outcomes in the pregnancies of asthmatic women: a prospective controlled analysis. Am J Respir Crit Care Med 1995. [DOI: 10.1164/ajrccm.151.4.7697248] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Kaempf JW, Porreco R, Molina R, Hale K, Pantoja AF, Rosenberg AA. Antenatal phenobarbital for the prevention of periventricular and intraventricular hemorrhage: a double-blind, randomized, placebo-controlled, multihospital trial. J Pediatr 1990; 117:933-8. [PMID: 2246697 DOI: 10.1016/s0022-3476(05)80141-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
To determine whether the neuroprotective properties of phenobarbital would alter the incidence and severity of intracranial hemorrhage in premature infants, we randomly assigned 110 women at less than 31 weeks of gestation to receive 10 mg/kg phenobarbital or placebo in a blinded fashion before delivery. Infants were examined postnatally with real-time ultrasonography for evidence of intracranial hemorrhage. Maternal demographics, pregnancy complications, antenatal management, and route of delivery did not differ between the phenobarbital group (n = 50) and the placebo group (n = 60). The total incidence of periventricular-intraventricular hemorrhage did not differ between the phenobarbital-treated (n = 54) and the placebo-treated (n = 67) infants. However, the frequency of grade 3 and grade 4 hemorrhages was 15% (10 infants) in the placebo group and 3.7% (2 infants) in the phenobarbital group (p less than 0.05). There were no differences in the severity of associated conditions in the babies to explain the difference in the incidence of severe hemorrhage between the study groups. We conclude that antenatal administration of phenobarbital appears to be effective in decreasing the severity of periventricular-intraventricular hemorrhage in infants delivered at less than 31 weeks of gestation.
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Affiliation(s)
- J W Kaempf
- Department of Pediatrics, University of Colorado School of Medicine, Denver
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17
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Berry R, Wilson H, Robinson J, Sandlin C, Tyson W, Campbell J, Porreco R, Manchester D. Apparent Smith-Lemli-Opitz syndrome and Miller-Dieker syndrome in a family with segregating translocation t(7;17)(q34;p13.1). Am J Med Genet 1989; 34:358-65. [PMID: 2596525 DOI: 10.1002/ajmg.1320340312] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
We describe a family in which one male infant presented with Miller-Dieker syndrome and four male relatives had a phenotype similar to the Smith-Lemli-Opitz (SLO) syndrome. High resolution cytogenetic analysis on the child with Miller-Dieker syndrome showed 46,XY,-17,+der17t(7;17)(q34:p13.1). Paternal chromosomes showed a balanced translocation: 46,XY,t(7;17)(q34:p13.1). The paternal grandmother had a history of multiple miscarriages, and a paternal uncle had two sons who died neonatally. Chromosomes on these children and their father had originally been reported as normal. There was also a paternal cousin to the father of the propositus who had had two sons with similar clinical findings. A diagnosis of SLO syndrome was considered. Image enhancement techniques on previous suboptimal preparations on these four children documented the subtle unbalanced translocation 46,XY,-7,+der7t(7;17)(q34:p13.1). Subsequent high resolution analysis on one of these four children who was still living confirmed this chromosome constitution. It is postulated that these apparent SLO cases may represent a contiguous gene syndrome in which SLO or a separate entity closely mimicking the syndrome in included.
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Affiliation(s)
- R Berry
- Department of Pediatric Medicine, Children's Hospital, Denver, CO 80218
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18
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Meier P, Porreco R. Reply to Rajaram and Oumachigui. Am J Obstet Gynecol 1984. [DOI: 10.1016/0002-9378(84)90174-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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19
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Abstract
The occurrence of grossly normal-appearing morula stage human embryos (8- to 12-cell) that developed from eggs fertilized in vitro containing three pronuclei is described. Serial section analysis by transmission electron microscopy demonstrated that 25% of the blastomeres were multinucleate, with as many as five deoxyribonucleic acid-containing nuclei (determined by fluorescence microscopy) in a single cell. Light and electron microscopy indicated that normal cortical and zona reactions had taken place. Fine-structural development of the cytoplasm was characteristic of morula stage human embryos. The results suggest the need to determine pronuclear number prior to syngamy and are discussed with respect to the notion that human embryos may have the capacity to develop normally in spite of the presence of abnormal cells.
