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Biomedical subjects

C R Harman

Publications and source records attributed to C R Harman.

At least 55 records · Page 3Linked to original sources
PubMed1992

Maternal Kell blood group alloimmunization.

BACKGROUND: Two recent paper have provided conflicting views regarding the severity of Kell hemolytic disease of the newborn. METHODS: We reviewed our experience during 1944-1990 with pregnant Kell-alloimmunized Manitoban women and similar women referred from outside of Manitoba. RESULTS: Between 1944-1990, 311 Kell-immunized Manitoban women had 459 pregnancies, of which 63 ended in abortion or stillbirth unrelated to anti-Kell. Of the infants born, 376 were unaffected and 20 were affected. Twelve did not require treatment; two needed phototherapy, one required a simple transfusion, and one an exchange transfusion. One died of kernicterus and three were hydropic and died; all four deaths occurred between 1948-1954. Fourteen Kell-immunized women with 16 pregnancies were referred from outside Manitoba. Eleven had a history of Kell hydropic fetuses and ten had hydropic fetuses at referral. Five of the hydropic fetuses survived and five died. Five women had Kell-negative infants correctly predicted by amniocentesis (two) and by fetal blood sampling (three). Serial amniotic fluid delta OD 450 readings were 83-89% accurate in predicting the presence and severity of Kell hemolytic disease. Life-threatening inaccuracies occurred, primarily in the early and middle second trimester. CONCLUSIONS: Kell hemolytic disease, although rare, may be as severe as Rh(D) hemolytic disease when it does occur. When there is a history of hydrops or the father is Kell-positive and the maternal anti-Kell indirect antiglobulin titer is 8 or greater, amniocentesis should be performed at 16-20 weeks' gestation. Fetal blood sampling followed by fetal intravascular transfusion is indicated if delta OD 450 readings approach the 65% level in modified zone 2 of Liley or if amniocentesis is precluded because of an anterior placenta and there is a history of hydrops or ultrasound evidence of fetal hemolytic disease.

Amniotic Fluid↗
PubMed1991

Bleeding after intravascular transfusion: experimental and clinical observations.

Characteristics of postpuncture bleeding of umbilical vessels were evaluated with an in vitro cord perfusion model and in vivo by ultrasonographic observation of bleeding duration after intravascular transfusion. Ultrasonographic determination of blood loss in vitro was very sensitive (0.01 ml/sec). In vitro blood loss varied directly with perfusion rate, but there were wide variations between cord specimens. Observed clinical bleeding occurred in 43% of cases; the duration of bleeding varied by vessel punctured, needle size, and fetal platelet count. The combined in vitro and clinical data help define the range of duration of bleeding and the probable volume of loss.

Bleeding Time↗
PubMed1991

Assessment of fetal well-being with ultrasound.

The practice of medicine is undergoing marked changes fueled by the infusion of vast amounts of new information concerning the etiology, the progressive pathophysiology, and the complexity of host response to disease states. It is only recently that we have begun to examine the present extent of fetal disease and to determine the characteristics of its advancements. This information now permits new and rational approaches to the management of fetal disease. Clinical significance, both real and potential, of this new wealth of information in reducing perinatal mortality and morbidity is difficult to overestimate. Cumulative experience with fetal biophysical scoring as a method for antepartum fetal risk assessment is now extensive. The cumulative data indicate that the method is sensitive for recognizing both the normal and the compromised fetus. Moreover, the method appears to offer the advantage of grading various degrees of fetal compromise. The additional information gained by real-time ultrasound scanning (gestational age determination, fetal morphometrics, and fetal anomaly screening), although not an integral part of the fetal biophysical profile score, nevertheless remains a critical aspect of antepartum fetal assessment. These data are collected simultaneously with fetal biophysical profile scoring. It is impossible to separate cleanly the advantage of fetal biophysical profile scoring in isolation of this additional information. It would, however, seem that such attempt at separation is artificial because the data in combination provide the key information that the physician needs to guide fetal management. It seems more reasonable to expect that continued modification and improvement of the existing fetal biophysical profile scoring method with inclusion of new testing techniques will be the steps that will occur to improve testing accuracy (Fig. 3). In medical schools in the 1960s, it was generally taught that the concept of "irreducible" perinatal mortality existed and that this figure was usually set at a perinatal mortality of around 8 per 1000. Now in the 1990s that perinatal mortality has already fallen below this irreducible level and continues to fall. We now observe perinatal mortality among tested fetuses of less than 7 per 1000 and corrected perinatal mortalities of less than 2 per 1000. These remarkable results strongly underscore the advantages obtained by ultrasound assessment of the fetus.

