1
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Roberts JM, King TL, Barton JR, Beck S, Bernstein IM, Buck TE, Forgues-Lackie MA, Facco FL, Gernand AD, Graves CR, Jeyabalan A, Hauspurg A, Manuck TA, Myers JE, Powell TM, Sutton EF, Tinker E, Tsigas E, Myatt L. Care plan for individuals at risk for preeclampsia: shared approach to education, strategies for prevention, surveillance, and follow-up. Am J Obstet Gynecol 2023; 229:193-213. [PMID: 37120055 DOI: 10.1016/j.ajog.2023.04.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 04/11/2023] [Accepted: 04/12/2023] [Indexed: 05/01/2023]
Abstract
Preeclampsia is a multisystemic disorder of pregnancy that affects 250,000 pregnant individuals in the United States and approximately 10 million worldwide per annum. Preeclampsia is associated with substantial immediate morbidity and mortality but also long-term morbidity for both mother and offspring. It is now clearly established that a low dose of aspirin given daily, beginning early in pregnancy modestly reduces the occurrence of preeclampsia. Low-dose aspirin seems safe, but because there is a paucity of information about long-term effects on the infant, it is not recommended for all pregnant individuals. Thus, several expert groups have identified clinical factors that indicate sufficient risk to recommend low-dose aspirin preventive therapy. These risk factors may be complemented by biochemical and/or biophysical tests that either indicate increased probability of preeclampsia in individuals with clinical risk factors, or more importantly, identify increased likelihood in those without other evident risk. In addition, the opportunity exists to provide this population with additional care that may prevent or mitigate the short- and long-term effects of preeclampsia. Patient and provider education, increased surveillance, behavioral modification, and other approaches to improve outcomes in these individuals can improve the chance of a healthy outcome. We assembled a group with diverse, relevant expertise (clinicians, investigators, advocates, and public and private stakeholders) to develop a care plan in which providers and pregnant individuals at risk can work together to reduce the risk of preeclampsia and associated morbidities. The plan is for care of individuals at moderate to high risk for developing preeclampsia, sufficient to receive low-dose aspirin therapy, as identified by clinical and/or laboratory findings. The recommendations are presented using the GRADE methodology with the quality of evidence upon which each is based. In addition, printable appendices with concise summaries of the care plan's recommendations for patients and healthcare providers are provided. We believe that this shared approach to care will facilitate prevention of preeclampsia and its attendant short- and long-term morbidity in patients identified as at risk for development of this disorder.
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Affiliation(s)
- James M Roberts
- Magee-Womens Research Institute and Clinical and Translational Science Institute, Department of Obstetrics, Gynecology and Reproductive Sciences and Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA.
| | - Tekoa L King
- School of Nursing, University of California, San Francisco, Oakland, CA
| | - John R Barton
- Maternal-Fetal Medicine, Baptist Health, Lexington, KY
| | - Stacy Beck
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA
| | - Ira M Bernstein
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Vermont, Burlington, VT
| | | | | | - Francesca L Facco
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA
| | - Alison D Gernand
- Nutritional Sciences, Pennsylvania State University, University Park, PA
| | - Cornelia R Graves
- Division of Maternal-Fetal Medicine, University of Tennessee College of Medicine, Nashville, TN
| | - Arundhati Jeyabalan
- Magee-Womens Research Institute, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA
| | - Alisse Hauspurg
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA
| | - Tracy A Manuck
- Obstetrics and Gynecology, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Jenny E Myers
- Division of Developmental Biology and Medicine, University of Manchester, Manchester, United Kingdom
| | - Trashaun M Powell
- National Racial Disparity Taskforce, Preeclampsia Foundation and New Jersey Family Planning League, Somerset, NJ
| | | | | | | | - Leslie Myatt
