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Workalemahu T, Dalton S, Son SL, Allshouse A, Carey AZ, Page JM, Blue NR, Thorsten V, Goldenberg RL, Pinar H, Reddy UM, Silver RM. Copy number variants and fetal structural abnormalities in stillborn fetuses: A secondary analysis of the Stillbirth Collaborative Research Network study. BJOG 2024; 131:157-162. [PMID: 37264725 PMCID: PMC10689565 DOI: 10.1111/1471-0528.17561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 05/07/2023] [Accepted: 05/15/2023] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To examine the association of placental and fetal DNA copy number variants (CNVs) with fetal structural malformations (FSMs) in stillborn fetuses. DESIGN A secondary analysis of stillbirth cases in the Stillbirth Collaborative Research Network (SCRN) study. SETTING Multicenter, 59 hospitals in five geographic regions in the USA. POPULATION 388 stillbirth cases of the SCRN study (2006-2008). METHODS Fetal structural malformations were grouped by anatomic system and specific malformation type (e.g. central nervous system, thoracic, cardiac, gastrointestinal, skeletal, umbilical cord and craniofacial defects). Single-nucleotide polymorphism array detected CNVs of at least 500 kb. CNVs were classified into two groups: normal, defined as no CNVs >500 kb or benign CNVs, and abnormal, defined as pathogenic or variants of unknown clinical significance. MAIN OUTCOME MEASURES The proportions of abnormal CNVs and normal CNVs were compared between stillbirth cases with and without FSMs using the Wald Chi-square test. RESULTS The proportion of stillbirth cases with any FSMs was higher among those with abnormal CNVs than among those with normal CNVs (47.5 versus 19.1%; P-value <0.001). The most common organ system-specific FSMs associated with abnormal CNVs were cardiac defects, followed by hydrops, craniofacial defects and skeletal defects. A pathogenic deletion of 1q21.1 involving 46 genes (e.g. CHD1L) and a duplication of 21q22.13 involving four genes (SIM2, CLDN14, CHAF1B, HLCS) were associated with a skeletal and cardiac defect, respectively. CONCLUSION Specific CNVs involving several genes were associated with FSMs in stillborn fetuses. The findings warrant further investigation and may inform counselling and care surrounding pregnancies affected by FSMs at risk for stillbirth.
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Affiliation(s)
| | | | - Shannon L. Son
- University of Utah Health, Salt Lake City, UT
- Intermountain Healthcare, Salt Lake City, UT
| | | | | | - Jessica M. Page
- University of Utah Health, Salt Lake City, UT
- Intermountain Healthcare, Salt Lake City, UT
| | | | - Vanessa Thorsten
- Columbia University Medical Center, New York, NY
- RTI International, Research Triangle Park, NC
| | | | - Halit Pinar
- Division of Perinatal Pathology, Brown University School of Medicine, Providence, RI
| | - Uma M. Reddy
- Obstetrics, Gynecology & Reproductive Sciences, Yale University, New Haven, CT
| | - Robert M. Silver
- University of Utah Health, Salt Lake City, UT
- Intermountain Healthcare, Salt Lake City, UT
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Jepson BM, Metz TD, Miller TA, Son SL, Ou Z, Presson AP, Nance A, Pinto NM. Pregnancy loss in major fetal congenital heart disease: incidence, risk factors and timing. Ultrasound Obstet Gynecol 2023; 62:75-87. [PMID: 37099500 DOI: 10.1002/uog.26231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 03/09/2023] [Accepted: 04/14/2023] [Indexed: 06/19/2023]
Abstract
OBJECTIVE Fetuses with congenital heart disease (CHD) are at increased risk of pregnancy loss compared with the general population. We aimed to assess the incidence, timing and risk factors of pregnancy loss in cases with major fetal CHD, overall and according to cardiac diagnosis. METHODS This was a retrospective, population-level cohort study of fetuses and infants diagnosed with major CHD between 1997 and 2018 identified by the Utah Birth Defect Network (UBDN), excluding cases with termination of pregnancy and minor cardiovascular diagnoses (e.g. isolated aortic/pulmonary pathology and isolated septal defects). The incidence and timing of pregnancy loss were recorded, overall and according to CHD diagnosis, with further stratification based on presence of isolated CHD vs additional fetal diagnosis (genetic diagnosis and/or extracardiac malformation). Adjusted risk of pregnancy loss was calculated and risk factors were assessed using multivariable models for the overall cohort and prenatal diagnosis subgroup. RESULTS Of 9351 UBDN cases with a cardiovascular code, 3251 cases with major CHD were identified, resulting in a study cohort of 3120 following exclusion of cases with pregnancy termination (n = 131). There were 2956 (94.7%) live births and 164 (5.3%) cases of pregnancy loss, which occurred at a median gestational age of 27.3 weeks. Of study cases, 1848 (59.2%) had isolated CHD and 1272 (40.8%) had an additional fetal diagnosis, including 736 (57.9%) with a genetic diagnosis and 536 (42.1%) with an extracardiac malformation. The observed incidence of pregnancy loss was highest in the presence of mitral stenosis (< 13.5%), hypoplastic left heart syndrome (HLHS) (10.7%), double-outlet