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Biomedical subjects

J A Spinnato

Publications and source records attributed to J A Spinnato.

At least 37 records · Page 2Linked to original sources
PubMed1995

Fetal macrosomia: does antenatal prediction affect delivery route and birth outcome?

OBJECTIVE: Our purpose was to determine whether clinical or ultrasonographic prediction of fetal macrosomia influences subsequent delivery route and birth outcome in a clinical setting where macrosomia is not considered an indication for cesarean delivery. STUDY DESIGN: The hospital records of 504 patients delivered of infants weighing > or = 4200 gm between October 1989 and March 1994 were reviewed. Statistical comparisons were made between patients in whom fetal macrosomia was predicted before delivery (n = 102) and those in whom it was not (n = 402). Cesarean delivery, shoulder dystocia, and birth trauma rates were the variables of interest. RESULTS: Cesarean sections were performed in 52% of the "predicted" group deliveries and in 30% of the "not predicted" group (p < 0.01). The increased cesarean delivery rate in the predicted group appeared to be related to an increased incidence of labor inductions (42.5% vs 26.6%, p = 0.005) and a greater proportion of failed inductions. The proportion of patients delivered by cesarean section without a trial of labor was similar in the predicted and not predicted groups (14.7% vs 10.2%, p = 0.21). There was no significant differences in the incidence of shoulder dystocia or the occurrence of birth trauma. CONCLUSIONS: The antenatal prediction of fetal macrosomia is associated with a marked increase in cesarean deliveries without a significant reduction in the incidence of shoulder dystocia or fetal injury. Ultrasonography and labor induction for patients at risk for fetal macrosomia should be discouraged.

Birth Injuries↗
PubMed1995

Aggressive intrapartum management of lethal fetal anomalies: beyond fetal beneficence.

OBJECTIVE: To evaluate management recommendations from the current literature for patients whose fetuses are certain to have lethal anomalies or absent (or virtually absent) cognitive function. These recommendations include termination of pregnancy or, for cases in the third trimester, nonaggressive intrapartum management, avoiding cesarean delivery for fetal indications. METHODS: We report our experience with several patients who voiced opposition to nonaggressive intrapartum care and present a rationale for selectively aggressive, intrapartum management for some of these cases. RESULTS: Four women whose fetuses had lethal anomalies requested aggressive intrapartum management. For three of the four, standard aggressive management of labor resulted in vaginal delivery of live-born infants who died shortly thereafter. The patients found comfort in the live births. The fourth patient accepted a recommendation to avoid fetal monitoring during labor, and the fetus was stillborn. This patient found the intrapartum experience to be very stressful. CONCLUSION: When a patient's desire to avoid an intrapartum stillbirth is strong enough that substantial psychological harm might result from one, the physician's beneficence-based obligation to her and respect for maternal autonomy justify selectively aggressive intrapartum therapy, even if no beneficence-based obligation to the fetus exists.

Adult↗
PubMed1995

Myometrial estradiol and progesterone receptor changes in preterm and term pregnancies.

OBJECTIVE: To determine if labor is associated with changes in myometrial estradiol (E2) and progesterone receptors. METHODS: Lower myometrial segments were obtained from women undergoing cesarean deliveries at term in labor (n = 10), term not in labor (n = 10), preterm in labor (n = 9), and preterm not in labor (n = 11). Western immunoblotting was used to determine the presence and molecular size of E2 and progesterone receptor proteins. Immunocytochemistry was used to determine E2 and progesterone receptor changes in preterm and term pregnancies. RESULTS: Myometrium from pregnant women contained 74-kilodalton (kDa) E2 receptor and 94- and 110-kDa progesterone receptor proteins. These receptors are present in both myometrial smooth muscle and myometrial blood vessels. The nuclei of myometrial smooth muscle cells primarily contain both receptors. The immunostaining for progesterone receptors was less in patients in labor compared with those not in labor in preterm and term pregnancies. In comparing patients not in labor, the immunostaining for progesterone receptors was less at term compared with preterm pregnancy. Unlike the differences in progesterone receptors, there are no obvious differences in E2 receptor immunostaining in myometrial samples from all four groups of women. CONCLUSION: A myometrial decrease in progesterone receptors, rather than an increase in E2 receptors, may play a role in the onset of labor in women with term or preterm pregnancies.