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR
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2
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Affiliation(s)
- Cornelia R Graves
- Collaborative Perinatal Cardiac Center St. Thomas Health Systems Nashville TN USA.,University of Tennessee Health Science Center-Nashville Ascension St. Thomas Midtown Hospital Nashville TN USA
| | - Ruth M Woldemichael
- University of Tennessee Health Science Center-Nashville Ascension St. Thomas Midtown Hospital Nashville TN USA
| | - Stacy F Davis
- Collaborative Perinatal Cardiac Center St. Thomas Health Systems Nashville TN USA.,St Thomas Midtown Comprehensive Heart Failure Center St. Thomas Health Systems Nashville TN USA
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3
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Wisotzkey AK, Leech AA, Graves CR, Zhu Y, Carpenter HL, Dawoud FM, Iwelu CC, Pourali SP, Osmundson SS. Obstetrical clinician opioid prescribing perspectives after cesarean delivery in Tennessee. Am J Obstet Gynecol MFM 2023; 5:100835. [PMID: 36509357 PMCID: PMC10170395 DOI: 10.1016/j.ajogmf.2022.100835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 11/23/2022] [Accepted: 12/06/2022] [Indexed: 12/14/2022]
Affiliation(s)
- Anna K Wisotzkey
- Department of Health Policy, Vanderbilt University School of Medicine, 2525 West End Ave., Ste. 1275, Nashville, TN 37203.
| | - Ashley A Leech
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, TN; Center for Child Health Policy, Vanderbilt University Medical Center, Nashville, TN
| | - Cornelia R Graves
- Department of Obstetrics and Gynecology, University of Tennessee Health Science Center, Nashville, TN; Division of Perinatal Services, Ascension Saint Thomas Health, Nashville, TN
| | - Yuwei Zhu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | | | - Febronia M Dawoud
- James H. Quillen College of Medicine, East Tennessee State University, Johnson City, TN
| | - Chibuzor C Iwelu
- Department of Obstetrics and Gynecology, University of Tennessee Health Science Center, Nashville, TN
| | | | - Sarah S Osmundson
- Center for Child Health Policy, Vanderbilt University Medical Center, Nashville, TN; Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN
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4
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Hameed AB, Tarsa M, Graves CR, Chang J, Billah M, Thiel de Bocanegra H. Testing of CVD risk assessment quality measures for pregnant and postpartum women. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.416] [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: 11/01/2022]
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5
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Murff HJ, Greevy RA, Sanghani RS, Hartmann KE, Hartert TV, Graves CR, Lee SS, Tindle HA. Investigating N-3 Fatty Acids to prevent Neonatal Tobacco-related outcomeS (INFANTS): study protocol for a double-blind, randomized, placebo-controlled parallel clinical trial of n-3 polyunsaturated fatty acids in pregnant smokers. Trials 2021; 22:922. [PMID: 34906201 PMCID: PMC8669400 DOI: 10.1186/s13063-021-05865-7] [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: 05/18/2021] [Accepted: 11/23/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Tobacco use during pregnancy is the most important modifiable risk factor associated with adverse pregnancy outcomes, increasing the risk of preterm birth, intrauterine growth restriction and sudden infant death syndrome. Fewer than half of pregnant smokers can quit on their own. Identifying safe and effective therapies to prevent tobacco-related adverse pregnancy outcomes and/or increase smoking cessation in pregnant women would have a substantial public health impact. Cigarette smoking is associated with a relative deficiency in circulating n-3 long-chain polyunsaturated fatty acid (n-3 LCPUFA) levels. A recent analysis found that smokers taking n-3 LCPUFAs during pregnancy had a reduction in preterm labor risk when compared to non-smokers. Studies have shown that supplemental n-3 LCPUFAs may also reduce nicotine cravings and daily cigarette use. Thus, smokers may benefit from supplemental n-3 LCPUFAs by lowering the risk of preterm labor and/or increased smoking cessation. To address important remaining knowledge gaps, we propose the Investigating N-3 Fatty Acids to prevent Neonatal Tobacco related outcomeS (INFANTS). METHODS The INFANTS study is a