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O'Brien JM, Defranco EA, Adair CD, Lewis DF, Hall DR, How H, Bsharat M, Creasy GW. Effect of progesterone on cervical shortening in women at risk for preterm birth: secondary analysis from a multinational, randomized, double-blind, placebo-controlled trial. Ultrasound Obstet Gynecol 2009; 34:653-659. [PMID: 19918965 DOI: 10.1002/uog.7338] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
OBJECTIVES To determine whether progesterone supplementation alters cervical shortening in women at increased risk for preterm birth. METHODS We performed a planned secondary analysis from a large, multinational preterm birth prevention trial of daily intravaginal progesterone gel, 90 mg, compared with placebo in women with a history of spontaneous preterm birth or premature cervical shortening. Transvaginal cervical length measurements were obtained in all randomized patients at baseline (18 + 0 to 22 + 6 weeks' gestation) and at 28 weeks' gestation. For this secondary analysis, the difference in cervical length between these time points was compared for the study population with a history of spontaneous preterm birth and for a population with premature cervical shortening (< or = 30 mm) at randomization. Differences between groups in cervical length for the 28-week examination were analyzed using ANCOVA, including adjustment for relevant clinical parameters and maternal characteristics. RESULTS Data were analyzed from 547 randomized patients with a history of preterm birth. The progesterone-treated patients had significantly less cervical shortening than the placebo group (difference 1.6 (95% CI, 0.3-3.0) mm; P = 0.02, ANCOVA). In the population of 104 subjects with premature cervical shortening at randomization, the cervical length also differed significantly on multivariable analysis, with the treatment group preserving more cervical length than the placebo group (difference 3.3 (95% CI, 0.3-6.2) mm; P = 0.03, ANCOVA), with adjustment for differences in cervical length at screening. A significant difference was also observed between groups for categorical outcomes including the frequency of cervical length progression to < or = 25 mm and a > or = 50% reduction in cervical length from baseline in this subpopulation. CONCLUSIONS Intravaginal progesterone enhances preservation of cervical length in women at high risk for preterm birth.
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Affiliation(s)
- J M O'Brien
- Perinatal Diagnostic Center, Central Baptist Hospital, Lexington, KY 40503, USA.
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Adair CD, Luper A, Rose JC, Russell G, Veille JC, Buckalew VM. The hemodynamic effects of intravenous digoxin-binding fab immunoglobulin in severe preeclampsia: a double-blind, randomized, clinical trial. J Perinatol 2009; 29:284-9. [PMID: 19148110 DOI: 10.1038/jp.2008.224] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [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: 11/09/2022]
Abstract
OBJECTIVE An endogenous digitalis-like factor (EDLF) has been implicated in the pathophysiology of preeclampsia (PE). This hypothesis is supported by two cases of preeclampsia in which administration of digoxin immune Fab (DIF) reduced mean arterial pressure (MAP). STUDY DESIGN To study this observation further, we performed a double-blind, placebo-controlled, randomized clinical trial to examine the effects on MAP of intravenous DIF given after delivery in 26 subjects with severe preeclampsia. Treating obstetricians were blinded to subject assignment and were allowed to use standard antihypertensive drugs during the trial. RESULTS The primary outcome, a significant difference in blood pressure between the two groups over the 24-h period of observation after the intervention, was not supported. However, mean MAP was significantly lower in the DIF-treated subjects for the first 4 h after therapy as compared with controls (P=0.05). Six subjects (46.2%) in the placebo arm were given conventional antihypertensive medications by their obstetrician for blood pressure >160 mm Hg systolic or >110 mm Hg diastolic, compared with zero subjects in the treatment arm (P=0.01). A trend towards increased creatinine clearance was observed in DIF-treated subjects (137.6+/-42.6 versus 104.1+/-43.4, P=0.07). CONCLUSION These results support the hypothesis that EDLF contributes to the elevated blood pressure in preeclampsia and suggests a possible role for DIF as a treatment for this condition.
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Affiliation(s)
- C D Adair
- Department of Obstetrics and Gynecology, Section of Maternal Fetal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
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Abstract
OBJECTIVE Elevated blood levels of endogenous digitalis-like factors (EDLF) may decrease erythrocyte sodium pump activity in preeclampsia. As the highest EDLF levels might be expected in severe preeclampsia, we investigated sodium pump activity in that group of patients. STUDY DESIGN Erythrocyte sodium pump activity was determined by (86)Rubidium uptake (in nM per hour per 10(6) cells) in women with severe preeclampsia and those with normal pregnancies, matched for gestational age, and in healthy nonpregnant women (n=12 in each group). Differences between groups were analyzed by a two-sided Student t-test. RESULT Sodium pump activity was significantly increased in normotensive pregnancies as compared with normotensive non-pregnant women (81.4+/-8.4 vs 61.1+/-7.4, mean+/-s.d., p<0.05), and was decreased 43% in severe preeclamptic pregnancies as compared with normotensive pregnancies (46.4+/-14.1 vs 81.4+/-8.4, p<0.05). CONCLUSION Severe preeclampsia is associated with significantly lower erythrocyte sodium pump activity than normotensive pregnancy. These data suggest that plasma levels of a biologically active EDLF are elevated in patients with severe preeclampsia.
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Affiliation(s)
- CD Adair
- Section on Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, The Wake Forest University School of Medicine, Winston Salem, NC, USA,Department of Obstetrics & Gynecology, Department of Biochemistry, Louisiana State University Medical Center, Shreveport, LA, USA,Section on Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, The University of Tennessee College of Medicine, Chattanooga, TN, USA
| | - GT Haupert
- The Renal Unit, Department of Internal Medicine, Harvard Medical School, Charleston, MA, USA
| | - HP Koh
- The Renal Unit, Department of Internal Medicine, Harvard Medical School, Charleston, MA, USA
| | - Y Wang
- Department of Obstetrics & Gynecology, Department of Biochemistry, Louisiana State University Medical Center, Shreveport, LA, USA
| | - J-C Veille
- Section on Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, The Wake Forest University School of Medicine, Winston Salem, NC, USA
| | - V Buckalew
- Section on Nephrology, Department of Internal Medicine, The Wake Forest University School of Medicine, Winston Salem, NC, USA
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Wang Y, Lewis DF, Adair CD, Gu Y, Mason L, Kipikasa JH. Digibind attenuates cytokine TNFalpha-induced endothelial inflammatory response: potential benefit role of digibind in preeclampsia. J Perinatol 2009; 29:195-200. [PMID: 19148111 PMCID: PMC3062270 DOI: 10.1038/jp.2008.222] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Exaggerated inflammatory response occurs in preeclampsia. Preeclampsia is also associated with elevated endogenous digoxin-like factors (EDLFs). Clinical data suggest that Digibind (a polyclonal sheep digoxin binding Fab fragment) binds to EDLF and may have the potential to attenuate vasoconstriction and other clinical symptoms of preeclampsia. This study was undertaken to determine if Digibind could attenuate increased endothelial inflammatory response induced by tumor necrosis factor-alpha (TNFalpha). STUDY DESIGN Confluent endothelial cells were treated with TNFalpha at different concentrations with or without Digibind in culture. Endothelial adhesion molecule ICAM, VCAM and E-selectin expressions were determined by an immunoassay directly detected on the endothelial surface. Effects of Digibind on TNFalpha-induced extracellular signal-regulated kinase and Na(+)/K(+)-ATPase expressions were also examined. RESULT (1) TNFalpha induced dose-dependent increases in ICAM, VCAM and E-selectin expressions in endothelial cells; (2) Digibind could attenuate and reduce TNFalpha-induced upregulation of endothelial E-selectin, ICAM and VCAM expressions. The blocking effect was in a concentration dependent manner; (3) Digibind had no effects on TNFalpha-induced upregulation of extracellular signal-regulated kinase phosphorylation, but could block TNFalpha-induced downregulation of Na(+)/K(+)-ATPase beta1 expression. CONCLUSION Digibind may exert beneficial effects by preserving cell membrane Na(+)/K(+)-ATPase function and consequently to offset increased inflammatory response in endothelial cells.
