Biomedical subjects
Publications and source records attributed to J C Hauth.
In the subsequent labor and delivery of 292 women who had a prior low transverse cesarean section the incidence of scar separation was low and was not affected by the method of uterine closure. A low transverse incision closed in one continuous layer should not preclude a subsequent trial of labor.
OBJECTIVE: To evaluate the association between fetal loss in the second trimester and subsequent adverse birth outcomes. METHODS: We identified 95 women in our system who had a pregnancy loss at 13-24 weeks in the years 1985-1990 and tabulated the rates of preterm delivery, stillbirth, and neonatal death in the next pregnancy. We compared these outcomes to two groups: women who delivered at 25-36 weeks in their index pregnancy and those who delivered at term in their index pregnancy. RESULTS: Thirty-nine percent of women who had a pregnancy loss at 13-24 weeks in the index pregnancy had a preterm delivery in their next pregnancy, 5% had a stillbirth, and 6% had a neonatal death, with all outcomes worse than those found in the two control populations. Delivery at 19-22 weeks in the index pregnancy was associated with a 62% preterm delivery rate in the subsequent pregnancy. CONCLUSION: A second-trimester loss, especially one occurring at 19-22 weeks, is associated with a poor prognosis in the subsequent pregnancy.
OBJECTIVE: Closure of a low transverse cesarean incision with one layer of suture results in less operating time, better hemostasis, and less infectious morbidity than a two-layer closure. STUDY DESIGN: At our institution 906 women were randomized to closure of a low transverse cesarean incision with either one continuous layer of a locking No. 1 chromic suture and a CTX needle (n = 457) or two continuous layers of No. 1 chromic suture with the first layer locked (n = 449). The Student t test, chi 2 test of proportion, and Wilcoxon rank sum test were used to compare groups of patients. RESULTS: A one-layer closure required less operative time, 43.8 versus 47.5 minutes (p = 0.0003). Fewer additional uterine hemostatic sutures were required in 369 women in whom either the one- (n = 179) or the two-layer (n = 190) closure did not achieve hemostasis (p = 0.046). Endometritis was similar in both groups, 83 (22%) in the one-layer group versus 65 (18%) in the two-layer group (p = 0.17). In no outcome assessment was the two-layer closure superior to the one-layer closure. CONCLUSION: We recommend a one-layer closure when its use is anatomically feasible.
OBJECTIVES: The purpose of this study was to determine whether a concentrated oxytocin infusion can reliably effect uterine evacuation in the midtrimester and whether such an infusion is associated with fewer side effects than prostaglandin E2 vaginal suppositories. STUDY DESIGN: Patients received either prostaglandin E2 (n = 42) or oxytocin (n = 45) for indicated midtrimester abortions in a prospective, randomized trial. Treatment consisted of either prostaglandin E2 vaginal suppositories (one every 4 hours) or infusions of an escalating concentration of oxytocin (one every 4 hours). Unless delivery had occurred or was imminent after 24 hours, the agent was considered to have failed, and patients were crossed to the alternative method. RESULTS: Delivery indications were similar between the two groups. There were 6 (14%) first-agent failures with prostaglandin E2 and 9 (20%) with oxytocin (p = 0.48). Considering the failures and subsequent crossovers, 103 patient trial regimens were completed. Fever, nausea, vomiting, and diarrhea were more frequent with prostaglandin E2 (p < 0.005). CONCLUSIONS: Concentrated oxytocin is a satisfactory alternative to prostaglandin E2 for midtrimester abortion.
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We retrospectively reviewed 29 cases of ventral abdominal wall defects to evaluate the usefulness of amniotic fluid markers in the prenatal assessment of those disorders. Amniotic fluid alpha-fetoprotein (AF-AFP) values were available in 17 cases diagnosed prior to 22 weeks' gestation and acetylcholinesterase (AF-ACE) values, in 21 cases. All 7 fetuses with a gastroschisis had an elevated AF-AFP, while only 2 of the 10 fetuses with an omphalocele had elevated values (P = .002). ACE was present in 80% of the cases of gastroschisis versus 27.3% of the cases of omphalocele (P = .03). With equivocal sonographic findings, a normal AF-AFP and negative AF-ACE may be more compatible with an omphalocele.