multicenter, randomized, double-blind, placebo-controlled study that will randomize 400 pregnant smokers to either supplemental n-3 LCPUFAs or placebo. Participants will be enrolled between 12 and 24 weeks' gestation and followed until 6 weeks after delivery. We will recruit from clinical centers throughout Middle Tennessee. We will assess smoking behavior after 12 weeks of supplementation using self-report and validated biomarkers of tobacco exposure. We will measure response to supplementation using biological markers of n-3 LCPUFA status. Our primary endpoint will be preterm labor as reflected by gestational age at delivery. Our secondary endpoint will be change from baseline in cigarettes per day at 12 weeks. DISCUSSION This study tests the hypothesis that smoking-induced n-3 LCPUFA deficiencies contribute to tobacco-related adverse pregnancy outcomes and that supplementation of n-3 LCPUFAs in pregnant smokers may prevent these complications. If our study demonstrates that supplemental n-3 LCPUFAs are effective at reducing the risk of tobacco-related adverse neonatal outcomes and/or reducing tobacco use during pregnancy, our results could have an immediate and major impact on pregnancy care and neonatal outcomes. TRIAL REGISTRATION ClinicalTrials.gov NCT04417595. Registered on April 21, 2020.
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Affiliation(s)
- Harvey J Murff
- Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 450, Nashville, TN, 37232, USA.
- Geriatric Research, Education and Clinical Center, Tennessee Valley Healthcare System, Nashville, TN, USA.
| | - Robert A Greevy
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, USA
| | - Reesha S Sanghani
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, USA
| | - Katherine E Hartmann
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, USA
| | - Tina V Hartert
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, USA
| | | | - Scott S Lee
- Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 450, Nashville, TN, 37232, USA
| | - Hilary A Tindle
- Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 450, Nashville, TN, 37232, USA
- Geriatric Research, Education and Clinical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
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Anderson J, Schauer J, Bryant S, Graves CR. The use of convalescent plasma therapy and remdesivir in the successful management of a critically ill obstetric patient with novel coronavirus 2019 infection: A case report. Case Rep Womens Health 2020; 27:e00221. [PMID: 32426243 PMCID: PMC7229947 DOI: 10.1016/j.crwh.2020.e00221] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 05/14/2020] [Indexed: 12/28/2022] Open
Abstract
Remdesivir is a novel therapeutic with known activity against SARS CoV-2 and related coronaviruses. Remdesivir, as well as convalescent plasma therapy, are currently under investigation as potential therapies for patients with Coronavirus Disease 19 (COVID-19). In this case report we summarize the use of convalescent plasma therapy and then remdesivir as a late addition in the treatment of a critically ill obstetric patient with COVID-19. The patient subsequently improved, was extubated 5 days after initiation of remdesivir, was transitioned to room air 24 h later, and discharged at the completion of remdesivir therapy.
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Affiliation(s)
- Jonathon Anderson
- University of Tennessee Health Science Center, Nashville, United States
| | - Jordan Schauer
- University of Tennessee Health Science Center, Nashville, United States
| | - Suzanne Bryant
- University of Tennessee Health Science Center, Nashville, United States
| | - Cornelia R Graves
- University of Tennessee Health Science Center, Nashville, United States
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7
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Affiliation(s)
- Cornelia R Graves
- Tennesee Maternal Fetal Medicine, Nashville (C.R.G.) .,Department of Obstetrics and Gynecology (C.R.G.).,Collaborative Perinatal Cardiac Center, Nashville, TN (C.R.G., S.F.D.).,University of Tennessee, Vanderbilt University, Nashville (C.R.G.).,Meharry Medical College, Nashville, TN (C.R.G.)
| | - Stacy F Davis
- Department of Cardiology (S.F.D.), St. Thomas Health Systems, Nashville, TN .,Collaborative Perinatal Cardiac Center, Nashville, TN (C.R.G., S.F.D.).,St Thomas Midtown Comprehensive Heart Failure Center, Nashville, TN (S.F.D.)