Amniotic Fluid↗
PubMed1990

Fetal assessment based on fetal biophysical profile scoring. III. Positive predictive accuracy of the very abnormal test (biophysical profile score = 0).

The relationship between complete absence of all components of the fetal biophysical profile score (biophysical profile score = 0) and adverse perinatal outcome was examined. Twenty-nine of 28,655 fetuses studied (0.092%) had a last biophysical profile score of 0; 48.3% of these perinates died (14 of 29 fetuses), the majority of whom (11 of 14) were stillborn, with death occurring as early as 30 minutes to as long as 11 days after the last test. Three asphyxia-related neonatal deaths occurred despite aggressive and immediate intervention. All survivors exhibited at least one of the five discrete markers used to assess perinatal morbidity. The positive predictive accuracy of a biophysical profile score of 0, with mortality and morbidity used as end points, was 100%. These data indicate the very abnormal fetal biophysical profile score to be a perinatal emergency.

Acidosis↗
PubMed1990

Fetal assessment based on fetal biophysical profile scoring. IV. An analysis of perinatal morbidity and mortality.

The relationship between the last biophysical profile score result and perinatal outcome was determined among a large referred population of high-risk pregnancies. A highly significant inverse linear correlation was observed for fetal distress, admission to neonatal intensive care unit, intrauterine growth retardation, 5-minute Apgar score less than 7, and umbilical cord pH less than 7.20 but not for the incidence of meconium or major anomaly. A highly significant inverse exponential (log 10) relationship was observed for perinatal mortality in total and by component parts and cause. These data strongly suggest the biophysical profile scoring method of fetal risk assessment is accurate and also provides insight into the extent of fetal compromise.

Female↗
PubMed1990

The abnormal fetal biophysical profile score. V. Predictive accuracy according to score composition.

The relationship between last abnormal biophysical profile score, in total and by variable composition, and a spectra of abnormal perinatal outcome end points was examined in 525 fetuses. Highly significant inverse relationships between last test score and outcome were observed; relationships were linear for most end points and exponential for perinatal mortality end points. For biophysical profile scores less than or equal to 6, 25 of the 26 possible variable combinations were observed, at varying frequencies. For a biophysical profile score of 6, the positive predictive accuracy for some end points was significantly higher with either nonreactive nonstress test/fetal tone absent or nonreactive nonstress test/absent fetal breathing movement, and significantly lower with absent fetal breathing movement and decreased amniotic fluid volume. For a biophysical profile score of 4, the positive predictive accuracy for some end points was significantly higher with nonreactive nonstress test/absent fetal breathing movement/decreased amniotic fluid and was significantly lower with absent fetal movement/fetal breathing movement/fetal tone. No significant variation was observed for a biophysical profile score of 2. These data indicate that not all abnormal biophysical profile scores are equal.

Apgar Score↗
PubMed1990

Maternal serum alpha-fetoprotein in twin pregnancy.

Maternal serum alpha-fetoprotein concentration was measured at 14 to 20 weeks' gestation in 138 twin pregnancies. All patients had at least one ultrasonographic examination (86% before 20 weeks' gestation). Two pregnancies were discordant for open fetal defects (one anencephaly, one gastroschisis). The median serum alpha-fetoprotein value in the remaining 136 twin pregnancies paralleled a curve 2.5 times the median curve for singleton pregnancies over the gestational range studied. Higher serum alpha-fetoprotein values correlated significantly with increasing incidence of fetal and neonatal death, premature delivery (less than 35 weeks' gestation), and twin-to-twin birth discordance (greater than 20%), most pronounced at greater than 4 multiples of the singleton median level. A significant negative correlation between alpha-fetoprotein and birth weight was observed (p less than 0.001), but was related more to prematurity than to poor fetal growth. Theoretically, serum alpha-fetoprotein screening detected 56.5% of the twins in this study when a cutoff level of 2.5 multiples of the median was used, enhancing twin detection in the study population by 40%. These data indicate that maternal serum alpha-fetoprotein screening has a valuable role in the management of twin pregnancy, both in the detection of twins and in the prediction of perinatal outcome in twin pregnancy.

Female↗
PubMed1990

Intrauterine transfusion--intraperitoneal versus intravascular approach: a case-control comparison.

Intravascular fetal transfusion has gained widespread acceptance and has supplanted the use of intraperitoneal fetal transfusion in management of severe alloimmune disease in many centers. This study compares the two methods with regard to multiple objective end points of performance, therapy, and outcome in a highly matched case-control fashion. The intravascular approach is better on almost every level. More surviving infants who are in better condition at a mature gestation and whose mothers have fewer complications and sequelae are the result. Whereas intraperitoneal transfusion should not be abandoned altogether, it is a second-line procedure used only in very limited circumstances. Intravascular fetal transfusion offers realistic prognosis for intact survival at virtually any extreme of alloimmune disease.