Adult↗
PubMed1994

Small hyperechoic ventricle: a benign foci of the fetal cardiac sonographic finding?

The objective of our study was to determine the significance of antenatally detected, small hyperechoic foci in the fetal cardiac ventricle. In a 13-month period, we identified 25 fetuses with such a finding, an incidence rate of 0.46%. The hyperechoic foci in 24/25 fetuses were seen during follow-up serial scans. The size ranged from 1 to 6 mm. All had a normal fetal echocardiogram at 20-22 weeks' gestation. Eleven of the 24 neonates had a normal postnatal echocardiogram in the first 4 weeks of birth. One neonate had a previously undiagnosed transposition of the great vessels and no residual hyperechoic focus. Twelve had an echogenic focus located at the level of the chordae tendineae and papillary muscles in the left ventricle. In each of these 12 neonates, there was normal ventricular function determined by measuring the shortening fraction, and a competent atrioventricular valve. When hyperechoic foci are identified, baseline antenatal echocardiography should be performed to confirm their benignity. With an otherwise normal fetal and clinical neonatal evaluation, serial antenatal and confirmatory postnatal echocardiography are unnecessary. A possible relationship to other cardiac anomalies or aneuploidies requires further study.

Journal Article↗
PubMed1994

Eicosanoid biosynthetic enzymes in placental and decidual tissues from preeclamptic pregnancies: increased expression of thromboxane-A2 synthase gene.

Preeclampsia is a disease of late pregnancy characterized by hypertension, edema, and proteinuria, in which vasoconstriction, platelet aggregation, and reduced uteroplacental blood flow contribute to preterm delivery, perinatal morbidity, and mortality. Increased thromboxane-A2 (TXA2) and/or decreased prostacyclin (PGI2) have been implicated as causative factors of this disease. The present studies investigated the expression of TXA2 synthase gene along with those of TXA2 receptors, PGI2 synthase, cyclooxygenase-1 (COX-1), and COX-2 in placental and decidual tissue from preeclamptic and normal pregnancies. In situ hybridization and immunocytochemistry showed that primarily trophoblast layer and decidual cells express TXA2 synthase, COX-1, and COX-2 enzymes. Immunocytochemistry for PGI2 synthase and in situ hybridization for TXA2 receptors showed similar results. Trophoblast layer and decidua from preeclamptic pregnancies contained a greater abundance of mRNA and protein of TXA2 synthase than the matched normal pregnancies. In summary, our findings suggest that an increased local expression of TXA2 synthase could be responsible for local and/or peripheral vascular changes in preeclampsia.

Decidua↗
PubMed1994

Expression of functional human chorionic gonadotropin/human luteinizing hormone receptor gene in human uterine arteries.

The present study investigated 1) whether extra- and intramyometrial arteries contain hCG/human LH receptor messenger ribonucleic acid (mRNA) and receptor protein, 2) whether hCG can bind to its vascular receptors and regulate the formation of vasoactive eicosanoids, and 3) whether hCG administration for ovulation induction can affect the vascular resistance in uterine arteries. The uterine arteries contain multiple hCG/LH receptor mRNA transcripts in endothelial and smooth muscle cells. The uterine arteries also contain an 80-kilodalton immunoreactive receptor protein in endothelial and smooth muscle cells. The extra- and intramyometrial arteries and an 80-kilodalton receptor protein bind [125I]hCG, which is inhibited by excess unlabeled hCG. The receptor mRNA, receptor protein, and ligand binding are higher in smaller intramyometrial arteries than in larger extramyometrial arteries. Incubation of uterine arteries with highly purified hCG resulted in a dose-dependent increase in immunoreactive cyclooxygenase-1, cyclooxygenase-2, prostacyclin synthase, and 6-keto-prostaglandin-F1 alpha and a decrease in prostaglandin-E2, thromboxane-A2 synthase, and thromboxane-B2. There was a significant decrease in the resistance index in uterine arteries, but not in common carotid arteries, by 16 h after the administration of 10,000 IU hCG for ovulation induction in women. This decrease is positively correlated with serum hCG levels, but not with progesterone or estradiol levels. In summary, these data, demonstrating the expression of functional hCG/LH receptors in human uterine arteries, are novel and may have important implications for physiological uterine blood flow regulation, reproductive failure, and obstetrical hemorrhage.