right ventricle with normally related great vessels or not otherwise specified (10.5%) and Ebstein's anomaly (9.9%). The adjusted risk of pregnancy loss was 5.3% (95% CI, 3.7-7.6%) in the overall CHD population and 1.4% (95% CI, 0.9-2.3%) in cases with isolated CHD (adjusted risk ratio, 9.0 (95% CI, 6.0-13.0) and 2.0 (95% CI, 1.0-6.0), respectively, based on the general population risk of 0.6%). On multivariable analysis, variables associated with pregnancy loss in the overall CHD population included female fetal sex (adjusted odds ratio (aOR), 1.6 (95% CI, 1.1-2.3)), Hispanic ethnicity (aOR, 1.6 (95% CI, 1.0-2.5)), hydrops (aOR, 6.7 (95% CI, 4.3-10.5)) and additional fetal diagnosis (aOR, 6.3 (95% CI, 4.1-10)). On multivariable analysis of the prenatal diagnosis subgroup, years of maternal education (aOR, 1.2 (95% CI, 1.0-1.4)), presence of an additional fetal diagnosis (aOR, 2.7 (95% CI, 1.4-5.6)), atrioventricular valve regurgitation ≥ moderate (aOR, 3.6 (95% CI, 1.3-8.8)) and ventricular dysfunction (aOR, 3.8 (95% CI, 1.2-11.1)) were associated with pregnancy loss. Diagnostic groups associated with pregnancy loss were HLHS and variants (aOR, 3.0 (95% CI, 1.7-5.3)), other single ventricles (aOR, 2.4 (95% CI, 1.1-4.9)) and other (aOR, 0.1 (95% CI, 0-0.97)). Time-to-pregnancy-loss analysis demonstrated a steeper survival curve for cases with an additional fetal diagnosis, indicating a higher rate of pregnancy loss compared to cases with isolated CHD (P < 0.0001). CONCLUSIONS The risk of pregnancy loss is higher in cases with major fetal CHD compared with the general population and varies according to CHD type and presence of additional fetal diagnoses. Improved understanding of the incidence, risk factors and timing of pregnancy loss in CHD cases should inform patient counseling, antenatal surveillance and delivery planning. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- B M Jepson
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - T D Metz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT, USA
| | - T A Miller
- Division of Pediatric Cardiology, Maine Medical Center, Portland, ME, USA
| | - S L Son
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Colorado, Aurora, CO, USA
| | - Z Ou
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - A P Presson
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - A Nance
- Utah Birth Defect Network, Office of Children with Special Healthcare Needs, Division of Family Health, Utah Department of Health and Human Services, Salt Lake City, UT, USA
| | - N M Pinto
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
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Bridges AG, Allshouse AA, Canfield DR, Grover BW, Son SL, Einerson BD, Silver RM, Haas DM, Grobman WA, Simhan HN, Day RC, Blue NR. Association of Prostaglandin Use for Cervical Ripening with Mode of Delivery in Small for Gestational Age versus Non-Small for Gestational Age Neonates. Am J Perinatol 2022. [PMID: 35863371 DOI: 10.1055/a-1906-8919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE Prostaglandins (PGs) use for cervical ripening with small for gestational age (SGA) fetuses is controversial since it remains uncertain if use increases the chance of cesarean delivery (CD). We aimed to assess the association between PG use for cervical ripening and mode of delivery between SGA and appropriate for gestational age (AGA) neonates. STUDY DESIGN Secondary analysis of the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be (nuMoM2b), a prospective observational cohort study of 10,038 nulliparas. We included women undergoing induction with nonanomalous fetuses in the cephalic presentation. Women with >2 cm cervical dilation or prior uterine scar were excluded. We assessed the association of PG use with CD among women with SGA and AGA neonates. SGA was defined as birth weight <10th percentile for gestational age and sex. Multivariable logistic regression was used to adjust for potential confounders and test for interaction. Secondary outcomes included adverse neonatal outcomes, indication for CD, maternal hemorrhage, and chorioamnionitis. RESULTS Among 2,353 women eligible, PGs were used in 54.8%, SGA occurred in 15.1%, and 35.0% had CD. The association between PG use and CD differed significantly (interaction p = 0.018) for SGA versus AGA neonates; CD occurred more often in SGA neonates exposed to PGs than not (35 vs. 22%, p = 0.009). PG use was not associated with CD among AGA neonates (36 vs. 36%, p = 0.8). This effect remained significant when adjusting for body mass index, race/ethnicity, and cervical dilation. Among SGA neonates, CD for "nonreassuring fetal status" was similar between PG groups. Among SGA neonates, PG use was not associated with adverse neonatal outcomes or postpartum hemorrhage but had a higher rate of chorioamnionitis (7.0 vs. 2.1%, p = 0.048). CONCLUSION PG use was associated with a higher rate of CD in SGA but not AGA neonates; however, further studies are needed before PG use is discouraged with SGA neonates. KEY POINTS · PGs are commonly used for cervical ripening.. · PG use was associated with increased risk of cesarean delivery in SGA neonates.. · PG use was not associated with adverse neonatal outcomes..