Blood Group Incompatibility↗
PubMed1990

TRAP sequence--successful outcome with indomethacin treatment.

A case of twin reversed arterial perfusion (TRAP) sequence (acardiac twin) complicated by hydramnios was managed by maternal administration of indomethacin. Successful outcome was achieved after 8.5 weeks of therapy with delivery of a normal live-born infant at 34 weeks.

Abnormalities, Severe Teratoid↗
PubMed1989

Twin with hydramnios: treating premature labor at source.

Six twin pregnancies complicated by hydramnios and premature labor were prospectively studied to determine whether indomethacin reduces amniotic fluid. Requirements for study entry included a gestational age less than 32 completed weeks and an amniotic fluid greater than 10 cm in one or both sacs. The amniotic fluid was measured using real-time ultrasonography before, during, and after treatment. Indomethacin treatment was initiated as a 100 mg rectal suppository and maintained thereafter by 50 mg orally every 6 hours. Treatment was discontinued after 32 completed weeks' gestation, if the patient was asymptomatic and the amniotic fluid was "normal" (less than 8 cm) or after the onset of oligohydramnios in one or both sacs (less than 2 cm). The interval from initiation of treatment to delivery ranged from 12 to 101 days. A coincidental reduction in amniotic fluid was observed in all seven treatment cycles. The time interval to obtain "normal" fluid ranged from 4 to 20 days (mean, 12.5 days). There were no perinatal complications attributable to indomethacin treatment. These data suggest that in selected pregnancies complicated by hydramnios, indomethacin may be of value not only in prolonging gestation but also in amniotic fluid reduction.

Delivery, Obstetric↗
PubMed1989

Family views of stigma.

The views of 487 members of the National Alliance for the Mentally Ill (NAMI) concerning stigma were surveyed in 20 different States. Almost all identified stigma as a problem for their mentally ill relatives and for families in general. The most frequently cited effects of stigma on ill relatives were damage to self-esteem, difficulty making and keeping friends, difficulty finding a job, and reluctance to admit mental illness. The most frequently cited effects on families were lowered self-esteem and damaged family relationships. NAMI respondents identified popular movies about mentally ill killers, news coverage of tragedies caused by mentally ill people, casual use of terms like "crazy" and "psycho," and jokes about mental illness as prominent sources of stigma. The things families reportedly found most helpful in dealing with stigma were factual information about mental illness, interaction with other families with mentally ill relatives, support within the family, and research findings that establish a biological basis for mental illness. Mental health professionals received mixed reviews from family members. While not generally viewed as contributing to stigma, mental health professionals were seen as least helpful in dealing with stigma. Overall, survey results indicate that considerable concern about stigma exists among families with mentally ill relatives and that substantial numbers of family members experience the stigma of mental illness in one form or another and perceive that their ill relatives experience it as well.

Adaptation, Psychological↗
PubMed1989

Current technique of intraperitoneal transfusion: do not throw away the renografin.

The original description of intraperitoneal transfusion calls for contrast-dye infusion and X-ray confirmation of placement of the needle free in the peritoneal cavity. Ultrasound methods, using air or saline as contrast media, have been described to replace the X-rays. This report illustrates at least one way in which the ultrasound findings at intraperitoneal transfusion may be illusory, allowing misplaced transfusion into the fetal colon. In specific instances, use of radiopaque dye at intraperitoneal transfusion may still be helpful.

Adult↗
PubMed1989

Fetal monitoring in the alloimmunized pregnancy.

At many points in the development of serious alloimmune disease, the progression of hemolysis can be monitored, and appropriate interventions will prevent the ultimate outcome in fetal disease. Careful attention to maternal monitoring, founded on an understanding of the pathophysiology of alloimmunization, provides the basis for invasive testing. Invasive testing, coupled with detailed real-time ultrasound fetal examination, quantitates disease and determines the necessity of intrauterine treatment. Expertise with these techniques provides the means for approaching 100 percent survival in even the most severely affected.

Female↗
PubMed1989

Severe fetal brain injury without evident intrapartum asphyxia or trauma.

Two appropriate-for-dates term infants were born after uncomplicated labors and atraumatic deliveries. They were depressed at birth, developed seizures on the first day of life, and followed clinical courses compatible with hypoxic-ischemic encephalopathy. However, the umbilical cord vessel pH and blood gases were normal. The children are now severely retarded and have cerebral palsy. These cases prove that the events of labor and delivery may not be responsible for all cases of brain damage in surviving children.

Adolescent↗