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Affiliation(s)
- Y Wang
- Department of Obstetrics and Gynecology, Louisiana State University Health Sciences Center, Shreveport, LA 71130, USA.
| | - DF Lewis
- Department of Obstetrics and Gynecology, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - CD Adair
- Section of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Tennessee College of Medicine, Chattanooga, TN, USA
| | - Y Gu
- Department of Obstetrics and Gynecology, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - L Mason
- Section of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Tennessee College of Medicine, Chattanooga, TN, USA
| | - JH Kipikasa
- Section of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Tennessee College of Medicine, Chattanooga, TN, USA
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O'Brien JM, Adair CD, Lewis DF, Hall DR, Defranco EA, Fusey S, Soma-Pillay P, Porter K, How H, Schackis R, Eller D, Trivedi Y, Vanburen G, Khandelwal M, Trofatter K, Vidyadhari D, Vijayaraghavan J, Weeks J, Dattel B, Newton E, Chazotte C, Valenzuela G, Calda P, Bsharat M, Creasy GW. Progesterone vaginal gel for the reduction of recurrent preterm birth: primary results from a randomized, double-blind, placebo-controlled trial. Ultrasound Obstet Gynecol 2007; 30:687-96. [PMID: 17899572 DOI: 10.1002/uog.5158] [Citation(s) in RCA: 165] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
OBJECTIVE Preterm birth is the leading cause of perinatal morbidity and mortality worldwide. Treatment of preterm labor with tocolysis has not been successful in improving infant outcome. The administration of progesterone and related compounds has been proposed as a strategy to prevent preterm birth. The objective of this trial was to determine whether prophylactic administration of vaginal progesterone reduces the risk of preterm birth in women with a history of spontaneous preterm birth. METHODS This randomized, double-blind, placebo- controlled, multinational trial enrolled and randomized 659 pregnant women with a history of spontaneous preterm birth. Between 18 + 0 and 22 + 6 weeks of gestation, patients were assigned randomly to once-daily treatment with either progesterone vaginal gel or placebo until either delivery, 37 weeks' gestation or development of preterm rupture of membranes. The primary outcome was preterm birth at </= 32 weeks of gestation. The trial was analyzed using an intent-to-treat strategy. RESULTS Baseline characteristics were similar in the two treatment groups. Progesterone did not decrease the frequency of preterm birth at </= 32 weeks. There was no difference between the groups with respect to the mean gestational age at delivery, infant morbidity or mortality or other maternal or neonatal outcome measures. Adverse events during the course of treatment were similar for the two groups. CONCLUSION Prophylactic treatment with vaginal progesterone did not reduce the frequency of recurrent preterm birth (</= 32 weeks) in women with a history of spontaneous preterm birth. The effect of progesterone administration in patients at high risk for preterm delivery as determined by methods other than history alone (e.g. sonographic cervical length) requires further investigation.
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Affiliation(s)
- J M O'Brien
- Perinatal Diagnostic Center, Central Baptist Hospital, Lexington, Kentucky, USA.
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DeFranco EA, O'Brien JM, Adair CD, Lewis DF, Hall DR, Fusey S, Soma-Pillay P, Porter K, How H, Schakis R, Eller D, Trivedi Y, Vanburen G, Khandelwal M, Trofatter K, Vidyadhari D, Vijayaraghavan J, Weeks J, Dattel B, Newton E, Chazotte C, Valenzuela G, Calda P, Bsharat M, Creasy GW. Vaginal progesterone is associated with a decrease in risk for early preterm birth and improved neonatal outcome in women with a short cervix: a secondary analysis from a randomized, double-blind, placebo-controlled trial. Ultrasound Obstet Gynecol 2007; 30:697-705. [PMID: 17899571 DOI: 10.1002/uog.5159] [Citation(s) in RCA: 164] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
OBJECTIVE To investigate the efficacy of vaginal progesterone to prevent early preterm birth in women with sonographic evidence of a short cervical length in the midtrimester. METHODS This was a planned, but modified, secondary analysis of our multinational, multicenter, randomized, placebo-controlled trial, in which women were randomized between 18 + 0 and 22 + 6 weeks of gestation to receive daily treatment with 90 mg of vaginal progesterone gel or placebo. Cervical length was measured with transvaginal ultrasound at enrollment and at 28 weeks of gestation. Treatment continued until either delivery, 37 weeks of gestation or development of preterm rupture of membranes. Maternal and neonatal outcomes were evaluated for the subset of all randomized women with cervical length < 28 mm at enrollment. The primary outcome was preterm birth at </= 32 weeks. RESULTS A cervical length < 28 mm was identified in 46 randomized women: 19 of 313 who received progesterone and 27 of 307 who received the placebo. Baseline characteristics of the two groups were similar. In women with a cervical length < 28 mm, the rate of preterm birth at </= 32 weeks was significantly lower for those receiving progesterone than it was for those receiving the placebo (0% vs. 29.6%, P = 0.014). With progesterone, there were fewer admissions into the neonatal intensive care unit (NICU; 15.8% vs. 51.9%, P = 0.016) and shorter NICU stays (1.1 vs. 16.5 days, P = 0.013). There was also a trend toward a decreased rate of neonatal respiratory distress syndrome (5.3% vs. 29.6%, P = 0.060). CONCLUSION Vaginal progesterone may reduce the rate of early preterm birth and improve neonatal outcome in women with a short sonographic cervical length.
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Affiliation(s)
- E A DeFranco
- Department of Obstetrics and Gynecology and Center for Preterm Birth Research, Washington University School of Medicine, St. Louis, Missouri, USA.
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Kipikasa JH, Adair CD, Williamson J, Breen JM, Medford LK, Sanchez-Ramos L. Use of misoprostol on an outpatient basis for postdate pregnancy. Int J Gynaecol Obstet 2004; 88:108-11. [PMID: 15694083 DOI: 10.1016/j.ijgo.2004.10.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2004] [Revised: 10/20/2004] [Accepted: 10/22/2004] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Within the obstetric community, several studies suggest that cervical ripening and labor induction after 40 weeks' gestation leads to improved maternal and neonatal outcomes. The most effective drug regimen to safely promote labor has not been determined. METHOD Forty-nine subjects followed in an outpatient obstetrical clinic with pregnancies of at least 40 weeks' gestation, and an unfavorable Bishop score were assigned randomly to receive oral misoprostol 50 or 25 microg every 3 days for a maximum of three doses. RESULTS Twenty-three subjects received misoprostol 25 microg and 26 received 50 microg. The mean interval (+/-standard deviation) from start of cervical ripening to delivery was 2.4 days +/-0.3 vs. 3.9 days +/-0.7 for the 50 and 25 microg groups (P<0.05). No adverse events were noted. However, due to small sample size, less frequent adverse events may be missed. Type II errors cannot be excluded. CONCLUSION In the prevention of postdate pregnancy, outpatients use of oral misoprostol 50 microg appears to result in earlier delivery, as compared to 25 microg.
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Affiliation(s)
- J H Kipikasa
- Department of Obstetrics and Gynecology, Section on Maternal-Fetal Medicine, The University of Tennessee College of Medicine, Chattanooga Unit, Chattanooga, TN, USA.
