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Biomedical subjects

J A Kuller

Publications and source records attributed to J A Kuller.

At least 19 recordsLinked to original sources
PubMed1996

Pharmacologic treatment of psychiatric disease in pregnancy and lactation: fetal and neonatal effects.

OBJECTIVE: To review published data pertaining to safety of psychoactive drugs used to treat psychiatric disorders during pregnancy and lactation. DATA SOURCES: A computerized search of articles published through July 1995 was performed on the MEDLINE data base. Additional sources were identified through cross-referencing. METHODS OF STUDY SELECTION: All identified references were reviewed with particular attention given to study design. DATA EXTRACTION AND SYNTHESIS: Each reference was reviewed to determine the safety of psychoactive agents to treat depression, bipolar disease, schizophrenia, and anxiety during pregnancy and lactation. Prospective or large retrospective studies were given more importance than case reports. CONCLUSION: Psychoactive medications may be used during pregnancy. Because data on safety are largely retrospective, treatment decisions must be weighed carefully.

Abnormalities, Drug-Induced↗
PubMed1996

Prenatal ultrasonographic findings associated with short bowel syndrome in two fetuses with gastroschisis.

BACKGROUND: Studies on the importance of prenatal ultrasonographic findings in gastroschisis have shown variable significance in predicting neonatal outcome. We report two cases of short bowel syndrome and poor neonatal outcome that had interesting prenatal ultrasonographic findings. CASES: Gastroschisis was confirmed in both cases. Throughout gestation, the extra-abdominal bowel remained unchanged in size, hyperechoic, and clustered. Amniotic fluid volume increased with increasing intra-abdominal bowel dilation. Both fetuses were delivered prematurely and found to have short bowel syndrome incompatible with life. CONCLUSION: Prenatal ultrasonographic findings of hyperechoic and clustered extra-abdominal bowel with progressive intra-abdominal bowel dilation and associated polyhydramnios may be indicative of high bowel obstruction, atresia, and poor neonatal outcome. Families should be counseled cautiously.

Abdominal Muscles↗
PubMed1996

Statewide assessment of a behavioral intervention to reduce cigarette smoking by pregnant women.

OBJECTIVE: Smoking in pregnancy is the foremost cause of preventable perinatal mortality. We have demonstrated that a behavioral intervention can alter smoking in pregnant women. We tested the utility of this intervention at multiple sites in varied settings across a suburban-rural state. STUDY DESIGN: We performed a prospective cohort study at 10 prenatal care sites across North Carolina. Carbon monoxide manometry was used to verify cessation; self-report confirmed reduction. Each site enrolled smokers for 1 year. Four outcome predictor variables were studied: clinic volume, prevalence of smoking, physician versus nonphysician intervenors, and public versus private clinics. RESULTS: Smoking prevalence varied from 4% to 85%. Biologically confirmed quit rates ranged from 0% to 45%. The prevalence of smoking within a clinic's population was able to explain differences in reduction (p < 0.01) of smoking between sites. CONCLUSION: We have demonstrated the effectiveness of an intervention to alter smoking behavior in pregnancy. It appears that this technique has the greatest utility in clinics with a high prevalence of smoking.

Behavior Therapy↗
PubMed1996

An association between fetal parvovirus B19 infection and fetal anomalies: a report of two cases.

The association between fetal parvovirus B19 infection and hydrops was first reported in 1984. The virus has a predilection for the erythroid cell line, which in the fetus may produce anemia. Recent cases of parvovirus infection in other fetal cell lines have raised concern that the infection may induce fetal anomalies in rare cases. We report two pregnancies complicated by parvovirus B19 infection. In each instance the patient had normal second trimester ultrasounds but subsequently developed fetal abnormalities--disruptions of normal structure. One infant has myocardial infarction, splenic calcifications, and mild hydrocephalus. The other had moderate hydrocephalus with central nervous system scarring. There are two possible mechanisms in which parvovirus may induce fetal anomalies. Both direct infection of fetal organs and vascular inflammation have been documented in association with B19 parvovirus. Although fetal abnormalities associated with parvovirus are rare, continued study of this organism may indicate a greater pathologic potential than is now thought.

Adult↗
PubMed1996

Pregnancy in a patient with Goodpasture syndrome and renal transplantation.

Patients with Goodpasture syndrome have classically had decreased fertility and associated pregnancy wastage. Renal transplantation can increase the likelihood of successful pregnancy. We describe a patient who carried a pregnancy into the third trimester and had a good neonatal outcome. However, she developed superimposed preeclampsia with subsequent graft rejection.

Adult↗
PubMed1996

Cancer in pregnancy: a review of the literature. Part I.

Cancer is an important cause of death in the United States in women of childbearing age. Approximately 1 per 1000 pregnant women will develop cancer. This review (Part II follows in this issue) examines the diagnosis, prognosis, and management of cancer during pregnancy; both in terms of the cancer's effect on the pregnancy, and the pregnancy's effect on the cancer. Some diagnostic modalities and some therapies are problematic to the fetus and placenta. However, in most cases and the pregnancy can be managed concurrently with a good outcome for the baby and without compromising the mother's prognosis.