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Affiliation(s)
- Alexis G Bridges
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah
- Department of Obstetrics and Gynecology, Intermountain Healthcare, Salt Lake City, Utah
| | - Amanda A Allshouse
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah
| | - Dana R Canfield
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah
- Department of Obstetrics and Gynecology, Intermountain Healthcare, Salt Lake City, Utah
| | - Bryan W Grover
- University of Utah School of Medicine, Salt Lake City, Utah
| | - Shannon L Son
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah
- Department of Obstetrics and Gynecology, Intermountain Healthcare, Salt Lake City, Utah
| | - Brett D Einerson
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah
- Department of Obstetrics and Gynecology, Intermountain Healthcare, Salt Lake City, Utah
| | - Robert M Silver
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah
- Department of Obstetrics and Gynecology, Intermountain Healthcare, Salt Lake City, Utah
| | - David M Haas
- Department of Obstetrics and Gynecology, Indiana University, Indianapolis, Indiana
| | - William A Grobman
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois
| | - Hyagriv N Simhan
- Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Robert C Day
- Department of Obstetrics and Gynecology, University of California-Irvine, Irvine, California
| | - Nathan R Blue
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah
- Department of Obstetrics and Gynecology, Intermountain Healthcare, Salt Lake City, Utah
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Gilner J, Kansal N, Biggio JR, Delaney S, Grotegut CA, Hardy E, Hirshberg A, Kachikis A, LaCourse SM, Martin J, Metz TD, Miller ES, Norton ME, Sinkey R, Sobhani NC, Son SL, Srinivas S, Tita A, Werner EF, Hughes BL. Universal Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Testing for Obstetric Inpatient Units Across the United States. Clin Infect Dis 2022; 75:e322-e328. [PMID: 34791093 PMCID: PMC8689996 DOI: 10.1093/cid/ciab955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND The purpose of this study was to estimate prevalence of asymptomatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among patients admitted to obstetric inpatient units throughout the United States as detected by universal screening. We sought to describe the relationship between obstetric inpatient asymptomatic infection rates and publicly available surrounding community infection rates. METHODS A cross-sectional study in which medical centers reported rates of positive SARS-CoV-2 testing in asymptomatic pregnant and immediate postpartum patients over a 1-3-month time span in 2020. Publicly reported SARS-CoV-2 case rates from the relevant county and state for each center were collected from the COVID Act Now dashboard and the COVID Tracking Project for correlation analysis. RESULTS Data were collected from 9 health centers, encompassing 18 hospitals. Participating health centers were located in Alabama, California, Illinois, Louisiana, New Jersey, North Carolina, Pennsylvania, Rhode Island, Utah, and Washington State. Each hospital had an active policy for universal SARS-CoV-2 testing on obstetric inpatient units. A total of 10 147 SARS-CoV-2 tests were administered, of which 124 were positive (1.2%). Positivity rates varied by site, ranging from 0-3.2%. While SARS-CoV-2 infection rates were lower in asymptomatic obstetric inpatient groups than the surrounding communities, there was a positive correlation between positivity rates in obstetric inpatient units and their surrounding county (P=.003, r=.782) and state (P=.007, r=.708). CONCLUSIONS Given the correlation between community and obstetric inpatient rates, the necessity of SARS-CoV-2-related healthcare resource utilization in obstetric inpatient units may be best informed by surrounding community infection rates.
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Affiliation(s)
- Jennifer Gilner
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina, USA
| | - Namita Kansal
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina, USA
| | - Joseph R Biggio
- Section of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Women’s Service Line, Ochsner Health, New Orleans, Louisiana, USA
| | - Shani Delaney
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, USA
| | - Chad A Grotegut
- Division of Maternal-Fetal Medicine, Duke University, Durham, North Carolina, USA
| | - Erica Hardy
- Departments of Medicine and Obstetrics and Gynecology, Division of Infectious Disease, Women & Infants Hospital, Providence, Rhode Island, USA
| | - Adi Hirshberg
- Division of Maternal Fetal Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Alisa Kachikis
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, USA
| | - Sylvia M LaCourse
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, USA
| | - Jane Martin
- Section of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Women’s Service Line, Ochsner Health, New Orleans, Louisiana, USA
| | - Torri D Metz
- University of Utah Health, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Salt Lake City, Utah, USA
| | - Emily S Miller
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Mary E Norton
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, California, USA
| | - Rachel Sinkey
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama, USAand
| | - Nasim C Sobhani
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, California, USA
| | - Shannon L Son
- University of Utah Health, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Salt Lake City, Utah, USA
| | - Sindhu Srinivas
- Division of Maternal Fetal Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Alan Tita
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama, USAand
| | - Erika F Werner
- Department of Obstetrics and Gynecology, Tufts Medical Center, North Dartmouth, Massachusetts, USA
| | - Brenna L Hughes
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina, USA
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Son SL, Hosek LL, Stein MC, Allshouse AA, Catino AB, Hoskoppal AK, Cox DA, Whitehead KJ, Lindsay IM, Esplin S, Metz TD. Association between pregnancy and long-term cardiac outcomes in individuals with congenital heart disease. Am J Obstet Gynecol 2022; 226:124.e1-124.e8. [PMID: 34331895 PMCID: PMC8748281 DOI: 10.1016/j.ajog.2021.07.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 07/07/2021] [Accepted: 07/19/2021] [Indexed: 01/17/2023]
Abstract