OBJECTIVE: To assess the influence of several maternal and neonatal variables on the recurrence of gestational diabetes mellitus. METHODS: A retrospective review was conducted on 90 of our patients whose index pregnancy was complicated by gestational diabetes mellitus and whose subsequent pregnancy was also managed at our institution. RESULTS: Forty-seven women (52%) had a recurrence of gestational diabetes mellitus in their subsequent pregnancy. These 47 women had an increased body mass index (BMI) (32.8 +/- 8.2 versus 28.9 +/- 7.2 kg/m2; P < .03) and more large for gestational age (LGA) neonates (38 versus 14%; P < .05) and more of them required insulin during their index pregnancy (38 versus 19%; P < .05) than did those who did not have a recurrence of gestational diabetes mellitus. Women who developed a recurrence of gestational diabetes mellitus also had higher fasting (P < .05), 1-hour, 2-hour, and total glucose tolerance test values (P < or = .01) during their index pregnancy. CONCLUSION: Women with a history of gestational diabetes mellitus who have a BMI greater than 35 kg/m2, whose previous newborn was LGA, and who required insulin during their previous pregnancy are at increased risk for recurrence of gestational diabetes mellitus.
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During August 1989, the urine of 5010 women of childbearing-age in Alabama was screened for marijuana, cocaine, opiates, amphetamines, and barbiturates. The data base consisted of 2970 pregnant women, 374 of whom were at high risk, and 2019 nonpregnant women. Our findings included the following information: (1) The statewide prevalence of positive screens for any drugs tested was 12.9% for all women (11.0% for those who were pregnant and 15.6% for those who were not pregnant). (2) There was no difference between urban and rural groups for any drugs tested. (3) Positive marijuana screens were increased among white and nonpregnant women (p less than 0.01). (4) Positive cocaine screens were increased among black and single women (p less than 0.01). (5) More screens were positive in women older than age 20 (p less than 0.01). (6) There was no difference between pregnant and nonpregnant women for positive cocaine screens. (7) No difference existed among the trimesters of pregnancy for positive cocaine screens. (8) Positive screens for marijuana were more frequent in the first trimester of pregnancy than in the second trimester (p = 0.02) or the third trimester (p = 0.001). (9) There was no difference between high-risk and low-risk maternity patients for any drugs tested.
The ability of prostaglandin E2 to prepare the unripe cervix before an indicated labor induction is controversial. We therefore tested 100 pregnant women in a randomized, double-blind trial with intracervical prostaglandin E2 gel, 0.5 mg. The 53 women who received the placebo gel had an outcome similar to that of the 47 women who received the prostaglandin E2 gel. The mean change in cervical score, mean application-to-delivery interval, incidence of uncomplicated spontaneous labor, incidence of cesarean delivery for a failed induction, and the overall cesarean section rate were not significantly different for the two groups. A meta-analysis, incorporating 18 studies of 1811 patients who received a single application of at least 5 mg prostaglandin E2 gel intravaginally or 0.5 mg intracervically, demonstrated no significant decrease in the overall cesarean delivery rate (p = 0.85). We conclude that the use of single-dose intracervical prostaglandin E2 gel for cervical ripening has little effect on labor induction. Moreover, the use of single-dose intracervical or intravaginal prostaglandin E2 gel does not alter the incidence of cesarean delivery, even when large numbers of patients are analyzed by combining the results of similar reports.
Animal and human studies suggest that fetal oliguria is a normal physiologic response to hypoxemia. To assess the clinical significance of this observation, we studied (before their admission) 51 fetuses of women whose pregnancies were complicated by oligohydramnios at greater than or equal to 38 weeks' gestation. We found that the mean hourly fetal urine production decreased significantly in relation to the severity of subsequent intrapartum fetal compromise. The mean antepartum rate was 95 ml/hr in the 21 fetuses with a normal intrapartum heart rate pattern; this fell to 59 ml/hr in the 18 fetuses who had an abnormal intrapartum heart rate pattern but who responded to intrauterine resuscitation. The rate was 33 ml/hr in the 12 fetuses who were delivered by cesarean section as a result of fetal distress. These findings suggest that oligohydramnios associated with fetal oliguria may be used to identify those fetuses who have less intrinsic or uteroplacental reserve than do those of women with oligohydramnios who have a higher rate of fetal urine production.
The degree of umbilical arterial acidemia associated with immediate newborn morbidity has not been determined. Therefore we compared 358 term infants with umbilical artery acidemia (pH less than 7.20) with 358 term, nonacidotic matched control infants, to evaluate immediate neonatal complications in both groups. Nonacidotic was defined as an umbilical artery pH greater than or equal to 7.20. Complications included seizures, persistent hypotonia, and/or signs of end-organ damage such as renal or cardiac dysfunction. None of the 693 newborns with an umbilical artery pH greater than or equal to 7.00 had such complications. Two of 23 infants with an umbilical artery pH less than 7.00 had sequelae related to intrapartum asphyxia. In these two infants the umbilical artery pH was less than 7.00, the 1-minute and 5-minute Apgar scores were less than or equal to 3 and the acidemia was metabolic in nature.