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Lewis DF, Barrilleaux PS, Wang Y, Adair CD, Baier J, Kruger T. Detection of interleukin-6 in maternal plasma predicts neonatal and infectious complications in preterm premature rupture of membranes. Am J Perinatol 2001; 18:387-91. [PMID: 11731892 DOI: 10.1055/s-2001-18694] [Citation(s) in RCA: 16] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
The objective of this study is to determine if the detection of interleukin-6 (IL-6) in maternal plasma prior to delivery predicts neonatal and/or infectious complications in patients with preterm premature rupture of membranes. Patients with preterm premature rupture of membranes between 24 and 35 weeks' gestation were asked to participate in the study. Maternal blood was obtained prior to delivery. All patients received Ampicillin-sulbactam and steroids. IL-6 concentrations were determined by enzyme-linked immunoadsorbent assay (ELISA) using 50 mL of plasma assayed in duplicate. ELISA sensitivity was 18 pg/mL. Neonatal and infectious complications examined were respiratory distress syndrome, necrotizing enterocolitis, intraventricular hemorrhage, intra-amniotic infection, presumed neonatal sepsis, neonatal sepsis, and congenital pneumonia. Fifty-seven patients' plasma was analyzed. Thirty-five had positive plasma IL-6 prior to delivery. Twenty-seven patients had at least one neonatal complication with 24 (89%) being positive for IL-6. Of the 30 patients without complications, only 11 (37%) were positive (p = 0.0001, OR 13.8. 95% CI, 2.93-74.7). A subanalysis of patients who received a course of corticosteroids was performed and significance was maintained. Ten of 13 patients (77%) with neonatal complications had positive IL-6 compared with 40% without complications (p <or=0.01). Infectious morbidity occurred in 32 patients with 24 having positive IL-6 values (75%). Only 11 of 25 (44%) without infections were positive (p <or=0.03, OR 3.82, 95%, CI 1.09-13.0). The presence of IL-6 in the maternal plasma predicted patients with neonatal complications. These correlations persisted when the data were stratified for those patients who received corticosteroids. It also predicted infectious complications.
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Affiliation(s)
- D F Lewis
- Department of Obstetrics and Gynecology and Pediatrics, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
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Abstract
OBJECTIVE To compare maternal and neonatal outcomes in elective cesarean vs. attempted vaginal delivery for breech presentation at or near term. METHODS We reviewed the maternal and neonatal charts of all singleton breech deliveries of at least 35 weeks' gestation or 2000 g delivered between 1986 and 1997 at our institution. Patients delivered by elective cesarean were compared to those attempting a vaginal delivery. The neonatal outcomes analyzed were: corrected mortality; Apgar scores less than 7 at 5 min; abnormal umbilical cord blood gases; birth trauma; and admissions to the intensive care nursery. Maternal morbidity was also assessed and compared. RESULTS Of 848 women meeting criteria for evaluation, 576 were delivered by elective cesarean while 272 attempted a vaginal delivery. Of 272 women undergoing a trial of labor, 203 (74.6%) were delivered vaginally, while 69 (25.4%) failed an attempt at vaginal delivery and underwent a cesarean. When comparing patients delivered by elective cesarean with those attempting a vaginal delivery, no significant differences were noted in neonatal outcomes. However, maternal morbidity was higher among women delivered by cesarean, regardless of the indications for the procedure. Similar neonatal and maternal results were noted when nulliparous patients were analyzed separately. CONCLUSIONS Cesarean delivery of selected near-term infants presenting as breech is associated with increased maternal morbidity without corresponding improvement in neonatal outcomes.
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Affiliation(s)
- L Sanchez-Ramos
- Department of Obstetrics and Gynecology, University of Florida Health Sciences Center, Jacksonville, FL, USA.
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10
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Abstract
Nonpharmacologic and alternative methods of cervical ripening are highly efficacious, safe, and, in general, have more favorable cost advantages when compared with their pharmacologic counterparts. Unfortunately, there have been limited research efforts to precisely determine the overall usefulness and the most clinically efficient application for many of these. These methods also share similar time courses to affect cervical change and are, in general, not as rapid as pharmacologic applications. Thus, limitations of time may ultimately determine the choice between alternative methods and pharmacologic modalities. Most of these alternative methods require more than 12 to 18 hours, and some even days to accomplish favorable changes in the cervix to promote ripening and subsequent labor initiation. These methods have also been shown to be efficient and safe, the most important criteria for any ripening agent, for both the maternal and fetal compartments. These alternative methods will continue to occupy an appropriate place in the armamentarium of cervical ripeners and labor-inducing agents.
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Affiliation(s)
- C D Adair
- University of Tennessee College of Medicine, Chattanooga, USA
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Lewis DF, Adair CD, Weeks JW, Barrilleaux PS, Edwards MS, Garite TJ. A randomized clinical trial of daily nonstress testing versus biophysical profile in the management of preterm premature rupture of membranes. Am J Obstet Gynecol 1999; 181:1495-9. [PMID: 10601934 DOI: 10.1016/s0002-9378(99)70395-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.4] [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: 11/19/2022]
Abstract
OBJECTIVE Our purpose was to evaluate the ability of 2 different antepartum testing modalities to predict infectious morbidity in patients with preterm premature rupture of membranes. STUDY DESIGN During a 36-month period, patients with preterm premature rupture of membranes (at 23 to 34 weeks of gestation) were randomly assigned to either a daily nonstress test or a biophysical profile, after a 24-hour observational period. We used the original scoring system of Manning et al for the biophysical profile, with a score of </=6 considered abnormal. Nonstress test results were considered abnormal if the test was nonreactive or if the patient had late decelerations or significant variable decelerations; abnormal results led to further evaluation with a biophysical profile. Results of the last test before delivery were evaluated to determine whether infectious complications had been predicted. RESULTS One hundred thirty-five patients were enrolled in the study. Demographics, pregnancy characteristics, and neonatal outcomes were similar. Neither the daily nonstress test nor the daily biophysical profile had good sensitivity for predicting infectious complications (39.1% and 25.0%, respectively). However, both had good specificity (84.6% and 92.6%, respectively). Positive and negative predictive values were 52.9% and 75.9%, respectively, for the daily nonstress test and 66.7% and 68.4%, respectively, for the daily biophysical profile. Cost was significantly higher in the daily biophysical profile group. Nonstress testing of patients at <28 weeks' gestation generally required a backup biophysical profile. CONCLUSION Neither the daily nonstress test nor the daily biophysical profile had good sensitivity for predicting infectious complications after preterm premature rupture of membranes.
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Affiliation(s)
- D F Lewis
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Louisiana State University Medical Center, Shreveport, USA
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12
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Wang Y, Baier J, Adair CD, Lewis DF, Krueger S, Kruger T, Gurski M, Brown E. Interleukin-8 stimulates placental prostacyclin production in preeclampsia. Am J Reprod Immunol 1999; 42:375-80. [PMID: 10622468 DOI: 10.1111/j.1600-0897.1999.tb00115.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [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: 11/29/2022] Open
Abstract
PROBLEM Our purpose was to determine placental interleukin (IL)-8 production and its correlation with the prostacyclin production in normal and preeclamptic pregnancies and to evaluate the beneficial effect of IL-8 on prostacyclin production. METHOD OF STUDY We determined 1) the in vitro production of IL-8 and prostacyclin by placental villous tissues from normal and preeclamptic pregnancies and 2) the production of prostacyclin by villous tissues from preeclampsia treated with recombinant human IL-8 (rhIL-8). IL-8 levels were measured by enzyme-linked immunosorbent assay and prostacyclin by radioimmunoassay of 6-keto PGF1alpha, the stable metabolite of prostacyclin. RESULTS 1) Placental production of IL-8 and 6-keto PGF1alpha were significantly less in preeclampsia than in normal pregnancies, P<0.05. 2) Placental production of 6-keto PGF1alpha and IL-8 was significantly correlated in preeclampsia, P<0.01. 3) Placental tissues treated with IL-8 exhibited a concentration-dependent increase in 6-keto PGF1alpha production. CONCLUSIONS Placental tissues from preeclampsia produce significantly less IL-8 than tissues from normal pregnancies, which correlates with decreased prostacyclin production. IL-8 improves placental prostacyclin production in preeclampsia.