BACKGROUND As early life interventions for congenital heart disease improve, more patients are living to adulthood and are considering pregnancy. Scoring and classification systems predict the maternal cardiovascular risk of pregnancy in the context of congenital heart disease, but these scoring systems do not assess the potential subsequent risks following pregnancy. Data on the long-term cardiac outcomes after pregnancy are unknown for most lesion types. This limits the ability of healthcare practitioners to thoroughly counsel patients who are considering pregnancy in the setting of congenital heart disease. OBJECTIVE We aimed to evaluate the association between pregnancy and the subsequent long-term cardiovascular health of individuals with congenital heart disease. STUDY DESIGN This was a retrospective longitudinal cohort study of individuals identifying as female who were receiving care in two adult congenital heart disease centers from 2014 to 2019. Patient data were abstracted longitudinally from a patient age of 15 years (or from the time of entry into the healthcare system) to the conclusion of the study, death, or exit from the healthcare system. The primary endpoint, a composite adverse cardiac outcome (death, stroke, heart failure, unanticipated cardiac surgery, or a requirement for a catheterized procedure), was compared between parous (at least one pregnancy >20 weeks' gestation) and nulliparous individuals. By accounting for differences in the follow-up, the effect of pregnancy was estimated based on the time to the composite adverse outcome in a proportional hazards regression model adjusted for the World Health Organization class, baseline cardiac medications, and number of previous sternotomies. Participants were also categorized according to their lesion type, including septal defects (ventricular septal defects, atrial septal defects, atrioventricular septal defects, or atrioventricular canal defects), right-sided valvular lesions, left-sided valvular lesions, complex cardiac anomalies, and aortopathies, to evaluate if there is a differential effect of pregnancy on the primary outcome when adjusting for lesion type in a sensitivity analysis. RESULTS Overall, 711 individuals were eligible for inclusion; 209 were parous and 502 nulliparous. People were classified according to the World Health Organization classification system with 86 (12.3%) being classified as class I, 76 (10.9%) being classified as class II, 272 (38.9%) being classified as class II to III, 155 (22.1%) being classified as class III, and 26 (3.7%) being classified as class IV. Aortic stenosis, bicuspid aortic valve, dilated ascending aorta or aortic root, aortic regurgitation, and pulmonary insufficiency were more common in parous individuals, whereas dextro-transposition of the great arteries, Turner syndrome, hypoplastic right heart, left superior vena cava, and other cardiac diagnoses were more common in nulliparous individuals. In multivariable modeling, pregnancy was associated with the composite adverse cardiac outcome (36.4%% vs 26.1%%; hazard ratio, 1.83; 95% confidence interval, 1.25-2.66). Parous individuals were more likely to have unanticipated cardiac surgery (28.2% vs 18.1%; P=.003). No other individual components of the primary outcome were statistically different between parous and nulliparous individuals in cross-sectional comparisons. The association between pregnancy and the primary outcome was similar in a sensitivity analysis that adjusted for cardiac lesion type (hazard ratio, 1.61; 95% confidence interval, 1.10-2.36). CONCLUSION Among individuals with congenital heart disease, pregnancy was associated with an increase in subsequent long-term adverse cardiac outcomes. These data may inform counseling of individuals with congenital heart disease who are considering pregnancy.
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Affiliation(s)
- Shannon L Son
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Intermountain Healthcare, Salt Lake City, UT.
| | - Lauren L Hosek
- University of Utah School of Medicine, Salt Lake City, UT
| | | | - Amanda A Allshouse
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT
| | - Anna B Catino
- Division of Cardiology, University of Utah Health, Salt Lake City, UT
| | - Arvind K Hoskoppal
- Division of Cardiology, University of Utah Health, Salt Lake City, UT; Division of Cardiology, Intermountain Healthcare, Salt Lake City, UT
| | - Daniel A Cox
- Division of Cardiology, University of Utah Health, Salt Lake City, UT; Division of Cardiology, Intermountain Healthcare, Salt Lake City, UT
| | - Kevin J Whitehead
- Division of Cardiology, University of Utah Health, Salt Lake City, UT; Division of Cardiology, Intermountain Healthcare, Salt Lake City, UT
| | - Ian M Lindsay
- Division of Cardiology, University of Utah Health, Salt Lake City, UT; Division of Cardiology, Intermountain Healthcare, Salt Lake City, UT
| | - Sean Esplin
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Intermountain Healthcare, Salt Lake City, UT
| | - Torri D Metz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Intermountain Healthcare, Salt Lake City, UT
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Son SL, Allshouse AA, Heinrichs GA, Garite TJ, Silver RM, Wapner RJ, Grobman WA, Chung JH, Mercer BM, Metz TD. Is Exposure to Intrapartum Prostaglandins for Labor Induction Associated with a Lower Incidence of Neonatal Respiratory Distress Syndrome? Am J Perinatol 2021; 38:993-998. [PMID: 33934327 DOI: 10.1055/s-0041-1728820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Respiratory distress syndrome (RDS) is implicated in 30% of neonatal deaths. Since prostaglandins promote surfactant secretion and labor is associated with a lower risk of RDS in term neonates, it is plausible that synthetic prostaglandin (sPG) exposure is associated with a lower risk of RDS. Thus, we evaluated the association between sPG exposure and RDS in neonates born after the induction of labor (IOL). STUDY DESIGN Secondary analysis of women with singleton pregnancies undergoing IOL at 340/7 to 420/7 weeks in the nuMoM2b study, a multicenter prospective cohort of nulliparous women. RDS rates and secondary neonatal outcomes in neonates with intrapartum sPG exposure were compared with those who had IOL with non-sPG methods (e.g., balloon catheter, amniotomy, oxytocin, and laminaria). Logistic regression models estimated the association of sPG with RDS and with secondary outcomes after adjustment for clinical and demographic factors (including gestational age). A sensitivity analysis was performed in which analysis was restricted to those with an admission cervical dilation ≤2 cm. RESULTS Of 10,038 women in the total cohort, 3,071 met inclusion criteria; 1,444 were exposed and 1,627 were unexposed to sPGs. Antenatal corticosteroid exposure rates were low (3.0%) and similar between groups. In univariable analysis, neonates with sPG exposure had higher rates of RDS (3.2 vs. 2.0%, odds ratio [OR]: 1.59, 95% confidence interval [CI]: 1.01-2.50). This relationship was similar by gestational age at delivery (term vs. preterm, interaction p = 0.14). After adjustment, the association between sPG and RDS was no longer significant (adjusted odds ratio: 1.4, 95% CI: 0.9-2.3). When analysis was restricted to subjects with admission cervical dilation of ≤2 cm, there was also no association between sPG exposure and RDS. CONCLUSION In pregnancies between 34 and 42 weeks of gestation, exposure to sPG for cervical ripening or labor induction was not associated with newborn RDS. KEY POINTS · RDS is implicated in 30% of neonatal deaths.. · sPG exposure was not associated with RDS.. · Avoiding preterm birth remains crucial in RDS prevention..