Breast Neoplasms↗
PubMed1996

Cesarean delivery for fetal malformations.

We reviewed existing data on fetal abnormalities to provide guidelines to determine which conditions have an improved neonatal outcome by cesarean delivery. We used Medline database to search for English language papers on a variety of fetal conditions that could influence the mode of delivery. We reviewed these sources with particular attention to how the mode of delivery influenced neonatal outcome. Conflicting data exist regarding optimal mode of delivery for many fetal conditions. Cesarean delivery may improve neonatal outcome for fetuses with isolated meningomyelocele, hydrocephalus with concomitant macrocephaly, anterior wall defects with extracorporeal liver, sacrococcygeal teratomas, hydrops, and alloimmune thrombocytopenia with low platelet count at term. Hydrocephalus without macrocephaly, anterior wall defects without an extracorporeal liver, ovarian cysts, skeletal dysplasias, fetuses whose mothers have immune thrombocytopenic puer-pura and fetuses with alloimmune thrombocytopenia with acceptable platelet counts may safely be delivered vaginally.

Cesarean Section↗
PubMed1996

Multiple congenital malformations in an infant prenatally diagnosed with mosaicism for dup(lq) and del(Xq).

After ultrasound diagnosis of a fetus with severe hydrocephalus and Dandy-Walker malformation, amniocentesis revealed chromosomal mosaicism for dup(lq) and del(Xq). The neonate had dysmorphic facial features, vertebral abnormalities, and pulmonary hypoplasia, and expired shortly after birth. This report confirms the poor prognosis reported for partial trisomies involving the long arm of chromosome number 1.

Abnormalities, Multiple↗
PubMed1996

Perinatal management of a lingual teratoma.

BACKGROUND: Teratomas of the head and neck are rare and occur almost exclusively in neonates. Prenatal diagnosis of these tumors allows for a carefully planned delivery that maintains an open airway and potentially improves perinatal outcome. We report the perinatal management of a huge intrapharyngeal and intra-oral teratoma that had a broad connection to the base of the tongue. CASE: An anterior neck mass (5 x 5 cm) in an otherwise normal-appearing fetus was detected at 19 weeks' gestation. The mass increased in size over the next 10 weeks to 8 x 6.8 x 4.3 cm. Marked fetal head deflexion was noted along with concomitant hydramnios. The mother had spontaneous rupture of membranes with preterm labor at 29 weeks' gestation. A 1860-g male neonate was delivered by classical cesarean delivery. A tracheostomy was performed in the delivery room for ventilation after the upper airway could not be accessed by bronchoscopy. Histologic examination after surgical excision confirmed a congenital teratoma with immature neuroectodermal tissue and alpha-fetoprotein-bearing endodermal sinus tumor components with exclusively polyvesicular vitelline characteristics. The origin of the pharyngeal mass was the base of the tongue. CONCLUSION: The prenatal diagnosis of a pharyngeal teratoma should prompt a careful delivery plan to optimize perinatal outcome.

Adult↗
PubMed1996

Assessment of the post-term pregnancy.

A post-term pregnancy is one that lasts beyond 42 weeks of confirmed gestational age. The goal of management in the post-term pregnancy is to avoid stillbirth, meconium aspiration and neonatal death. Ultrasonography obtained at term does not accurately predict gestational age. In pregnancies that progress beyond 41 weeks of confirmed gestational age, fetal well-being has been assessed by ultrasound evaluation of amniotic fluid volume, fetal breathing, fetal tone and fetal movement, in addition to nonstress testing. A definitive assessment plan for the post-term pregnancy should reduce the risk of maternal, fetal and neonatal morbidity.

Amniotic Fluid↗
PubMed1996

Fatal lupus pleuritis presenting in pregnancy. A case report.

BACKGROUND: Lupus, one of the most common autoimmune diseases in pregnancy, may involve multiple organ systems with varying severity. The diagnosis and treatment of the disease may be complicated by the physiologic changes of pregnancy. CASE: A 22-year-old woman presented at 29 weeks' gestation with a 4-week history of dyspnea and mild hypertension. She was found to have large bilateral pleural effusions. Her antinuclear antibody level was 1:640, with a speckled pattern, and her complement levels were low. Her urine had 2+ hemoglobin and 2+ protein with hyaline casts. Over the next three days, respiratory compromise increased despite high-dose steroids. A cesarean delivery was performed for fetal compromise. The infant did well after moderate respiratory distress. The mother developed worsening respiratory distress with adult respiratory distress syndrome, and she could not be weaned from the ventilator. Bilateral chest tubes were placed to control her effusions. Urine output remained poor despite pressors and diuretics. Staphylococcal sepsis occurred on postoperative day 5 and precluded our use of other antiinflammatory agents. Over the next 14 days the mother developed seizures, hypotension and eventual respiratory collapse. Autopsy was notable for lupus nephritis and serositis. CONCLUSION: The diagnosis and management of systemic lupus in pregnancy may be extremely difficult. Serositis and nephritis may lead to maternal compromise despite early diagnosis and treatment.