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Affiliation(s)
- Y Wang
- Department of Obstetrics and Gynecology, Louisiana State University Medical Center, Shreveport 71130, USA
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Wang Y, Adair CD, Weeks JW, Lewis DF, Alexander JS. Increased neutrophil-endothelial adhesion induced by placental factors is mediated by platelet-activating factor in preeclampsia. J Soc Gynecol Investig 1999; 6:136-41. [PMID: 10376269 DOI: 10.1016/s1071-5576(99)00004-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Endothelial cell activation or dysfunction and neutrophil-endothelial cell adhesion have been suggested to be important in the pathophysiology of preeclampsia. However, the mechanisms that underlie the alteration of endothelial cell function in preeclampsia are unknown. Placenta from preeclamptic pregnancies produces mediators and autacoids, which may be released into the maternal circulation and modulate endothelial function. In this study, the effect of placental factor(s) on neutrophil-endothelial adhesion and the possible role of platelet-activating factor (PAF) in mediating the response have been examined. METHODS Endothelial cells were isolated from human umbilical veins (HUVECs) from normal pregnancies. Confluent primary passage HUVECs were exposed to conditioned medium derived from normal and preeclamptic placental tissue cultures, with unconditioned medium as a control. Placental-conditioned medium was prepared by incubation of placental whole villous tissue in Dulbecco's Modified Eagle's Medium (DMEM) for 48 hours. Neutrophil-endothelial adhesion assays were performed to evaluate placental factors in mediating neutrophil-endothelial adhesion, and a PAF-3H scintillation proximity assay (SPA) system was used to determine endothelial PAF production. The PAF-receptor antagonist WEB 2086 was used to block placental factor-mediated increased neutrophil-endothelial adhesion induced by conditioned medium derived from preeclamptic placenta. RESULTS Neutrophils were significantly more adherent to HUVECs treated with conditioned medium from preeclamptic placentas (28.44 +/- 2.47%) than to HUVECs treated with conditioned medium from normal placentas (18.95 +/- 1.57%) or with unconditioned medium (14.60 +/- 1.29%, P < .01). Also, HUVECs exposed to preeclamptic placental-conditioned medium produced more PAF than the cells exposed to normal conditioned medium and unconditioned medium, 416.18 +/- 17.14 pg/1 x 10(7) cells versus 330.90 +/- 35.70 and 296.43 +/- 44.40 pg/1 x 10(7) cells, P < .05, respectively. The PAF receptor antagonist WEB 2086 completely blocked increased neutrophil-endothelial adhesion induced by preeclamptic placental-conditioned medium (13.24 +/- 0.81% versus 31.31 +/- 4.75%, P < .01). CONCLUSION In preeclampsia, the placenta releases one or more factors promoting neutrophil-endothelial adhesion. The increased neutrophil-endothelial adhesion thereby induced is a PAF-mediated event. It is suggested that if preeclamptic placentas release toxic factors into the maternal circulation in vivo, these factors may contribute to the altered vascular endothelial cell function in preeclampsia.
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Affiliation(s)
- Y Wang
- Department of Obstetrics and Gynecology, Louisiana State University Medical Center, Shreveport 71130, USA.
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Adair CD, Weeks JW, Barrilleaux S, Edwards M, Burlison K, Lewis DF. Oral or vaginal misoprostol administration for induction of labor: a randomized, double-blind trial. Obstet Gynecol 1998; 92:810-3. [PMID: 9794674 DOI: 10.1016/s0029-7844(98)00278-6] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.5] [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: 02/09/2023]
Abstract
OBJECTIVE To compare the efficacy and vaginal birth intervals after intravaginal or oral misoprostol for labor induction. METHODS One hundred seventy-eight women were randomized to one of two double-blind groups: 1) oral misoprostol 200 microg and one-half tablet placebo intravaginal or 2) oral placebo tablet and one-half tablet of a 100-microg misoprostol intravaginal (dose 50 microg). Doses were repeated every 6 hours until labor was established (maximum of three doses). RESULTS Ninety-three subjects were assigned to oral misoprostol and 85 to intravaginal administration. Oral administration was accompanied by significantly shorter intervals to the onset of uterine contractility (133+/-78 minutes versus 168+/-93, P < .01) but a higher incidence of abnormal uterine contractile activity (tachysystole 38.7% versus 20.0%, P < .01; hyperstimulation syndrome 44.1% versus 21.2%, P < .01). No adverse maternal or neonatal outcomes were noted, nor were there differences in cesarean delivery rates or total lengths of labor. CONCLUSION Oral administration of 200 microg misoprostol has similar efficacy to intravaginal administration of 50 microg but is associated with more frequent abnormal uterine contractility.
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Affiliation(s)
- C D Adair
- Department of Obstetrics and Gynecology, Louisiana State University School of Medicine-Shreveport, USA
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Wang Y, Adair CD, Coe L, Weeks JW, Lewis DF, Alexander JS. Activation of endothelial cells in preeclampsia: increased neutrophil-endothelial adhesion correlates with up-regulation of adhesion molecule P-selectin in human umbilical vein endothelial cells isolated from preeclampsia. J Soc Gynecol Investig 1998; 5:237-43. [PMID: 9773398 DOI: 10.1016/s1071-5576(98)00023-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
OBJECTIVE Increased endothelial activation has been suggested to be important in the pathophysiology for preeclampsia. Our objective was to examine whether in preeclampsia neutrophil adherence to endothelial cells is increased and whether endothelial cell-surface adhesion molecule expression is up-regulated. METHODS Endothelial cells were isolated from normal (n = 10) and preeclamptic (n = 9) human umbilical veins (HUVECs). Neutrophils were isolated from normal, healthy, nonpregnant female volunteers. Freshly isolated neutrophils were labeled with 51Cr, and labeled neutrophils were coincubated with confluent normal and preeclamptic endothelial monolayers. Adhesion assays were then performed. To determine whether in preeclampsia endothelial cellular-surface adhesion molecules are responsible for increased neutrophil-endothelial adhesion, cellular adhesion molecule expression of P-selectin, intercellular adhesion molecule-1 (ICAM-1), vascular cellular adhesion molecule-1 (VCAM-1), and E-selectin were examined by an enzyme-linked binding assay. Furthermore, adhesion assays were also performed on HUVECs pretreated with antibodies against P-selectin, ICAM-1, VCAM-1, and E-selectin. RESULTS Neutrophil adhesion to the HUVECs from preeclamptic pregnancies was significantly increased compared with neutrophil adhesion to the HUVECs from normal pregnancies (P < .01). Expression of cellular-surface adhesion molecule of P-selectin was significantly higher (P < .01) and ICAM-1 was significantly lower (P < .05) in HUVECs isolated from preeclampsia than from normal controls, whereas there was no difference for VCAM-1 and E-selectin expression between HUVECs from normal and preeclamptic pregnancies. No differences were found for neutrophil-endothelial adhesion on normal HUVECs pretreated with anti-P-selectin, anti-ICAM-1, anti-VCAM-1, and anti-E-selectin compared with the untreated cells. However, pretreatment of preeclampsia HUVECs with anti-P-selectin, anti-ICAM-1, anti-VCAM-1, and anti-E-selectin completely or partially blocked the neutrophil-endothelial adhesion compared to the untreated cells. CONCLUSION There is a significant increase in neutrophil adhesion to HUVECs that are isolated from preeclamptic pregnancies compared with normal controls. This increase appears to be a result of up-regulation of the cell-surface adhesion molecule P-selectin. Elevated P-selectin expression may play a significant role in neutrophil-endothelial hyperadhesiveness and contribute to vascular complications associated with preeclampsia.