Adult↗
PubMed1994

Vaginal birth after cesarean section in a university setting.

Despite numerous reports in the literature almost universally endorsing the safety of a trial of labor after a prior cesarean section, it is used in only a small fraction of eligible patients. Our investigation, conducted at the University of Louisville, examines the safety of such a protocol. Two thousand seven hundred fifty-seven patients were delivered during one year; 282 had a history of at least one prior cesarean section. Of the 259 patients eligible, 218 (84%) underwent a trial of labor, and 168/218 (77%) were delivered vaginally. There were 6 cases of uterine dehiscence and 1 uterine rupture. No hysterectomies were performed. Maternal morbidity was significantly greater in the failed trial-of-labor group. There was one perinatal death that was unrelated to a trial of labor. A previous diagnosis of cephalopelvic disproportion or failure to progress did not preclude a trial of labor, and 69% of these patients delivered vaginally. Our data suggest that a trial of labor following one or more previous cesarean sections is a safe option in a carefully selected population.

Cesarean Section↗
PubMed1993

Association between maternal-fetal HLA-DR relationships and fetal growth.

PROBLEM: To determine whether maternal-fetal human leukocyte antigen (HLA) antigenic relationships are associated with differential fetal growth in weight. METHOD: A cohort of 659 primigravid women were enrolled in this study in the prepartum period and their neonates were subsequently examined. Anthropometric, maternal cigarette smoking behavior, health, pregnancy, and delivery data were collected; serogenetic typing was conducted on maternal and cord bloods to determine maternal and neonatal HLA antigenic phenotypes. Women and their neonates were assigned to one of the four different types of maternal-fetal relationships existing at each of the HLA-A, B, DR, and DQ loci. Birthweights were treated quantitatively and qualitatively (neonates classified as growth-retarded or normal). RESULTS: After controlling for other factors influencing birthweight (e.g., smoking, maternal body size), significantly lower birthweight trends (P < .01) were found when neonates expressed a single HLA-DR antigen and their mothers expressed a second HLA-DR antigen that was foreign (allogeneic) to their neonate. CONCLUSION: Our findings supports the hypothesis that lack of maternal immune exposure to fetal HLA antigens is associated with a slowing of fetal growth. However, in this situation slowed fetal growth is most likely to occur when the fetus is potentially exposed to maternal HLA-DR alloantigens. We believe this sheds new light on immunologic events at the maternal-fetal interface influencing fetal growth. We present one possible explanation to account for this finding.

Birth Weight↗
PubMed1992

Hemolytic disease of the fetus: a plea for restraint.

The recent addition of fetal blood sampling and transfusion techniques to the management schemes for hemolytic disease of the fetus has expanded clinical options for patient care. Coincident with these techniques is a new aggressiveness toward sensitized pregnancies that, upon review of available data, selects more patients for early and invasive testing than appears necessary. This paper explores the issues of invasive testing and offers guidelines that are more conservative than those recommended in recent reports.

Amniocentesis↗
PubMed1992

Maternal-fetal HLA-DR relationships and pregnancy-induced hypertension.

OBJECTIVE: Some studies have found an increased prevalence of pregnancy-induced hypertension among women sharing HLA antigens with their spouses or fetuses, thus supporting the hypothesis that maternal sensitization to fetal HLA alloantigens reduces the risk for pregnancy-induced hypertension. However, not all studies have confirmed these findings. No investigators have examined the four different types of maternal-fetal HLA relationships in their studies of pregnancy-induced hypertension. Our goal was to examine such associations to test further the HLA-allosensitization hypothesis. METHODS: We conducted a cohort study of pregnancy-induced hypertension among 683 nulliparous women. Women and their neonates were typed for HLA-A, -B, -DR, and -DQ antigens using serologic techniques to establish maternal-fetal relationships. RESULTS: We found an increased prevalence of pregnancy-induced hypertension when the fetus, but not the mother, was potentially exposed to HLA-DR alloantigens (maternal allogenicity) compared with the other three conditions combined (P < .003). Controlling for confounding factors, the increased prevalence of pregnancy-induced hypertension persisted in situations of maternal HLA-DR allogenicity (P < .007). CONCLUSIONS: Based upon our observations and other immunologic studies of pregnancy-induced hypertensive and uncomplicated pregnancies, we conclude that a maternal humoral response against fetal anti-HLA-DR immunoglobulin (IgG) antibody may influence the development of pregnancy-induced hypertension. This could occur when an immunocompetent fetus is exposed to maternal HLA-DR alloantigens, maternal exposure to fetal HLA-DR alloantigens alloantigens, maternal exposure to fetal HLA-DR alloantigens is not possible, and fetal IgG antibody bears paternally inherited markers allogeneic to the mother.

