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Biomedical subjects

J L Kitzmiller

Publications and source records attributed to J L Kitzmiller.

At least 37 records · Page 2Linked to original sources
PubMed1992

Erythropoietin in pregnancies complicated by severe anemia of renal failure.

BACKGROUND: Recombinant human erythropoietin has been approved for treatment of the anemia of renal failure since 1989, yet data regarding the safety and efficacy of this drug in pregnancy are limited. We used recombinant human erythropoietin to treat the anemia of renal disease in three pregnant women. CASES: Nadir hematocrit values before initiation of erythropoietin were 19-23%. Erythropoietin, 50-160 U/kg/week subcutaneously, was begun at 14-26 weeks' gestation. Initially, the rise in hematocrit averaged 0.6-2% each week, with peak values of 26.7-32%. Iron supplementation was given simultaneously. Maternal and neonatal outcomes were favorable despite the development of preeclampsia or worsening renal function requiring early delivery. CONCLUSION: In this small series, erythropoietin begun during the second trimester in a dose of about 100 U/kg/week, in conjunction with orally administered iron, appeared to be effective in treating the anemia of renal failure during pregnancy. Additional experience is needed to evaluate the safety of this medication during pregnancy.

Adult↗
PubMed1991

Preconception care of diabetes. Glycemic control prevents congenital anomalies.

To test the value of intensive management of diabetes before and during early pregnancy, 84 women recruited prior to conception were compared with 110 women who were already pregnant referred at 6 to 30 weeks' gestation. All underwent daily measurement of fasting and postprandial capillary blood glucose levels. Mean blood glucose levels during embryogenesis and organogenesis were within 3.3 to 7.8 mmol/L in 50% of preconception subjects and exceeded 10 mmol/L in 6.5%. One major congenital anomaly occurred in 84 infants (1.2%) of women treated before conception compared with 12 anomalies in 110 infants (10.9%) of mothers in the postconception group. Transient symptomatic hypoglycemia occurred during embryogenesis in 60% of women in the preconception group, with a median frequency of 2.7 episodes per week, but was not associated with excess malformations. We conclude that education and intensive management for glycemic control of diabetic women before and during early pregnancy will prevent excess rates of congenital anomalies in their infants.

Adult↗
PubMed1991

Urinary protein/creatinine ratio before and during pregnancy in women with diabetes mellitus.

Quantitation of urinary protein excretion has traditionally involved collection of a 24-hour urine specimen. Recent reports have suggested that the ratio of protein to creatinine in a single-voided urine specimen may be used as a screening test of proteinuria, obviating the need for a 24-hour urine collection. This study was undertaken to determine whether the urinary protein/creatinine ratio was correlated with 24-hour protein excretion in women with diabetes, to determine whether pregnancy had any effect on the correlation, and to test the accuracy of estimates of 24-hour protein excretion on the basis of the protein/creatinine ratio. We studied 329 24-hour urine specimens from 133 women with classes B through RF diabetes. The protein/creatinine ratio was highly correlated with total protein excretion (r = 0.977, p less than 0.0001). The correlation was not affected by pregnancy, trimester, or preeclampsia. Three methods were used to predict protein excretion on the basis of the ratio. Compared with actual protein excretion, predicted values had mean errors of 19% to 27%; 6% to 13% of predictions were in error by greater than or equal to 50%. Because of these large errors, we conclude that this method of estimating protein excretion has limited value in pregnant women with diabetes.

Creatinine↗
PubMed1991

Spontaneous abortion and congenital malformations in diabetes.

The first few weeks after conception are a critical period for the embryo of a diabetic mother. If the mother is in good glycaemic control during this time, the risk of spontaneous abortion or major congenital malformation is low. Otherwise, the risk increases in proportion to the degree of blood glucose elevation. Glycohaemoglobin determination in the first trimester can be useful in retrospectively evaluating the degree of glycaemic control present around the time of conception and in roughly estimating the risk of spontaneous abortion or major malformation. For women with high risk, early prenatal diagnosis of congenital anomalies is warranted using detailed ultrasound examination, fetal echocardiography and alpha-fetoprotein determinations. Encouraging diabetic women to achieve strict control prior to conception should virtually eliminate the excess risk of spontaneous abortion or major malformation.