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Affiliation(s)
- Shannon L Son
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah.,Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Intermountain Healthcare, Salt Lake City, Utah
| | - Amanda A Allshouse
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah
| | - Gretchen A Heinrichs
- Department of Obstetrics and Gynecology, Denver Health and Hospital Authority, Denver, Colorado
| | - Thomas J Garite
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of California Irvine, Orange, California
| | - Robert M Silver
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah.,Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Intermountain Healthcare, Salt Lake City, Utah
| | - Ronald J Wapner
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Medical Center, New York City, New York
| | - William A Grobman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Judith H Chung
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of California Irvine, Orange, California
| | - Brian M Mercer
- Department of Obstetrics & Gynecology, The MetroHealth System, Case Western Reserve University, Clevelend, Ohio
| | - Torri D Metz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah.,Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Intermountain Healthcare, Salt Lake City, Utah
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Benson AE, Son SL, Einerson BD, Stoddard GJ, Richards DS. 1110 Predictive value of elevated MCA doppler in patients with alloimmunization. Am J Obstet Gynecol 2021. [DOI: 10.1016/j.ajog.2020.12.1134] [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: 11/27/2022]
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Debbink MP, Son SL, Woodward PJ, Kennedy AM. Sonographic Assessment of Fetal Growth Abnormalities. Radiographics 2021. [DOI: 10.1148/rg.2021200081.pres] [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: 11/11/2022]
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Son SL, Allshouse AA, Page JM, Debbink MP, Pinar H, Reddy U, Gibbins KJ, Stoll BJ, Parker CB, Dudley DJ, Varner MW, Silver RM. Stillbirth and fetal anomalies: secondary analysis of a case-control study. BJOG 2021; 128:252-258. [PMID: 32946651 PMCID: PMC7902300 DOI: 10.1111/1471-0528.16517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Approximately 10% of stillbirths are attributed to fetal anomalies, but anomalies are also common in live births. We aimed to assess the relationship between anomalies, by system and stillbirth. DESIGN Secondary analysis of a prospective, case-control study. SETTING Multicentre, 59 hospitals in five regional catchment areas in the USA. POPULATION OR SAMPLE All stillbirths and representative live birth controls. METHODS Standardised postmortem examinations performed in stillbirths, medical record abstraction for stillbirths and live births. MAIN OUTCOME MEASURES Incidence of major anomalies, by type, compared between stillbirths and live births with univariable and multivariable analyses using weighted analysis to account for study design and differential consent. RESULTS Of 465 singleton stillbirths included, 23.4% had one or more major anomalies compared with 4.3% of 1871 live births. Having an anomaly increased the odds of stillbirth; an increasing number of anomalies was more highly associated with stillbirth. Regardless of organ system affected, the presence of an anomaly increased the odds of stillbirth. These relationships remained significant if stillbirths with known genetic abnormalities were excluded. After multivariable analyses, the adjusted odds ratio (aOR) of stillbirth for any anomaly was 4.33 (95% CI 2.80-6.70) and the systems most strongly associated with stillbirth were cystic hygroma (aOR 29.97, 95% CI 5.85-153.57), and thoracic (aOR16.18, 95% CI 4.30-60.94) and craniofacial (aOR 35.25, 95% CI 9.22-134.68) systems. CONCLUSIONS In pregnancies affected by anomalies, the odds of stillbirth are higher with increasing numbers of anomalies. Anomalies of nearly any organ system increased the odds of stillbirth even when adjusting for gestational age and maternal race. TWEETABLE ABSTRACT Stillbirth risk increases with anomalies of nearly any organ system and with number of anomalies seen.