Eclampsia↗
PubMed1991

Should anticardiolipin tests be performed in otherwise healthy pregnant women?

Positive anticardiolipin and lupus anticoagulant tests are not confined to patients with the antiphospholipid syndrome, and the usefulness of these tests in healthy pregnant women is uncertain. This study sought to determine the prevalence of anticardiolipin antibodies and correlation with pregnancy outcome in 1449 pregnant women. Results were compared with 40 patients with the antiphospholipid syndrome. Persistence of positive anticardiolipin antibody tests was also ascertained. Twenty-six of 1449 sera (1.79%) were immunoglobulin G anticardiolipin positive, and 63 (4.3%) were immunoglobulin M anticardiolipin positive. Twenty-three of 26 positive for immunoglobulin G anticardiolipin and 55 of 63 positive for immunoglobulin M anticardiolipin results were low. Anticardiolipin positivity did not correlate with complications or outcome. Immunoglobulin G isotype and level distinguished patients with antiphospholipid syndrome from otherwise healthy women with positive anticardiolipin tests. In healthy pregnant women positive anticardiolipin tests occur infrequently, at low levels, and are rarely associated with adverse pregnancy outcome. This test should be requested only when the antiphospholipid syndrome is suspected.

Adult↗
PubMed1991

Amniotic fluid bilirubin and fetal hemolytic disease.

Six different methods for assessing amniotic fluid bilirubin were compared in 111 samples from 37 patients. When the Liley methods were compared, the chloroform extraction and 5% correction methods resulted in 20% and 4% reductions, respectively, in the mean change in optical density at 450 nm when compared with the uncorrected mean (0.086 +/- 0.06 [p less than 0.05] and 0.104 +/- 0.07 [p, not significant] vs 0.108 +/- 0.08). This reduction was observed in spite of significant visual blood contamination being rarely noted. The predictions based on amniotic fluid analysis were compared with the first fetal or neonatal hematocrit. The chloroform-extracted change in optical density at 450 nm accurately predicted fetal status in all patients, whereas lesser degrees of accuracy were observed with other methods. Hydrops fetalis did not occur during the observation period, and fetuses needing transfusion (n = 5) or early delivery (n = 10) were indicated correctly. The chloroform extraction change in optical density at 450 nm accurately predicts fetal status, and its use should continue.

Amniotic Fluid↗
PubMed1990

Prophylactic insulin in the management of gestational diabetes.

One hundred eight gestational diabetics were randomized to receive either diet alone or diet plus insulin (20 units NPH and 10 units regular) for glycemic control. Blood glucose levels were evaluated weekly in a high-risk clinic where medical and nutritional support and counseling were provided. Among 68 women successfully treated for a minimum of 6 weeks, the mean birth weight, macrosomia rate, and ponderal index were reduced significantly in the insulin-treated group. Insulin reduced birth weights significantly in women with a delivery weight of 200 lb or more (4060 +/- 342 versus 3397 +/- 640 g) and in those with a delivery weight less than 200 lb (3324 +/- 448 versus 3047 +/- 394 g). No patient with good glucose control and a maternal delivery weight under 200 lb had a newborn over 4000 g. Patients failing glycemic control were at greatest risk (30%) for fetal overgrowth whether initially receiving insulin or not. Maternal obesity or failure to achieve glycemic control should alert the clinician to a substantially increased risk of macrosomia.

Adult↗