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Affiliation(s)
- Y Wang
- Department of Obstetrics and Gynecology, Louisiana State University Medical Center, Shreveport, USA.
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Lewis DF, Edwards MS, Asrat T, Adair CD, Brooks G, London S. Can shoulder dystocia be predicted? Preconceptive and prenatal factors. J Reprod Med 1998; 43:654-8. [PMID: 9749414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To evaluate the predictability of shoulder dystocia using preconceptive and prenatal risk factors. STUDY DESIGN Data from 1,622 term patients with prenatal care prior to 20 weeks who delivered single, vertex fetuses during a consecutive 12-month period were analyzed. Two groups were chosen. The first group was patients whose fetuses experienced shoulder dystocia during delivery (cases). The second group (controls) consisted of the remaining patients, whose fetuses had not experienced shoulder dystocia. The two groups were compared with regard to demographics and pregnancy characteristics. RESULTS Factors not significantly different between the two groups included were obesity, multiparity, history of diabetes, short maternal stature, postdatism and advanced maternal age. The incidence of macrosomia was significantly higher (P < .001) in cases (35.4%) than in controls (4.8%). Other factors associated with shoulder dystocia were previous shoulder dystocia, concurrent diabetes, prior delivery of a fetus > 4,000 g and excessive weight gain during pregnancy. Many factors previously associated with shoulder dystocia were found to be nonsignificant in our study. CONCLUSION Macrosomia appears to be the single important factor associated with shoulder dystocia which, even in the presence of significant risk factors, remains largely unpredictable.
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Affiliation(s)
- D F Lewis
- Department of Obstetrics and Gynecology, Louisiana State University Medical Center, Shreveport 71130, USA
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Abstract
Obesity is known to increase maternal morbidity and mortality. We describe a case of obstructive sleep apnea due to obesity and discuss our treatment of the resulting pulmonary hypertension. A patient was transferred to our hospital at 29 weeks' gestation with severe anasarca and more than a 100-pound weight gain during pregnancy. Pulmonary hypertension due to obstructive sleep apnea was diagnosed. The patient was treated with nasal continuous positive airway pressure (CPAP) during sleep and remained in the hospital the remainder of her pregnancy. She had a massive spontaneous diuresis during her hospital stay and lost more than 100 pounds. She was delivered at term via cesarean section because of transverse lie. Preoperative hemodynamic monitoring confirmed the diagnosis of pulmonary hypertension. This represents the first case in the literature of obstructive sleep apnea leading to pulmonary hypertension in pregnancy. This patient responded well to nasal CPAP as evident by the massive diuresis and good maternal outcome.
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Affiliation(s)
- D F Lewis
- Department of Obstetrics and Gynecology, Louisiana State University Medical Center, Shreveport 71130-3932, USA
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Abstract
OBJECTIVE To determine side effect profiles and cure rates of azithromycin compared with erythromycin in the treatment of chlamydial cervicitis complicating pregnancy. METHODS Pregnant patients with positive DNA antigen assays for Chlamydia trachomatis were randomized to either azithromycin, 1 g oral slurry in a single dose, or erythromycin, 500 mg every 6 hours for 7 days. Repeat assays were planned for 3 weeks after therapy. Side effects, compliance, and treatment efficacy were assessed. RESULTS One hundred six women were enrolled, and eighty-five women completed the protocol. Significantly fewer gastrointestinal side effects were noted in the azithromycin group than in the erythromycin group (11.9% versus 58.1%, P < or = .01). Enhanced compliance was noted with azithromycin, because it was given in a single observed dose. Similar treatment efficacy was noted between azithromycin and erythromycin (88.1% versus 93.0%, P > .05). CONCLUSION Compared with erythromycin, azithromycin is associated with significantly fewer gastrointestinal side effects in pregnancy. This association, along with the ease of administration and similar efficacy, suggests that azithromycin should be considered for the initial treatment of chlamydial cervicitis in pregnancy.
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Affiliation(s)
- C D Adair
- Department of Obstetrics and Gynecology, The Bowman Gray School of Medicine/Wake Forest University, Winston-Salem, North Carolina, USA.
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Lewis DF, Bergstedt S, Edwards MS, Burlison S, Gallaspy JW, Brooks GG, Adair CD. Successful magnesium sulfate tocolysis: is "weaning" the drug necessary? Am J Obstet Gynecol 1997; 177:742-5. [PMID: 9369812 DOI: 10.1016/s0002-9378(97)70261-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [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: 02/05/2023]
Abstract
OBJECTIVE Magnesium sulfate is the most commonly used tocolytic agent for preterm labor. A common clinical practice is to slowly discontinue the drug (wean) after successful tocolysis. Our objective was to determine the necessity of this practice. STUDY DESIGN A prospective, randomized clinical trial was performed from June 1993 to July 1996. After successful magnesium sulfate tocolysis, patients with preterm labor were randomized to two groups: stopping the drug abruptly (no weaning) or gradually weaning the drug (approximately 1 gm every 4 hours). Preterm labor was defined as documented cervical change with regular uterine contractions or regular uterine contractions with a cervix of 2 cm and 75% effacement. The primary outcome variable was the necessity to reinstitute magnesium sulfate therapy within 24 hours of discontinuation of successful tocolysis. RESULTS One hundred forty-one patients completed the study. No patient in the no-wean group required retocolysis within 24 hours of magnesium discontinuation. However, eight patients in the wean group required retocolysis within 24 hours of magnesium discontinuation (p = 0.01). Significantly more patients in the wean group had retocolysis during pregnancy (3 vs 12, p = 0.03). Patients in the wean group were also in the labor and delivery unit longer and, as would be anticipated, received magnesium sulfate significantly longer. No differences in the neonatal outcomes were noted between the two groups. Seventy-seven percent of the patients in the study were delivered prematurely. CONCLUSION This study demonstrated an increased need for retocolysis in the group weaned from magnesium sulfate. We also found that patients in the wean group had an increased labor and delivery time and a longer administration time of magnesium sulfate. Thus weaning magnesium sulfate increases health care cost. The practice of weaning magnesium sulfate does not appear beneficial.
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Affiliation(s)
- D F Lewis
- Department of Obstetrics and Gynecology, Louisiana State University Medical Center, Shreveport 71130-3932, USA
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Del Valle GO, Adair CD, Ramos EE, Gaudier FL, Sanchez-Ramos L, Morales R. Interpretation of the TDx-FLM fluorescence polarization assay in pregnancies complicated by diabetes mellitus. Am J Perinatol 1997; 14:241-4. [PMID: 9259935 DOI: 10.1055/s-2007-994135] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The objective of this paper is to determine the applicability of the Abbott TDx-FLM fluorescence polarization assay in pregnancies complicated by diabetes mellitus. Retrospective review of records of women with pregnancies complicated by diabetes who underwent amniocentesis for fetal lung maturity using the Abbott TDx-FLM assay within 3 days of delivery was considered. Maternal diabetic control, neonatal birth weight, Apgar scores, umbilical cord gases, admissions to Neonatal Intensive Care Unit (NICU), development of respiratory distress syndrome (RDS) were evaluated. One hundred twenty-one patients with diabetes mellitus were identified. Thirteen (10.7%) had an FLM < or = 70 mg/g and 108 patients had > or = 70 mg/g. All obstetrical and diabetic variables were similar. RDS was not observed in neonates who had an FLM of > or = 70 mg/g. One neonate had RDS (FLM = 7.2 mg/g). The TDx-FLM > or = 70 mg/g may be interpreted as mature when obtained from transabdominal amniocentesis.