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8
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Moroz L, Riley LE, D'Alton M, Brown HL, Davis AR, Foley M, Graves CR, Sheffield JS, Zerden ML, Bryant AS. SMFM Special Report: Putting the "M" back in MFM: Addressing education about disparities in maternal outcomes and care. Am J Obstet Gynecol 2018; 218:B2-B8. [PMID: 29175250 DOI: 10.1016/j.ajog.2017.11.592] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 11/20/2017] [Indexed: 11/30/2022]
Abstract
At the 36th Annual meeting of the Society for Maternal-Fetal Medicine (SMFM), leaders in the field of maternal-fetal medicine (MFM) convened to address maternal outcome and care inequities from 3 perspectives: (1) education, (2) clinical care, and (3) research. Meeting attendees identified knowledge gaps regarding disparities within the provider community; reviewed possible frameworks to address these knowledge gaps; and identified models with which to address key clinical issues. Collaboration and communication between all stakeholders will be needed to gain a better understanding of these prevailing disparities and formulate strategies to eliminate them.
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Affiliation(s)
- Leslie Moroz
- Columbia University Irving Medical Center, New York, NY
| | | | - Mary D'Alton
- Columbia University Irving Medical Center, New York, NY
| | | | - Anne R Davis
- Columbia University Irving Medical Center, New York, NY
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9
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Gensheimer M, Jones CA, Graves CR, Merchant NB, Lockhart AC. Administration of oxaliplatin to a pregnant woman with rectal cancer. Cancer Chemother Pharmacol 2008; 63:371-3. [PMID: 18357450 DOI: 10.1007/s00280-008-0731-9] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2007] [Accepted: 03/05/2008] [Indexed: 11/28/2022]
Abstract
PURPOSE The platinum agent oxaliplatin could be useful in treatment of cancer in pregnant women, but it is fetotoxic in rats and its effect on the human fetus is unknown. METHODS Oxaliplatin was administered to a 25-year-old pregnant woman with metastatic rectal cancer from 20 to 30 weeks gestational age as part of the mFOLFOX-6 regimen. RESULTS The patient gave birth to a healthy girl at 33 weeks gestational age. At follow-up, the 3-year-old child had achieved all appropriate growth and developmental milestones. DISCUSSION Oxaliplatin is a component of several modern chemotherapy regimens. This report demonstrates the administration of oxaliplatin in the second and third trimesters of pregnancy without apparent fetal harm.
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Affiliation(s)
- Michael Gensheimer
- Vanderbilt University School of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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10
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Tai JH, Udoji MA, Barkanic G, Byrne DW, Rebeiro PF, Byram BR, Kheshti A, Carter JD, Graves CR, Raffanti SP, Sterling TR. Pregnancy and HIV disease progression during the era of highly active antiretroviral therapy. J Infect Dis 2007; 196:1044-52. [PMID: 17763327 DOI: 10.1086/520814] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2006] [Accepted: 02/23/2007] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Before the availability of highly active antiretroviral therapy (HAART), there was no clear effect of pregnancy on human immunodeficiency virus (HIV) disease progression. This has not been assessed during the HAART era. METHODS We conducted an observational cohort study among HIV-infected women with >or=1 outpatient clinic visit between January 1997 and December 2004. HIV disease progression was defined as the occurrence of an AIDS-defining event or death. RESULTS Of 759 women who met the inclusion criteria, 139 (18%) had had >1 pregnancy, and 540 (71%) had received HAART. There was no difference in HAART duration by pregnancy status. Eleven pregnant (8%) and 149 nonpregnant (24%) women progressed to AIDS or death. After controlling for age, baseline CD4(+) lymphocyte count, baseline HIV-1 RNA level, and durable virologic suppression in a Cox proportional hazards model that included propensity score for pregnancy, pregnancy was associated with a decreased risk of disease progression (hazard ratio [HR], 0.40 [95% confidence interval {CI}, 0.20-0.79]; P=.009]). In a matched-pair analysis of 81 pregnant women matched to 81 nonpregnant women according to age, baseline CD4(+) lymphocyte count, receipt of HAART, and date of cohort entry, pregnant women had a lower risk of disease progression both before (HR, 0.10 [95% CI, 0.01-0.89]; P=.04) and after (HR, 0.44 [95% CI, 0.19-1.00]; P=.05) the pregnancy event. CONCLUSION Pregnancy was associated with a lower risk of HIV disease progression in this HAART-era study. This finding could be the result of the healthier immune status of women who become pregnant or could possibly be related to a beneficial interaction between pregnancy and HAART.