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Affiliation(s)
- S L Son
- Division of Maternal-Fetal Medicine, University of Utah Health, Salt Lake City, UT, USA
- Division of Maternal-Fetal Medicine, Intermountain Healthcare, Salt Lake City, UT, USA
| | - A A Allshouse
- Division of Maternal-Fetal Medicine, University of Utah Health, Salt Lake City, UT, USA
| | - J M Page
- Division of Maternal-Fetal Medicine, University of Utah Health, Salt Lake City, UT, USA
- Division of Maternal-Fetal Medicine, Intermountain Healthcare, Salt Lake City, UT, USA
| | - M P Debbink
- Division of Maternal-Fetal Medicine, University of Utah Health, Salt Lake City, UT, USA
- Division of Maternal-Fetal Medicine, Intermountain Healthcare, Salt Lake City, UT, USA
| | - H Pinar
- Division of Perinatal Pathology, Alpert Medical School of Brown University, Providence, RI, USA
| | - U Reddy
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Yale School of Medicine, New Haven, CT, USA
| | - K J Gibbins
- Division of Maternal-Fetal Medicine, University of Utah Health, Salt Lake City, UT, USA
| | - B J Stoll
- Department of Pediatrics, University of Texas Health McGovern Medical School, Houston, TX, USA
| | - C B Parker
- RTI International, Research Triangle Park, NC, USA
| | - D J Dudley
- University of Virginia School of Medicine, Charlottesville, VA, USA
| | - M W Varner
- Division of Maternal-Fetal Medicine, University of Utah Health, Salt Lake City, UT, USA
- Division of Maternal-Fetal Medicine, Intermountain Healthcare, Salt Lake City, UT, USA
| | - R M Silver
- Division of Maternal-Fetal Medicine, University of Utah Health, Salt Lake City, UT, USA
- Division of Maternal-Fetal Medicine, Intermountain Healthcare, Salt Lake City, UT, USA
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Abstract
Fetal growth abnormalities have significant consequences for pregnancy management and maternal and fetal well-being. The accurate diagnosis of fetal growth abnormalities contributes to optimal antenatal management, which may minimize the sequelae of inadequate or excessive fetal growth. An accurate diagnosis of abnormal fetal growth depends on accurate pregnancy dating and serial growth measurements. The fetal size at any given stage of pregnancy is either appropriate or inappropriate for the given gestational age (GA). Pregnancy dating is most accurate in the first trimester, as biologic variability does not come into play until the second and third trimesters. The authors describe the determination of GA with use of standard US measurements and how additional parameters can be used to confirm dating. Once dates are established, serial measurements are used to identity abnormal growth patterns. The sometimes confusing definitions of abnormal growth are clarified, the differentiation of a constitutionally small but healthy fetus from a growth-restricted at-risk fetus is described, and the roles of Doppler US and other adjunctive examinations in the management of growth restriction are discussed. In addition, the definition of selective growth restriction in twin pregnancy is briefly discussed, as is the role of Doppler US in the classification of subtypes of selective growth restriction in monochorionic twinning. The criteria for diagnosing macrosomia and the management of affected pregnancies also are reviewed. The importance of correct pregnancy dating in the detection and surveillance of abnormal fetal growth and for prevention of perinatal maternal and fetal morbidity and mortality cannot be overstated. The online slide presentation from the RSNA Annual Meeting is available for this article. ©RSNA, 2020.
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Affiliation(s)
- Michelle P Debbink
- From the Departments of Obstetrics and Gynecology (M.P.D., S.L.S.) and Radiology and Imaging Sciences (P.J.W., A.M.K.), University of Utah, 50 N Medical Dr, Salt Lake City, UT 84132
| | - Shannon L Son
- From the Departments of Obstetrics and Gynecology (M.P.D., S.L.S.) and Radiology and Imaging Sciences (P.J.W., A.M.K.), University of Utah, 50 N Medical Dr, Salt Lake City, UT 84132
| | - Paula J Woodward
- From the Departments of Obstetrics and Gynecology (M.P.D., S.L.S.) and Radiology and Imaging Sciences (P.J.W., A.M.K.), University of Utah, 50 N Medical Dr, Salt Lake City, UT 84132
| | - Anne M Kennedy
- From the Departments of Obstetrics and Gynecology (M.P.D., S.L.S.) and Radiology and Imaging Sciences (P.J.W., A.M.K.), University of Utah, 50 N Medical Dr, Salt Lake City, UT 84132
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Debbink MP, Son SL, Woodward PJ, Kennedy AM. Sonographic Assessment of Fetal Growth Abnormalities. Radiographics 2020. [DOI: 10.1148/rg.2020200081.pres] [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: 11/11/2022]
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Abstract
OBJECTIVE To evaluate cost of outpatient (OP) versus inpatient (IP) ripening with transcervical balloons, and determine circumstances in which each strategy would be cost saving. STUDY DESIGN We created a decision model comparing OP and IP balloon ripening in term (≥37 weeks) singleton pregnancies with unfavorable cervix. We performed a cost-minimization analysis and threshold analyses comparing two OP ripening strategies (broad and limited use) to IP ripening from a health system perspective. Base case estimates of probability, utilization, and cost were derived from the literature. The primary outcome was incremental cost of OP versus IP ripening from a hospital perspective. One- and two-way sensitivity analyses explored uncertainty in the model. RESULTS Both OP ripening strategies were cost saving compared with IP ripening: incremental cost -$228.40/patient with broad use and -$73.48/patient with limited use. OP ripening was no longer cost saving if hours saved on labor and delivery (L&D) were <3.5, insertion visit cost >$714, or facility cost/hour on L&D <$61. Two-way sensitivity analyses showed that OP ripening was cost saving under the most plausible clinical circumstances. CONCLUSION In patients with unfavorable cervix, OP transcervical balloon ripening was cost saving under a wide range of circumstances, particularly if OP ripening can shorten time spent on L&D by 3.5 hours.