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Affiliation(s)
- G O Del Valle
- Regional Obstetric Consultants, Jacksonville, FL 32207, USA
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Lewis DF, Bergstedt S, Adair CD, Edwards MS, Burlison S, Gallaspy JW, Brooks GG. Successful magnesium sulfate tocolysis: is “weaning” the drug necessary. Am J Obstet Gynecol 1997. [DOI: 10.1016/s0002-9378(97)80085-3] [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: 10/24/2022]
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Abstract
OBJECTIVE To assess prospectively the utility of a modification of the Mueller-Hillis maneuver in predicting abnormalities of the second stage of labor. METHODS The Mueller-Hillis maneuver was modified by limiting its use to the second stage of labor during a contraction. The maneuver was performed by one examiner; descent of 1 cm or more was deemed a positive maneuver. Descent less than 1 cm was deemed a negative maneuver. Labor outcomes were analyzed according to the results of this maneuver. RESULTS Seventy patients were enrolled in this study. Fifty-one (72.9%) had > or = 1 cm descent maneuver and 19 (27.1%) had < or = 1 cm descent. A descent > or = 1 cm was significantly predictive of vaginal delivery (100%) and a descent < or = 1 cm was significantly associated with an increased cesarean section rate (P = 0.001), prolonged second stage of labor (P = 0.001), abnormal position (P = 0.01) and higher station (P = 0.001). CONCLUSIONS A positive modified Mueller-Hillis maneuver in second stage labor had a high predictive value for vaginal delivery, whereas a negative maneuver was significantly associated with high operative delivery rate, prolonged second stage labor and abnormal position. These results indicate that this modification of the Mueller-Hillis maneuver needs to be considered for its utility in second stage labor.
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Affiliation(s)
- M R March
- Department of Obstetrics and Gynecology, Bowman Gray School of Medicine of Wake Forest University, Winston-Salem, NC, USA
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Adair CD, Sanchez-Ramos L, Briones DL, Ogburn P. The effect of high dietary n-3 fatty acid supplementation on angiotensin II pressor response in human pregnancy. Am J Obstet Gynecol 1996; 175:688-91. [PMID: 8828435 DOI: 10.1053/ob.1996.v175.a74248] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [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: 02/02/2023]
Abstract
OBJECTIVE Our purpose was to evaluate the effects of n-3 fatty acid supplementation on vascular reactivity as measured by the angiotensin II sensitivity test. STUDY DESIGN Ten subjects with uneventful pregnancies, who were free of any chronic medical illnesses, between 24 and 34 weeks' gestation participated. Each subject was provided with OMEGA-3 700 softgel capsules and instructed to take three tablets three times daily (approximately 3.6 gm of eicosapentaenoic acid). The angiotensin II sensitivity test was performed before and 28 days after supplementation. Compliance was assessed by analysis of computerized pill bottles. Statistical analyses of the data were performed with a paired t test for evenly distributed continuous data. A sample size of eight patients was required to detect a difference in effective pressor dose of > or = 10 ng/kg/min between the presupplement and postsupplement results, assuming an alpha of 0.05 and a beta of 0.20 (80% power). RESULTS The effective pressor dose before treatment (13.6 +/- 6.3 ng/kg/min) (mean +/- SD) was significantly less (p = 0.001) than after supplementation (35.8 +/- 15.9 ng/kg/min). CONCLUSIONS High-dose n-3 fatty acid supplementation resulted in an enhancement of the pregnancy-acquired refractoriness to angiotensin II.
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Affiliation(s)
- C D Adair
- Department of Obstetrics and Gynecology, University of Florida Health Science Center, Jacksonville, USA
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Adair CD, Ernest JM, Sanchez-Ramos L, Burrus DR, Boles ML, Veille JC. Meconium-stained amniotic fluid-associated infectious morbidity: a randomized, double-blind trial of ampicillin-sulbactam prophylaxis. Obstet Gynecol 1996; 88:216-20. [PMID: 8692505 DOI: 10.1016/0029-7844(96)00148-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.9] [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
OBJECTIVE To evaluate the efficacy of intrapartum prophylactic administration of ampicillin-sulbactam in reducing intraamniotic infection and postpartum endometritis in patients with meconium-stained amniotic fluid (AF). METHODS Patients with intrapartum meconium-stained AF were randomized to receive either ampicillin-sulbactam or normal saline (placebo) intravenously at the time of diagnosis of meconium and every 6 hours until delivery. The outcomes of the two groups were compared with respect to intra-amniotic infection and postpartum endometritis. RESULTS During the study period, 332 patients with meconium-stained AF were approached for participation, and 120 patients met inclusion criteria and were enrolled. Patient demographics, labor, and delivery characteristics were similar. Ampicillin-sulbactam reduced the incidence of intra-amniotic infection from 23.3 to 6.7%, (P = .02; relative risk [RR] 0.48, 95% confidence interval [CI] 0.22-0.98). The incidence of postpartum endometritis was also reduced, but the difference was statistically nonsignificant (8.3 versus 16.7%, P = .16; RR 0.64, 95% CI 0.30-1.33). CONCLUSION Prophylactic intravenous ampicillin-sulbactam significantly reduces intra-amniotic infection in patients with meconium-stained AF.
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Affiliation(s)
- C D Adair
- Department of Obstetrics and Gynecology, Bowman Gray School of Medicine, Winston-Salem, North Carolina, USA
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Adair CD, Sanchez-Ramos L, Whitaker D, McDyer DC, Farah L, Briones D. Trial of labor in patients with a previous lower uterine vertical cesarean section. Am J Obstet Gynecol 1996; 174:966-70. [PMID: 8633677 DOI: 10.1016/s0002-9378(96)70334-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.1] [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
OBJECTIVE Our purpose was to determine the efficacy and safety of a trial of labor in patients previously delivered at least once by a lower uterine vertical cesarean section. STUDY DESIGN A retrospective review was performed at a single tertiary perinatal center, The University of Florida Health Science Center, Jacksonville. The medical records of all patients with a previous low vertical cesarean section who underwent a trial of labor during a 72-month period from January 1988 until December 1993 were reviewed. The medical records of the next two patients who did not have a prior uterine incision admitted to labor and delivery after the index case served as the controls. The duration and outcome of labor, including mode of delivery, maternal and perinatal morbidity, and birth trauma were evaluated. RESULTS Of 77 patients with a previous low vertical cesarean incision, 11 (14.3%) had a repeat operation compared with 14 of 154 patients (9.0%) in the no previous cesarean section group (not significant). No differences were noted in the incidences of operative vaginal deliveries or prolonged duration of the first or second stages of labor, or in the rate or maximum dose of oxytocin infusion between the two groups. One patient in the previous cesarean section group had uterine rupture. The incidence of umbilical artery pH < or = 7.20 was similar. No difference in the number of infants with 1- or 5-minute Apgar scores < or = 7 was noted. CONCLUSION A trial of labor in women with previous low vertical cesarean sections results in an acceptable rate of vaginal delivery and appears safe for both mother and fetus.
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Affiliation(s)
- C D Adair
- Bowman Gray School of Medicine, Department of Obstetrics and Gynecology, Winston-Salem, NC 27157-1066, USA
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Abstract
OBJECTIVE To evaluate the perinatal morbidity and mortality of fetuses diagnosed with gastroschisis at our Fetal Diagnosis and Treatment Center. METHODS A retrospective review of a regional prenatal diagnostic center. Twenty-nine cases of gastroschisis which were diagnosed, managed, delivered and had corrective surgeries through the Fetal Diagnosis and Treatment Center were identified from 1985 to 1994. Perinatal morbidity and mortality were reviewed. Antepartum testing schemes were reviewed when available to determine whether morbidity or mortality could have potentially been prevented. RESULTS Meconium occurrence, intrauterine growth retardation (IUGR) and oligohydramnios complicated 79%, 41% and 36% of the cases, respectively. The perinatal mortality of this series was 241/1000. Significant differences in perinatal mortality were noted when fetal testing was incorporated (200/1000 vs. 286/1000, P < or = 0.001). CONCLUSION Gastroschisis is associated with a high incidence of IUGR, meconium, oligohydramnios and high perinatal mortality. Antenatal testing appears to significantly lower perinatal mortality in pregnancies complicated by gastroschisis.