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Affiliation(s)
- Jennifer H Tai
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
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11
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Abstract
Intrauterine devices (IUDs) have been used worldwide for contraception for decades. They are easily deployed, inexpensive and one of the most reliable contraceptive methods. Though ease of placement is such that they are frequently placed by midwives in the outpatient setting in developing countries, some complications due to its misplacement occasionally can occur. We present two cases with unknown uterine septum in which IUDs were placed without prior ultrasound examination of the pelvis. We conclude evaluation of the pelvis by ultrasound prior to placement of IUDs in women with a history of breech presentation, preterm labour, or recurrent miscarriage may be helpful in identifying uterine anomalies that make IUD placement unsuitable.
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Affiliation(s)
- E Dikensoy
- Vanderbilt University, Department of Obstetrics and Gynecology, Nashville, TN 37235, USA
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12
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Abstract
Diabetes mellitus complicates 3-5% of all pregnancies and is a major cause of perinatal morbidity and mortality, as well as maternal morbidity. The availability of a variety of new insulins, the insulin pump, and self-monitoring of blood glucose have revolutionized the care of the pregnancy complicated by diabetes mellitus. However, challenges remain in caring for the pregnant patient with pregestational diabetes. Relatively few women receive preconceptional counseling, and major fetal malformations as a result of poor glucose control before and during the early weeks of gestation have emerged as the major cause of perinatal mortality. When the patient has diabetic vasculopathy, the obstetrician, maternal-fetal specialist, and/or endocrinologist and other members of the health care team must perform a challenging balancing act that promotes fetal health while minimizing maternal risk. As obesity increases in this country and our population becomes more diversified, the rate of gestational diabetes mellitus (GDM) will rise. Although there is controversy regarding which diagnostic standards to use for GDM, there is agreement that excellent blood glucose control, with diet and, when necessary, insulin will result in improved perinatal outcome. Finally, the goal of our educational programs should be not only to improve pregnancy outcome but also to promote healthy lifestyle changes for the mother that will last long after delivery.
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Affiliation(s)
- Steven G Gabbe
- Department of Obstetrics and Gynecology, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, USA.
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13
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Affiliation(s)
- A G Roberts
- Vanderbilt University Medical Center, Nashville, TN 37212-3375, USA
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14
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Affiliation(s)
- Cornelia R Graves
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University, Nashville, Tennessee 37232-2519, USA.
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15
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Abstract
Elevation of established blood tumour markers correlates with the stage of breast cancer. The major role of current blood markers is therefore in the diagnosis and monitoring of metastatic disease. A combination of markers is better than a single marker with the most widely adopted combination being CEA and one MUC1 mucin, commonly detected as either CA15.3 or CA27.29. Tumour marker measurement is now used as a complementary test in the diagnosis of symptomatic metastases. In the monitoring of therapeutic response to both endocrine and cytotoxic therapies in advanced disease, biochemical assessment using blood markers not only correlates with conventional UICC criteria but has a lot of advantages which make it a potentially superior way of assessment. In this regard, CA15.3, CEA and ESR are the best validated combination. Studies are ongoing to evaluate the use of sequential blood tumour marker measurements in the follow-up of patients after treatment for their primary breast cancer, in terms of both early detection and early therapeutic intervention. Further randomized studies are also required to ascertain that marker-directed therapy is superior to the current practice for metastatic disease. In line with clinical studies, intensive laboratory work is being carried out to optimize the use of blood markers in advanced disease as well as to exploit their use in screening and diagnosis of early primary breast cancer.