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Affiliation(s)
- Shannon L Son
- Division of Maternal-Fetal Medicine, University of Utah Health, Salt Lake City, Utah.,Division of Maternal-Fetal Medicine, Intermountain Healthcare, Salt Lake City, Utah
| | - Ashley E Benson
- Division of Maternal-Fetal Medicine, University of Utah Health, Salt Lake City, Utah.,Division of Maternal-Fetal Medicine, Intermountain Healthcare, Salt Lake City, Utah
| | | | - Akila Subramaniam
- Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, Alabama.,Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Erin A S Clark
- Division of Maternal-Fetal Medicine, University of Utah Health, Salt Lake City, Utah.,Division of Maternal-Fetal Medicine, Intermountain Healthcare, Salt Lake City, Utah
| | - Brett D Einerson
- Division of Maternal-Fetal Medicine, University of Utah Health, Salt Lake City, Utah.,Division of Maternal-Fetal Medicine, Intermountain Healthcare, Salt Lake City, Utah
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Son SL, Hosek LL, Stein MC, Allshouse AA, Catino AB, Hoskoppal AK, Cox DA, Whitehead KJ, Lindsay IM, Esplin S, Metz TD. 964: Does pregnancy impact subsequent cardiac outcomes of women with congenital heart disease (CHD)? Am J Obstet Gynecol 2020. [DOI: 10.1016/j.ajog.2019.11.975] [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: 10/25/2022]
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Son SL, Allshouse AA, Heinrichs GA, Garite TJ, Silver RM, Wapner RJ, Grobman WA, Chung JH, Mercer BM, Metz TD. 439: Association between intrapartum prostaglandin exposure and neonatal respiratory distress syndrome (RDS). Am J Obstet Gynecol 2020. [DOI: 10.1016/j.ajog.2019.11.455] [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: 11/28/2022]
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Son SL, Benson AE, Hayes EH, Subramaniam A, Clark EA, Einerson BD. 756: Outpatient cervical ripening: a cost-minimization and threshold analysis. Am J Obstet Gynecol 2019. [DOI: 10.1016/j.ajog.2018.11.779] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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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Son SL, Gumina DL, Driscoll BE, Gillan A, Harper T, Hobbins JC, Galan HL. 449: Discrepant Doppler values in paired umbilical arteries in the growth restricted fetus and the relationship to fetal biometry. Am J Obstet Gynecol 2018. [DOI: 10.1016/j.ajog.2017.10.385] [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: 10/18/2022]
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Son SL, Gumina D, Pinter M, Gillan A, Cioffi-Ragan D, Behrendt N, Reeves S, Zaretsky M, Hobbins JC, Galan HL. 244: Correlation of 3D fractional limb volumes of the fetal thigh in fetal growth restriction (FGR) with normal and abnormal doppler studies. Am J Obstet Gynecol 2017. [DOI: 10.1016/j.ajog.2016.11.149] [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: 12/01/2022]
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Son SL, Häberle H, Aurich H, Pham DT. Druckdekompensation nach Kataraktoperation bei Glaukompatienten. Klin Monbl Augenheilkd 2012. [DOI: 10.1055/s-0032-1331535] [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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Talke P, Chen R, Thomas B, Aggarwall A, Gottlieb A, Thorborg P, Heard S, Cheung A, Son SL, Kallio A. The hemodynamic and adrenergic effects of perioperative dexmedetomidine infusion after vascular surgery. Anesth Analg 2000; 90:834-9. [PMID: 10735784 DOI: 10.1097/00000539-200004000-00011] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.0] [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: 11/26/2022]
Abstract
UNLABELLED We tested dexmedetomidine, an alpha(2) agonist that decreases heart rate, blood pressure, and plasma norepinephrine concentration, for its ability to attenuate stress responses during emergence from anesthesia after major vascular operations. Patients scheduled for vascular surgery received either dexmedetomidine (n = 22) or placebo (n = 19) IV beginning 20 min before the induction of anesthesia and continuing until 48 h after the end of surgery. All patients received standardized anesthesia. Heart rate and arterial blood pressure were kept within predetermined limits by varying anesthetic level and using vasoactive medications. Heart rate, arterial blood pressure, and inhaled anesthetic concentration were monitored continuously; additional measurements included plasma and urine catecholamines. During emergence from anesthesia, heart rate was slower with dexmedetomidine (73 +/- 11 bpm) than placebo (83 +/- 20 bpm) (P = 0.006), and the percentage of time the heart rate was within the predetermined hemodynamic limits was more frequent with dexmedetomidine (P < 0.05). Plasma norepinephrine levels increased only in the placebo group and were significantly lower for the dexmedetomidine group during the immediate postoperative period (P = 0.0002). We conclude that dexmedetomidine attenuates increases in heart rate and plasma norepinephrine concentrations during emergence from anesthesia. IMPLICATIONS The alpha(2) agonist, dexmedetomidine, attenuates increases in heart rate and plasma norepinephrine concentrations during emergence from anesthesia in vascular surgery patients.
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Affiliation(s)
- P Talke
- Departments of Anesthesia, University of California, San Francisco, CA 94143-0648, USA.