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Affiliation(s)
- C D Adair
- Department of Obstetrics and Gynecology, The Bowman Gray School of Medicine, Winston-Salem, NC, USA
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Adair CD, Buckalew V, Taylor K, Ernest JM, Frye AH, Evans C, Veille JC. Elevated endoxin-like factor complicating a multifetal second trimester pregnancy: treatment with digoxin-binding immunoglobulin. Am J Nephrol 1996; 16:529-31. [PMID: 8955766 DOI: 10.1159/000169054] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.5] [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: 02/03/2023]
Abstract
We report a case of a second trimester multifetal pregnancy with preeclampsia associated with an elevated digoxin-like immune factor. Due to the remoteness from viability the patient was offered therapy with digoxin-binding immunoglobulin. No untoward maternal effects were noted.
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Affiliation(s)
- C D Adair
- Bowman Gray School of Medicine, Department of Obstetrics and Gynecology, Winston-Salem, N.C., USA
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Abstract
To determine the efficacy and safety of labor induction in patients previously delivered by at least one low transverse cesarean section, a retrospective review was done at a single tertiary perinatal center, the University of Florida Health Science Center, Jacksonville. All patients with a previous cesarean section who required labor induction from 1988 until the end of 1992 were identified. Duration and outcome of labor induction, including mode of delivery, maternal and perinatal morbidity, and birth trauma, were evaluated. Of 160 patients with a previous cesarean, 50 (31.3%) had a repeat operation compared to 18 (11.2%) in the no previous cesarean group (p = 0.001, odds ratio = 3.59; 95% confidence interval, 1.98, 6.49). Women in the cesarean group had a higher incidence of operative vaginal deliveries, prolonged duration of the first and second stages of labor, rate and maximum dose of oxytocin infusion. One patient in the previous cesarean group experienced uterine rupture. There was no difference in the rate of infants with low 5-minute Apgar scores or with cord pH values less than 7.20. Labor induction in women with previous low transverse cesarean sections results in an acceptable rate of vaginal delivery and appears safe for both mother and fetus.
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Affiliation(s)
- C D Adair
- Department of Obstetrics and Gynecology, University of Florida Health Science Center, Jacksonville, USA
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Debevec C, Adair CD, Veille JC. Transvaginal visualization of the cervix after instillation of water in the vaginal canal. J Ultrasound Med 1995; 14:804. [PMID: 8551544 DOI: 10.7863/jum.1995.14.11.804] [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] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
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Adair CD, Sanchez-Ramos L, McDyer DL, Gaudier FL, Del Valle GO, Delke I. Predicting fetal lung maturity by visual assessment of amniotic fluid turbidity: comparison with fluorescence polarization assay. South Med J 1995; 88:1031-3. [PMID: 7481958 DOI: 10.1097/00007611-199510000-00006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [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: 01/25/2023]
Abstract
We prospectively studied 159 patients having clinically indicated amniocentesis. Amniotic fluid (3 to 5 mL) was placed in a nonheparinized glass tube. This sample was then classified as turbid (indicating maturity) or clear (indicating immaturity) on the basis of a single examiner's ability to read newspaper print through the glass tube. These results were then compared with fluorescence polarization values for the same sample. A value of 70 mg/g was considered positive evidence of fetal lung maturity. By study criteria, 62 samples (39%) indicated immaturity and 97 (61%) indicated maturity. Turbidity correctly identified 89 samples that produced fluorescence polarization values of at least 70 mg/g. Turbidity as a predictor of fetal lung maturity when compared with fluorescence polarization assay has a 91% positive and 87% negative predictive value. Visual inspection of amniotic fluid may be of value in areas where sophisticated methods are unavailable.
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Affiliation(s)
- C D Adair
- Department of Obstetrics and Gynecology, University of Florida Health Science Center, Jacksonville, USA
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Sanchez-Ramos L, Farah LA, Kaunitz AM, Adair CD, Del Valle GO, Fuqua P. Preinduction cervical ripening with commercially available prostaglandin E2 gel: a randomized, double-blind comparison with a hospital-compounded preparation. Am J Obstet Gynecol 1995; 173:1079-84. [PMID: 7485297 DOI: 10.1016/0002-9378(95)91330-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [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
OBJECTIVE Our purpose was to compare the efficacy, safety, and cost of commercially available dinoprostone cervical gel 0.5 mg with a hospital-compounded formulation. STUDY DESIGN One hundred thirty-four patients undergoing labor induction were randomly assigned to one of two cervical ripening groups. Commercially available dinoprostone gel 0.5 mg or a compounded formulation of 0.5 mg of prostaglandin E2 gel was administered endocervically. On the basis of cervical scores, gel was reapplied at 6-hour intervals for a maximum of three doses. Physicians managing labor were blinded as to treatment group allocation. RESULTS Among 134 patients evaluated, 70 were allocated to the commercially available gel and 64 to the compounded gel. No statistically significant differences were noted between the treatment groups with respect to start-to-delivery interval, number of doses, amount of oxytocin, or neonatal adverse outcomes. However, cesarean delivery was performed less frequently in patients in the group receiving the commercially available gel (12.9%) than in the group receiving the compounded gel (28.1%) (p = 0.03). Because of the higher cesarean delivery rate in the compound group, use of this formulation was not associated with cost savings. CONCLUSIONS The two prostaglandin E2 formulations appeared equivalent with respect to efficacy. An unexplained higher cesarean section rate, however, was associated with the use of the compounded preparation.
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Affiliation(s)
- L Sanchez-Ramos
- Department of Obstetrics and Gynecology, University of Florida Health Science Center, Jacksonville, USA
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Abstract
Amnioinfusion has become accepted in the management of intrapartum cord compression, meconium-stained fluid, and oligohydramnios. Limited experience exists regarding amnioinfusion in patients undergoing a trial of labor after cesarean section and its potential complications. We report a case of trial of labor in which uterine rupture occurred following intrapartum amnioinfusion. This case demonstrates the need for careful attention to amnioinfusion volumes and administration in patients with a previous cesarean section.
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Affiliation(s)
- C D Adair
- Department of Obstetrics and Gynecology, University of Flordia Health Science Center, Jacksonville, USA
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Abstract
We describe two pregnancies in the same patient with Caroli's disease (congenital dilatation of the intrahepatic bile ducts). The first pregnancy was uneventful concerning the maternal Caroli's disease. The second pregnancy highlights the serious and potentially lethal complications of an acute episode to both the fetus and mother. The patient had acute ascending cholangitis, disseminated intravascular coagulopathy, and septic shock. Fetal distress necessitated delivery by cesarean section. The mother's postoperative course required prolonged critical care and interdisciplinary consultation. Both mother and neonate survived. We present the first report of Caroli's disease in pregnancy and review implications to the pregnant patient.