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Affiliation(s)
- K L Cheung
- Professorial Unit of Surgery, City Hospital, Nottingham, UK
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16
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Abstract
Fulminant hepatic dysfunction in the third trimester of pregnancy accompanied by fever may result from disseminated herpes simplex virus. Since 1969, 24 cases of herpes simplex hepatitis, including the current case, have been reported. Mucocutaneous lesions are present in only half of cases; therefore, suspicion for diagnosis of this disease is low. Twenty-five percent of cases were not diagnosed until autopsy. Maternal and perinatal mortality are high, approaching 39 percent for both mother and fetus. Early recognition with initiation of antiviral therapy appears to be most important in maximizing survival.
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MESH Headings
- Acyclovir/therapeutic use
- Adult
- Antiviral Agents/therapeutic use
- Female
- Hepatitis, Viral, Human/drug therapy
- Hepatitis, Viral, Human/epidemiology
- Hepatitis, Viral, Human/virology
- Herpes Simplex/diagnosis
- Herpes Simplex/drug therapy
- Herpes Simplex/epidemiology
- Herpesvirus 1, Human/isolation & purification
- Herpesvirus 2, Human/isolation & purification
- Humans
- Pregnancy
- Pregnancy Complications, Infectious/drug therapy
- Pregnancy Complications, Infectious/epidemiology
- Pregnancy Complications, Infectious/virology
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Affiliation(s)
- A H Kang
- Department of Obstetrics and Gynecology, Vanderbilt University, Nashville, Tennessee 37232, USA
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17
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Abstract
BACKGROUND Sterile fibrinous vegetations on the mitral valve (Libman-Sacks endocarditis) might be found in one-third of patients with antiphospholipid antibodies. Usually of minor hemodynamic significance, these vegetations might complicate acute respiratory distress syndrome in pregnancy. CASE Despite delivery and aggressive medical therapy, a 17-year-old primigravida with pyelonephritis and acute respiratory distress syndrome suffered rapid decompensation. Echocardiography showed mitral valve vegetations with severe regurgitation. Blood cultures were negative, but antinuclear antibody test and lupus anticoagulant were positive. The patient died of massive cerebral infarction and brainstem herniation. Autopsy found a patent foramen ovale and Libman-Sacks endocarditis. CONCLUSION With rapid decompensation of acute respiratory distress syndrome in pregnancy, despite aggressive medical therapy, complicating processes must be considered, especially with antiphospholipid antibodies, which can be associated with sterile heart vegetations and subsequent fatal thromboembolism.
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Affiliation(s)
- A H Kang
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee 37232, USA.
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18
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Denton G, Brady K, Lo BK, Murray A, Graves CR, Hughes OD, Tendler SJ, Laughton CA, Price MR. Production and characterization of an anti-(MUC1 mucin) recombinant diabody. Cancer Immunol Immunother 1999; 48:29-38. [PMID: 10235486 PMCID: PMC11037161 DOI: 10.1007/s002620050545] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
A recombinant diabody fragment based on the anti-MUC1 monoclonal antibody, C595 has been produced in a bacterial expression system. Substitution of a 7-amino-acid linker sequence (Gly6Ser) for the original single-chain (sc)Fv 15-amino-acid linker (Gly4-Ser)3, using polymerase-chain-reaction-based strategies, forces variable heavy (V(H)) and light (V(L)) domains to pair with complementary domains on neighbouring scFv molecules, forming a scFv dimer (diabody). This recombinant protein shows similar binding characteristics to the parental C595 monoclonal antibody. The ability to bind to MUC1 mucin on carcinoma cell surfaces will allow its potential as a diagnostic and therapeutic reagent of clinical utility to be investigated.