No marker except repeated fasting glucose determinations has proven useful to ascertain prospectively which women with gestational diabetes mellitus will remain euglycemic by diet modification or will require insulin therapy. We screened 183 black women with gestational diabetes mellitus to determine if the presence of islet cell, mitochondrial, nuclear, DNA, parietal cell, smooth muscle, thyroid microsomal, thyroid thyroglobulin autoantibodies, or rheumatoid factor predicted the need for insulin therapy to maintain euglycemia in women with gestational diabetes mellitus. One hundred forty-two women maintained normal fasting plasma glucose levels with dietary modifications and 41 required institution of split-dose insulin therapy. We found no significant differences in the prevalence of these autoantibodies in black women with Class GB versus Class A1 diabetes mellitus. We conclude that screening for autoantibodies in women with gestational diabetes mellitus is not useful in determining which patients will subsequently require insulin therapy during their pregnancies.
Insulin-dependent diabetes mellitus is associated with an increased frequency of certain histocompatibility antigens located on chromosome six, the most common types being B-8, B-15, DR-3, DR-4, and DR-7. We therefore theorized that screening for these subtypes may allow the identification of those women with gestational diabetes who will remain euglycemic on dietary modification (class A1) compared with those who will require insulin to achieve euglycemia (class GB). From 1982 to 1987, 228 black women with gestational diabetes were screened for the above histocompatibility antigens. As theorized, certain histocompatibility antigen subtypes were more common in women with class GB gestational diabetes mellitus; DR-2 (41.8% versus 23.7% p = 0.015), B-15 (p = 0.07), and DR-3 (p = 0.08). However, because of the low sensitivity (42%), specificity (75%), and positive predictive value (36%), this test is impractical in the clinical management of women with gestational diabetes mellitus.
The pregnancy outcomes of 155 women who underwent an amniocentesis for a prenatal karyotype after being diagnosed by ultrasound as having one or more nonlethal structural anomalies are presented. Thirty-three (21%) patients were found to have an abnormal karyotype. Knowledge of the prenatal karyotype was useful in the subsequent management of these pregnancies. A pregnancy with a fetal anomaly diagnosed prior to 24 weeks was more likely to be terminated if an abnormal karyotype was also present. In women who were diagnosed as having a fetal anomaly with an abnormal karyotype at 24 weeks or later, only 3 of 13 (23%) infants survived the neonatal period. Knowledge of the karyotype results influenced decisions regarding the place, timing, and route of delivery in these fetuses. In 32 women, (21%) a karyotype was beneficial by avoiding maternal transport, cesarean delivery, and neonatal expenses at a Level III perinatal center.
A concentrated oxytocin infusion and prostaglandin E2 (PGE2) vaginal suppositories were compared in a retrospective analysis for indicated abortion in the mid-second trimester (17-24 weeks' gestation). Eighty-one women underwent second-trimester pregnancy termination, 59 by PGE2 suppositories and 22 by concentrated oxytocin infusion. Success was achieved by PGE2 in 93% (55 of 59) and oxytocin in 91% (20 of 22). The mean duration of labor was 13.1 hours with PGE2 and 8.2 hours with oxytocin. The mean dose of PGE2 was 65.2 mg; of oxytocin, 200 units. Women who received PGE2 experienced nausea (46%), vomiting (37%), fever (64%), and diarrhea (20%) despite appropriate premedication. Few side effects occurred in the women who were treated with oxytocin. We conclude that concentrated oxytocin infusion seems to be a reasonable alternative to PGE2 vaginal suppositories for induction of labor in the mid-second trimester.
An adequate trial of labor preceding cesarean delivery for arrest of cervical dilatation in the active phase of labor has not been defined precisely. We reviewed the records of 85 consecutive women at term who received oxytocin for induction or augmentation of labor and who subsequently delivered by cesarean for arrest of labor in the active phase. The mean duration of oxytocin infusion was 15 hours for induction of labor and 8.9 hours for augmentation. Thirty-four (92%) of the 37 women who received oxytocin induction and 44 (92%) of the 48 who had oxytocin for augmentation achieved at least 200 Montevideo units of uterine pressure. All 85 newborns were vigorous at birth and had no complications during their stay in the hospital nursery. Evaluation of uterine contraction pressure can provide a quantifiable end point for the management of oxytocin induction or augmentation of labor.