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Hickey C, Gugino LD, Aglio LS, Mark JB, Son SL, Maddi R. Intraoperative somatosensory evoked potential monitoring predicts peripheral nerve injury during cardiac surgery. Anesthesiology 1993; 78:29-35. [PMID: 8424568 DOI: 10.1097/00000542-199301000-00006] [Citation(s) in RCA: 68] [Impact Index Per Article: 2.2] [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: 01/30/2023]
Abstract
BACKGROUND Brachial plexus injury may occur without obvious cause in patients undergoing cardiac surgery. To determine whether such peripheral nerve injury can be predicted intraoperatively, we monitored somatosensory evoked potentials (SEPs) from bilateral median and ulnar nerves in 30 patients undergoing coronary artery bypass surgery. METHODS SEPs were analyzed for changes during central venous cannulation and during use of the Favoloro and Canadian self-retaining sternal retractors, events hereto implicated in brachial plexus injury. Brachial plexus injury was evaluated during physical examination in the postoperative period by an individual blinded to results of SEP monitoring. RESULTS Central venous cannulation was associated with transient changes in SEPs in four patients (13%). These changes occurred intermittently during insertion of the cannula but completely resolved within 5 min. Postoperative neurologic deficits did not occur in these cases. Use of the Canadian and Favoloro retractors was associated with significant changes in 21 patients (70%). In 16 of these, waveforms reverted toward baseline levels intraoperatively and were not associated with postoperative neurologic deficits. Five patients demonstrated a neurologic deficit postoperatively. In each of these, SEP change associated with use of surgical retractors persisted to the end of surgery compared to the immediate pre-bypass period. CONCLUSION Intraoperative upper extremity SEPs may be used to predict peripheral nerve injury occurring during cardiac surgery.
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Affiliation(s)
- C Hickey
- Department of Anesthesia, Brigham and Women's Hospital, Boston, Massachusetts 02115
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Raemer DB, Horrow JC, Mark JB, Maddi R, Collins JJ, Son SL. A new surgical monitoring and resuscitation cart. Med Instrum 1984; 18:189-90. [PMID: 6748999] [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: 01/21/2023]
Abstract
To enhance patient safety after cardiac surgery, a new surgical cart has been designed to allow monitoring and resuscitation during transport of patients from operating room to intensive care unit.
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Abstract
ORG NC45, a neuromuscular blocking agent not producing tachycardia, was examined first, to establish the kinetics of the anatagonism it produces, and second, to test the hypothesis that the tachycardia seen with pancuronium and gallamine reflects an action on vagal postganglionic nerve endings. The action of ORG NC45 was studied on end-plate depolarization and neuromuscular transmission in the guinea pig lumbrical muscle. Also, the effect of ORG NC45 on the response of the cardiac pacemaker to carbachol and on the response of the pacemaker to pre- and postganglionic vagal stimulation was examined in isolated guinea pig atria. ORG NC45 was a potent neuromuscular blocking agent (twice as potent as pancuronium) in this species and showed typical competitive kinetics with a dissociation constant of 0.0103 micro M. However, ORG NC45 affected the atrial system only at very high concentrations and did not affect release of transmitter from vagal nerve terminals. These results thus confirm the hypothesis that presence or absence of vagolytic action goes hand-in-hand with tachycardia or its absence clinically.
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Abstract
The ability of gallamine, metocurine, pancuronium, tubocurarine and atropine to block the response to postganglionic stimulation of the vagus nerve were measured in isolated, spontaneously beating guineapig atria. From analysis of the results in conjunction with those of earlier assays of concentrations that block effects of preganglionic vagal stimulation, it was concluded that only tubocurarine possessed ganglionic blocking activity. From calculation of the extent of block of muscarinic receptors at drug concentrations which blocked the response to postganglionic vagal stimulation, it was concluded that gallamine and pancuronium have an antivagal action exerted most probably on the postganglionic nerve terminal, and that this action is the most likely explanation of the tachycardia seen clinically with these two drugs.
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Son SL. Zero suppression in cardiovascular pressure monitoring. Anesthesiology 1979; 51:573-4. [PMID: 517796 DOI: 10.1097/00000542-197912000-00031] [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] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Abstract
To examine the basis of tachycardia seen clinically with some neuromuscular blocking agents, the potencies of d-tubocurarine, dimethyltubocurarine, gallamine, and pancuronium in antagonizing the effects of vagal stimulation on the guinea pig atrial pacemaker were determined and expressed as an ED50 for vagal blockade. These ED50 values were compared with the respective potency values of these agents at the motor endplate. This comparison showed that in clinical doses, gallamine and pancuronium may reach levels that produce vagal blockade. Comparison with atropine indicated that the vagolytic action of the neuromuscular blocking agents was not attributable to receptor occlusion, but reflected instead an action on the vagus nerve itself.
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Abstract
Drug receptor dissociation constants (KB) were determined for four neuromuscular relaxants at the cardiac pacemaker as well as at the motor endplate. The ratios KB(atrium)/KB(lumbrical) were found to be high for d-tubocurarine and dimethyltubocurarine, 264 and 136, respectively. Thus, interaction at muscarinic sites would occur only with large doses of these drugs. In contrast, the ratios were low for pancuronium and gallamine, 5.3 and 2.4, respectively. Hence, the concentrations of these drugs needed for clinical neuromuscular blockade would occupy appreciable fractions of cardiac muscarinic receptors, and thus might produce vagal blockade and thereby produce the tachycardia seen clinically with these two agents.
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