Adult↗
PubMed1995

Successful treatment of a cervical pregnancy with a single low dose methotrexate regimen.

Until very recently cervical pregnancies have been treated with surgery, usually hysterectomy. The development of endovaginal ultrasound, which allows early diagnosis, and methotrexate chemotherapy have opened up new therapeutic options. A 45-year-old multigravida presented at 8 weeks' gestation with vaginal bleeding. Endovaginal ultrasound demonstrated a cervical pregnancy with a fetal pole, 1.2 x 1.4 cm sac, no cardiac pulsations, and an empty uterus. After discussion with the patient, single low dose methotrexate 1.5 mg/m2 was given intramuscularly. The patient's hCG titre was 5882 IU-(Third International Standard). Over a 5-week period the hCG titres fell, and the gestational sac disappeared. The patient experienced intermittent vaginal bleeding and cramping but was managed as an outpatient. Single low dose methotrexate may be a successful management option in selected cases of cervical pregnancy.

Cervix Uteri↗
PubMed1995

Prenatal diagnosis and management of massive bilateral axillary cystic lymphangioma.

BACKGROUND: Fetal lymphangiomas can occur in many different anatomic locations, including the most commonly seen nuchal cystic hygroma. CASE: A fetus at 18 weeks' gestation was found to have a massive right axillary hygroma. The fetal karyotype was normal. Serial ultrasound examinations indicated progressive enlargement, but no hydrops. At 32 weeks' gestation, a left axillary hygroma was also diagnosed. The patient underwent cesarean delivery. CONCLUSION: Prenatal diagnosis of nuchal cystic hygromas has a high association with karyotypic abnormalities, hydrops, and fetal demise; however, this association may not apply to cystic lymphangiomas at other locations.

Adult↗
PubMed1995

Porencephaly secondary to fetal trauma during amniocentesis.

BACKGROUND: There has been one reported case of porencephaly diagnosed postnatally as a result of amniocentesis. We report the first antenatal diagnosis of porencephaly, which apparently resulted from penetration of the fetal skull during amniocentesis. CASE: A 37-year-old woman had genetic amniocentesis at 16 weeks' gestation. The fetal skull was penetrated during the unguided procedure. Porencephaly discovered at 28 weeks' gestation was confirmed by imaging studies in the neonatal period. CONCLUSION: Inadvertent fetal skull penetration appeared to result from amniocentesis unguided by continuous ultrasound.

Adult↗
PubMed1995

Non-immune hydrops after 20 weeks' gestation: review of 10 years' experience with suggestions for management.

OBJECTIVE: To analyze the etiologies and outcomes for a southeastern section of the United States, and to organize an efficient approach to evaluation. METHODS: We reviewed 82 cases of non-immune hydrops presenting after 20 weeks' gestation over a 10-year period. RESULTS: Overall perinatal mortality was 86.6%. Fetuses diagnosed with hydrops before 24 weeks' gestation had a perinatal mortality of 95%, with nearly one-third having abnormal karyotypes. The etiology of hydrops diagnosed after 24 weeks' gestation was more likely to remain idiopathic or to be related to cardiothoracic abnormalities. CONCLUSION: Before 24 weeks' gestation, the high risk of mortality and abnormal karyotype justifies offering families funipuncture in the hope of finding a treatable cause of non-immune hydrops. After 24 weeks' gestation, when fewer abnormal karyotypes are found, funipuncture may also be pivotal in diagnosing the cause of non-immune hydrops.

Adult↗
PubMed1995

Cesarean delivery: a reconsideration of terminology.

The terminology we employ influences our perceptions. Thus, we believe in reviewing terminology regularly. The term "cesarean section" should be abandoned. A medical procedure is rarely named after a historic figure, and almost never after an ancient Roman law. Cesarean section has recently been amended to cesarean birth; however, the term is still inadequate. The word "hysterotomy" more appropriately describes the procedure we regularly perform. The adjectives used to describe cesarean birth should also be reevaluated. If we are to keep the term "classical" for the original fundal vertical uterine incision, then the other designations of hysterotomy should retain the same architectural context. Contemporary hysterotomy should be used in reference to a low transverse cesarean. Neoclassical hysterotomy might be used to describe the low vertical procedure. Transitional hysterotomy may be an appropriate term for the "hockey stick" or "J" incision. Cesarean delivery best describes a postmortem cesarean. Vaginal birth after cesarean (VBAC) is inappropriate because a vaginal birth after a cesarean section would not occur if cesarean section refers to a perimortem procedure. Vaginal birth after hysterotomy should be substituted for VBAC. Such revision of our terminology will keep obstetrics at the forefront of medical science and bring us most efficiently into the 21st century.

Cesarean Section↗