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20
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Henry GP, Van Blerkom J, Porreco R. Human in vitro fertilization in a private program: Reproductive Genetics in Vitro, P.C. J In Vitro Fert Embryo Transf 1984; 1:76-9. [PMID: 6336090 DOI: 10.1007/bf01129625] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Reproductive Genetics in Vitro, P.C., began a program of human in vitro fertilization in a private practice setting in September of 1982, after nearly 1 year of preparation prior to the cycling of the first patient. Ovarian stimulation is most often by Clomid, 50 mg tid, on days 3 through 9 of the cycle. Follicle development is monitored by daily ultrasound, estradiol, follicle-stimulating hormone (FSH), and luteinizing hormone (LH) measurements. Serum progesterone measurements are made the last few days prior to anticipated ovulation to detect early signs of luteinization. In the first phase of our program 12 patients with pure tubal obstruction have had one or more oocytes retrieved by laparoscopy. All oocytes fertilized such that every patient who had oocytes retrieved had embryos placed in the uterus. Of the first 12 patients who had embryo placement, 2 are ongoing and normal in the second trimester of pregnancy, with delivery expected shortly after the first issue of this journal. Five others showed early signs of clinical pregnancy as indicated by acentrically located gestational sacs (as opposed to the typical centrally located pseudogestational sac) or transiently elevated human chorionic gonadotropin (HCG).
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21
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Cousins L, Benirschke K, Porreco R, Resnik R. Placentomegaly due to fetal congestive failure in a pregnancy with a sacrococcygeal teratoma. J Reprod Med 1980; 25:142-4. [PMID: 7431360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Conditions associated with placentomegaly in which the disproportionate placental enlargement is understood include erythroblastosis fetalis, intrauterine infections and chorioangioma. This report suggests that in a pregnancy complicated by a large sacrococcygeal teratoma, placentomegaly results from high-output fetal cardiac failure secondary to the mass acting as an arteriovenous fistula.
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22
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Meier P, Porreco R. Husbanding the blood-glucose in pregnancy. Lancet 1980; 1:553-4. [PMID: 6102283 DOI: 10.1016/s0140-6736(80)92819-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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23
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Coen RW, Porreco R, Cousins L, Sandler JA. Postpartum glycosylated hemoglobin levels in mothers of large--for--gestational age infants. Am J Obstet Gynecol 1980; 136:380-2. [PMID: 7352528 DOI: 10.1016/0002-9378(80)90865-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Glycosylated hemoglobin levels were determined in 19 women who were delivered of large--for--gestational age (greater than 4,082 grams) infants and compared to control values. Although the mean level for each group did not differ significantly (6.7% +/- 1.5% versus 6.5% +/- 0.2%) three women had increased hemoglobin glycosylation. In this series the birth of a large infant correlated with prepregnancy obesity and greater weight gain during pregnancy.
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24
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Wedberg R, Kaplan C, Leopold G, Porreco R, Resnik R, Benirschke K. Cephalothoracopagus (Janiceps) twinning. Obstet Gynecol 1979; 54:392-6. [PMID: 471390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Conjoined twins occur with a frequency of 1/50,000--1/100,000 deliveries. The cephalothoracopagus variety is particularly rare. This paper presents a case report of cephalothoracopagus (Janiceps) twinning, with a detailed pathologic analysis, as well as an historical review and discussion of diagnostic modalities.
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Porreco R, Penn I, Droegemueller W, Greer B, Makowski E. Gynecologic malignancies in immunosuppressed organ homograft recipients. Obstet Gynecol 1975; 45:359-64. [PMID: 1091896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Immunosuppressed organ homograft recipients have a 5 to 6% incidence of de novo malignancies at some time after transplantation. Gynecologic cancers were encountered in 21 of 224 patients (9%) with these tumors. The predominant lesion was carcinoma of the cervix (18 cases), of which 16 were intraepithelial and 2 were invasive. Gynecologic malignancies have also been encountered in non-transplant patients who were treated with immunosuppressive agents or cancer chemotherapy. All such individuals require gynecologic examination before commencement of treatment and at regular intervals thereafter so that malignancies may be diagnosed at an early stage and treated effectively. Most neoplasms respond well to conventional cancer therapy, but high-grade malignancies may necessitate reduction or cessation of immunosuppressive therapy as well.
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