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MESH Headings
- Amino Acid Sequence
- Animals
- Antibodies, Bispecific/biosynthesis
- Antibodies, Bispecific/chemistry
- Antibodies, Bispecific/genetics
- Antibodies, Monoclonal/biosynthesis
- Antibodies, Monoclonal/genetics
- Antibodies, Monoclonal/immunology
- Antibody Specificity
- Dimerization
- Electrophoresis, Polyacrylamide Gel
- Enzyme-Linked Immunosorbent Assay
- Humans
- Immunoglobulin Fragments/biosynthesis
- Immunoglobulin Fragments/genetics
- Immunoglobulin Fragments/immunology
- Mice
- Models, Molecular
- Molecular Sequence Data
- Mucin-1/genetics
- Mucin-1/immunology
- Polymerase Chain Reaction
- Protein Conformation
- Recombinant Proteins/biosynthesis
- Recombinant Proteins/chemistry
- Recombinant Proteins/genetics
- Sequence Homology, Amino Acid
- Tumor Cells, Cultured
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Affiliation(s)
- G Denton
- Cancer Research Laboratories, School of Pharmaceutical Sciences, University of Nottingham, University Park, UK
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19
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Price MR, Graves CR. Blood-Borne Tumour Markers - A Sideways Look. Int J Biol Markers 1999; 14:27-8. [PMID: 10367246 DOI: 10.1177/172460089901400105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- M R Price
- Cancer Research Laboratory, School of Pharmaceutical Sciences, University of Nottingham, UK
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20
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Abstract
The use of a balloon-tipped, flow-directed pulmonary artery catheter in critically ill and surgical patients has become commonplace in the United States since its introduction into clinical medicine in 1970. The capability of acquiring continuous hemodynamic and, more recently, oxygen transport data, has led to an enhanced understanding of pathophysiologic processes in disease states and to an improved ability to guide therapeutic decision making. The purpose of this paper is to review experience with the pulmonary artery catheter in subsets of women with severe preeclampsia.
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Affiliation(s)
- D B Fox
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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21
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Abstract
OBJECTIVE To evaluate the relationship of anaerobic metabolism, as reflected by the calculated base deficit, with oxygen transport and left ventricular function in women with severe preeclampsia. METHODS Forty women with singleton pregnancies and severe preeclampsia who met prescribed criteria for invasive hemodynamic monitoring had arterial blood gas and hemodynamic values obtained immediately after placement of a pulmonary artery catheter. Oxygen transport indices were stratified according to the admission base deficit. RESULTS Linear regression analysis demonstrated a strong negative correlation between the calculated base deficit and the oxygen delivery index (r = -0.64), cardiac index (r = -0.62), and left ventricular stroke work index (r = -0.58). A baseline maternal base deficit exceeding -8.0 mEq/L consistently predicted fetal acidosis, fetal death, and maternal end-organ ischemic injury. CONCLUSION The calculated base deficit reliably reflects maternal oxygen transport dynamics and identifies patients at risk for end-organ injury. Ventricular contractility and oxygen delivery decline with mounting oxygen debt.
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Affiliation(s)
- T C Wheeler
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN, USA
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Graves CR. Domestic extremists: dealing with demonstrators. J Healthc Prot Manage 1996; 11:1-7. [PMID: 10144020] [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: 02/11/2023]
Abstract
The security department of any healthcare facility faces delicate security problems. In addition to guarding staff and the facility, security professionals must protect the patients. This duty becomes even more difficult, says the author, when hospitals become political and moral battlegrounds for demonstrators.
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Graves CR. Screening hospital personnel for security. Hosp Secur Saf Manage 1996; 16:13-4. [PMID: 10154609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
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