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J A Kuller

Publications and source records attributed to J A Kuller.

At least 37 records · Page 2Linked to original sources
PubMed1997

Risk of preeclampsia in second-trimester triploid pregnancies.

OBJECTIVE: To determine the magnitude of the risk and the predictive clinical characteristics for development of preeclampsia when triploidy is diagnosed in the second trimester. METHODS: A retrospective analysis of databases maintained by the cytogenetics laboratories at the University of Iowa and University of North Carolina was performed to identify all cases of triploidy. We examined the karyotype, maternal serum screening (particularly the hCG level), ultrasound results, and evidence of maternal hypertensive disease. RESULTS: Seventeen cases of triploidy were identified between 1987 and 1996. Preeclampsia or hypertension complicated six of these cases with onset between 15 and 22.5 weeks' gestation. In these six cases, the serum hCG level was extremely high. Serum screening results were available in seven cases in which preeclampsia did not develop, and the hCG levels were under 0.09 multiples of the median in five of the seven cases. In all six cases in which preeclampsia or hypertension developed, there was sonographic evidence of placentomegaly. Sonographic findings in 16 of 17 cases revealed fetal growth restriction, oligohydramnios, fetal anomalies, placentomegaly, or a combination of these. CONCLUSION: In our series of pregnancies complicated by triploidy, the risk of developing preeclampsia or hypertension in the second trimester was 35%. It appears that elevated serum hCG levels and placentomegaly are associated with a higher risk of preeclampsia but low hCG levels are not. This information is important in counseling patients who are hesitant to terminate a pregnancy purely for a fetal abnormality, even if the anomaly is lethal.

Adolescent↗
PubMed1997

Analysis of the risks associated with calcium channel blockade: implications for the obstetrician-gynecologist.

Calcium channel antagonists are widely prescribed in obstetrics and gynecology for blood pressure control and tocolysis. Concerns have recently arisen regarding the safety of these agents. Several studies found that short-acting forms of calcium channel blockers were associated with increased cardiovascular mortality, malignancy, and gastrointestinal bleeding. A recent meta-analysis found a significant increase in the risk of mortality in patients treated with a short-acting form of nifedipine. Another subgroup analysis of an observational study of older hypertensive patients found a significantly increased risk of cancer and gastrointestinal hemorrhage in patients prescribed calcium channel blockers. Both in vitro and small human in vitro series have reported a potential for cardiac toxicity in pregnant women treated concomitantly with calcium channel blockers and magnesium sulfate. Until additional data are available, we suggest that when calcium channel blockers are used in obstetrics and gynecology, the long-acting variety be prescribed. Concurrent use of calcium channel blockers and magnesium sulfate should be undertaken cautiously because of the potential for synergistic depression of cardiac function.

Calcium Channel Blockers↗
PubMed1997

Prenatal diagnosis using fetal cells from the maternal circulation.

Current prenatal diagnosis relies on invasive methods such as amniocentesis and chorionic villus sampling. Because these methods carry a low, but finite risk of pregnancy loss, noninvasive genetic screening techniques are the focus of intense research. Isolating fetal cells from maternal blood for genetic analysis is the least invasive method currently being investigated. We discuss the various methods that have been used to isolate these cells. Nucleated red blood cells have emerged as the ideal fetal cell type. This is because they have the DNA material necessary for genetic analysis, they are consistently present in maternal blood, they can be easily identified based on their morphology, and they have a definite gestational life span.

Congenital Abnormalities↗
PubMed1997

A guide to the safety of CNS-active agents during breastfeeding.

For most agents with CNS activity, there are limited data regarding their safety in breastfeeding. Any decision to institute treatment for a neurological or psychiatric disorder must weigh the benefits of maternal treatment against the potential harm to the breastfeeding mother of withholding medication which may improve her illness. For the neonate, one must balance the risk of medication exposure against the benefit of receiving breast milk. Most tricyclic antidepressants can be used in lactating women. Because of the limited data, selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors should only be used with due consideration of the potential adverse effects. Breastfeeding is best avoided by women who require lithium therapy, because of both the immature excretory systems in the infant and relatively high doses received by the infant. There is little information about the safety of antipsychotic medications in breastfeeding. Concerns include toxicity and abnormal neurological development in the infant. These agents may be used with caution. Most agents which cause depression of the CNS, including opiates and sedatives, can be used in small doses and for short courses in breastfeeding mothers. Most anticonvulsants can be used in lactating women. Reference texts and consultation with experts are useful adjuncts to discussion of the risks and benefits of therapy with the patient. The scope of this review is limited to drugs with therapeutic uses, thus drugs of abuse are not discussed, nor are caffeine and alcohol (ethanol).

Adult↗
PubMed1996

Magnetic resonance imaging of the pelvic floor in the postpartum patient.

Magnetic resonance imaging (MRI) was used to assess anatomical changes in the pelvic floor after childbirth. Six women underwent serial MRI examination within 30 hours and at 1 week, 2 weeks, 6 weeks and 6 months after delivery; 8 additional women were studied only within 30 hours of delivery. T-1 and T-2-weighted images of the pelvis in the transverse and sagittal planes with a 1.5-T MR imager were obtained. In the sagittal section we assessed the urethrovesical angle, urethral length, distance from the symphysis to the proximal and distal vagina, vaginal length, width and length of the sphincters, and the presence of sphincter defects. Axial sections were assessed for sphincter defects for the distance between the symphysis and midurethra, vagina and rectum. Only one parameter (distance between symphysis and distal vagina) changed significantly over time, without a clear trend in direction. Interobserver variation was reasonable (<15%) except for anal canal length, urethral length and distance between symphysis and anus. There were no significant correlations between birthweight and MRI parameters. There was a non-significant association (P = 0.09) between the sole combined sphincter defect and rectal injury, but not with episiotomy or parity. We concluded that it is feasible to determine multiple measurements on MR images to evaluate structures of the pelvic floor.

Adult↗
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

Aneurysm of the vein of Galen: prenatal diagnosis and perinatal management.

An aneurysm of the vein of Galen is a rare arteriovenous malformation of the central nervous system. Fetal manifestations have included nonimmune hydrops, hydrocephalus, and intracranial hemorrhage. This anomaly may be diagnosed prenatally by several imaging modalities. A cystic cranial mass was identified by ultrasound in a fetus at 30 weeks gestation. Both pulsed-wave Doppler and color-velocity imaging studies suggested aneurysm of the vein of Galen was the most likely diagnosis. The fetus demonstrated no evidence of hydrops on serial ultrasound examinations. A 2430 g female infant was delivered vaginally at 35 weeks gestation. Postnatal management included transarterial embolization of the vessels feeding the aneurysm with craniectomy, an intra-aneurysmal balloon, and vascular microcoils. Hydrocephalus developed and a ventriculo-peritoneal shunt was placed. The infant has grown appropriately in the first year of life. An aneurysm of the vein of Galen may be diagnosed prenatally by real-time ultrasound, pulsed-wave Doppler, color-velocity imaging, or magnetic resonance imaging. The presence of this malformation should prompt close follow-up for the remainder of the pregnancy. Careful obstetric management and early postnatal intervention may lead to a favorable outcome.

Adolescent↗
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↗