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Affiliation(s)
- C D Adair
- Baptis Medical Center, Jacksonville, FL, USA
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Sanchez-Ramos L, Adair CD, Kaunitz AM, Briones DK, Del Valle GO, Delke I. Calcium supplementation in mild preeclampsia remote from term: a randomized double-blind clinical trial. Obstet Gynecol 1995; 85:915-8. [PMID: 7770260 DOI: 10.1016/0029-7844(95)00052-s] [Citation(s) in RCA: 20] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To determine whether calcium supplementation prevents progression to severe disease in preterm nulliparous women with mild preeclampsia. METHODS Seventy-five women hospitalized at 24-36 weeks' gestation because of mild preeclampsia were randomized to receive either 2 g/day of elemental calcium (36 women) or placebo (39). Both groups had similar demographic characteristics, initial blood pressure measurements, and amount of proteinuria. Diagnostic criteria and clinical management for severe preeclampsia were applied consistently. RESULTS Eighteen of 36 calcium-treated subjects (50%, 95% confidence interval [CI] 33-67) developed severe preeclampsia, compared with 19 of 39 (48.7%, 95% CI 32-65) in the placebo group (relative risk 1.03, 95% CI 0.64-1.03; P = 1.00). Blood pressure values, gestational age at delivery, newborn weights, incidence of low Apgar scores, and umbilical arterial blood gases were similar for the two groups. CONCLUSION Calcium supplementation does not prevent severe preeclampsia in preterm patients with mild disease.
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Affiliation(s)
- L Sanchez-Ramos
- Department of Obstetrics and Gynecology, University of Florida Health Science Center, Jacksonville, USA
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Morales R, Adair CD, Sanchez-Ramos L, Gaudier FL. Vacuum extraction of preterm infants with birth weights of 1,500-2,499 grams. J Reprod Med 1995; 40:127-30. [PMID: 7738922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
This study evaluated neonatal morbidity in preterm infants with birth weights of 1,500-2,499 who were delivered by vacuum extraction. The retrospective, observational study covered 61 infants delivered vaginally with vacuum extraction versus 122 matched controls delivered spontaneously. All infants were at < 37 weeks of gestation, with birth weights ranging from 1,500 to 2,499 g. Main neonatal outcomes studied were Apgar scores, umbilical artery blood pH and base excess, intraventricular hemorrhage, admission to the neonatal intensive care unit and length of hospital stay. The study population did not differ in any maternal or neonatal demographic parameter. There was a decreased need for episiotomies in the vacuum-assisted deliveries versus the controls (41% versus 57%, P = .01, odds ratio = .51, confidence interval = .27, .96). Neonatal morbidity was not significantly different in infants with vacuum-assisted deliveries. Vacuum extraction does not seem to increase neonatal morbidity in preterm infants with birth weights of 1,500-2,499 g.
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Affiliation(s)
- R Morales
- Department of Obstetrics and Gynecology, University of Florida Health Science Center, Jacksonville, USA
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Sanchez-Ramos L, McAlpine KJ, Adair CD, Kaunitz AM, Delke I, Briones DK. Pyelonephritis in pregnancy: once-a-day ceftriaxone versus multiple doses of cefazolin. A randomized, double-blind trial. Am J Obstet Gynecol 1995; 172:129-33. [PMID: 7847521 DOI: 10.1016/0002-9378(95)90100-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.0] [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: 01/27/2023]
Abstract
OBJECTIVE The purpose of this study was to compare the efficacy of a single daily dose of intravenous ceftriaxone with that of multiple-dose cefazolin in the treatment of acute pyelonephritis in pregnancy. STUDY DESIGN This was a double-blind, randomized, clinical trial. Patients admitted to the hospital with the diagnosis of acute pyelonephritis in pregnancy were enrolled and randomized according to a computer-generated randomization schedule. The study group received a single daily 1 gm dose of ceftriaxone intravenously along with two additional doses of normal saline solution. The comparison group received three daily 2 gm doses of cefazolin intravenously. All infusions were given on an 8-hour schedule. Treatments were continued until the patient became afebrile. Each patient was discharged from the hospital on a regimen of appropriate oral antibiotics as directed by urine culture and sensitivities. At follow-up visits test-of-cure cultures were obtained. RESULTS During the 2-year study period, 178 patients were randomized: 88 received cefazolin and 90 ceftriaxone. Patient demographics and presenting signs and symptoms were similar in both groups. No differences were noted between the groups regarding days of febrile morbidity, length of hospital stay, or treatment failures. CONCLUSIONS Daily single-dose intravenous ceftriaxone is as effective as multiple-dose cefazolin in the treatment of patients with acute pyelonephritis during pregnancy.
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Affiliation(s)
- L Sanchez-Ramos
- Department of Obstetrics and Gynecology, University of Florida Health Science Center, Jacksonville 32209-6561
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Sanchez-Ramos L, Farah L, Kaunitz AM, Adair CD, Walker C, Del Valle GO, Fuqua P. Prepidil gel versus an extemporaneous preparation of prostaglandin E2 for pre-induction cervical ripening. Am J Obstet Gynecol 1995. [DOI: 10.1016/0002-9378(95)90822-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [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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Sanchez-Ramos L, Chami YG, Bass TA, DelValle GO, Adair CD. Myocardial infarction during pregnancy: management with transluminal coronary angioplasty and metallic intracoronary stents. Am J Obstet Gynecol 1994; 171:1392-3. [PMID: 7977558 DOI: 10.1016/0002-9378(94)90172-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [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: 01/28/2023]
Abstract
A 29-year-old primiparous woman had an inferior myocardial infarction at 26 weeks' gestation. Coronary angiography showed subtotal occlusion of the right coronary artery. Percutaneous transluminal angioplasty and intracoronary urokinase infusion failed to relieve the obstruction. Placement of two Gianturco-Roubin flexible stents created adequate coronary perfusion.
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Affiliation(s)
- L Sanchez-Ramos
- Department of Obstetrics and Gynecology, University of Florida Health Science Center, Jacksonville
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Abstract
OBJECTIVE To evaluate the safety and efficacy of preinduction cervical ripening in women with previous cesarean deliveries undergoing induction of labor. METHODS Retrospective study of women with previous low transverse cesarean deliveries who underwent ripening of an unfavorable cervix prior to induction of labor (n = 89). Multiparas without previous cesarean deliveries undergoing ripening and induction of labor during the same time period were used for comparison (n = 61). Ripening was performed with prostaglandin E2 (PGE2) gel, or an osmotic dilator, or both. Induction of labor with oxytocin followed the American College of Obstetricians and Gynecologists' guidelines. Outcome data were analyzed using the unpaired Student's t-test or chi 2-test as appropriate. Significance was established at P < 0.05. RESULTS The mean gestational age was 39.6 +/- 2.6 and 38.2 +/- 2.9 weeks for the study and comparison groups, respectively. There were no differences between the groups in Bishop score, duration of the first stage of labor, maximum dose of oxytocin, indications for cesarean delivery, puerperal morbidity, birthweight, Apgar scores or NICU admissions. Sixty-four percent (57 of 89) of study women delivered vaginally compared with 82% (50 of 61) of women in the comparison group (P < 0.03). The data were analyzed separately for those women undergoing cervical ripening with PGE2 gel only. No differences were observed between the groups in any of the categories mentioned above. CONCLUSION Cervical ripening appears to be safe and effective in women with previous low transverse cesarean deliveries undergoing induction of labor with an unfavorable cervix.
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Affiliation(s)
- G O Del Valle
- Department of Obstetrics and Gynecology, University of Florida Health Science Center, Jacksonville 32209-6511
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Adair CD, Benrubi GI, Sanchez-Ramos L, Rhatigan R. Bilateral tubal ectopic pregnancies after bilateral partial salpingectomy. A case report. J Reprod Med 1994; 39:131-3. [PMID: 8169930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The incidence of bilateral tubal ectopic pregnancies is reported to range from 1/725 to 1/1,580 extrauterine pregnancies. We report a case of bilateral ectopic pregnancies in a patient who had previously undergone bilateral partial salpingectomies for contraception. An extensive literature review identified one patient with a similar sterilization history in whom a bilateral ectopic pregnancy occurred.
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Affiliation(s)
- C D Adair
- Department of Obstetrics and Gynecology, University of Florida Health Science Center/Jacksonville
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