Abortion, Spontaneous↗
PubMed1991

Obstetric complications with GDM. Effects of maternal weight.

Obstetric complications recorded prospectively were assessed retrospectively in 150 women with gestational diabetes mellitus (GDM) and 305 control subjects matched for age, parity, and ethnicity. Intensive diet therapy and self-monitoring of capillary blood glucose were used to obtain postprandial euglycemia; 22% of GDM subjects required insulin. GDM and control subjects were grouped by body mass index to detect any influence of maternal prepregnancy weight on outcome. Polyhydramnios, preterm labor, and pyelonephritis were not more frequent in GDM, but hypertension without proteinuria (7.3 vs. 3.3%) and preeclampsia (8 vs. 3.9%) were more frequent in GDM. The frequency of hypertensive complications in GDM was not totally attributable to being overweight. Abnormalities of labor, birth trauma, and fetal macrosomia were not more common in GDM; 6.7% of the infants of mothers with GDM weighed greater than 4200 g at birth compared with 3.6% of control infants (NS), and 10% were large for gestational age and sex compared with 6.6% of control infants (NS). Despite this, cesarean delivery was more common in GDM (35.3 vs. 22%, P less than 0.01), mostly due to significantly more cesarean births without labor.

Birth Weight↗
PubMed1991

Pregnancy complicated by collagen vascular disease.

Pregnancies complicated by collagen vascular diseases present a challenge to the obstetrician, internist, and other consulting physicians caring for the patient. Although most pregnancies complicated by these disorders result in satisfactory outcomes, a significant number develop manifestations sufficiently serious to require admission to an intensive care unit. Such manifestations include lupus nephritis, CNS lupus, ARDS, massive alveolar hemorrhage, scleroderma renal crisis, pulmonary hypertension, severe myositis, and diffuse vasculitis. Of the numerous therapeutic options available, many may be used to optimize maternal and perinatal outcome.

Autoimmune Diseases↗
PubMed1990

Perinatal survival with expectant management of midtrimester rupture of membranes.

A retrospective study of 70 patients with preterm premature rupture of membranes before 26 weeks of gestation was performed. The purpose of this study was to examine the perinatal outcome and the potential maternal and neonatal morbidity associated with this obstetric condition. The mean gestational age at diagnosis of rupture of membranes was 23.7 weeks. The latency period ranged from 24 hours to 60 days with the mean being 12 days. There was no correlation between gestational age at rupture of membranes and latency period. Seventy-one infants were delivered. The perinatal survival was 63%. Sixty-eight percent of the survivors had normal neurological and physical development at 1-year follow-up. Amnionitis developed in 43% of patients. The incidence of respiratory distress syndrome in the neonates was 52%. Betamethasone did not appear to reduce this incidence. The perinatal survival in patients with midtrimester rupture of membranes appears to be improving with the advancements in neonatal care of the extremely premature infant.

Adolescent↗
PubMed1989

Insulin-like growth factors in fetal macrosomia with and without maternal diabetes.

Insulin-like growth factors (IGFs/somatomedins) have been implicated as regulators of fetal growth. This study investigates whether IGFs are related to macrosomia in infants of normal or insulin-dependent diabetic mothers. Cord concentrations of IGF-I (radioimmunoassay), total IGF (radioreceptor assay) and IGF binding protein (radiobinding assay) were measured in 15 term infants of diabetic mothers (IDM) and 29 term infants of nondiabetic mothers. In infants of control mothers cord IGF and total IGF levels were significantly higher in large-for-gestational-age than appropriate-for-gestational-age infants; but this relationship was lost in IDM, in whom IGF-I concentrations were similar to control infants. IGF binding protein levels were not significantly different in any of these groups. The absence of elevated IGF levels in macrosomic IDM indicates that the pathologic process does not involve a simple increase in these growth factors.

Adult↗
PubMed1988

Serum and urinary magnesium, calcium and copper levels in insulin-dependent diabetic women.

Eighteen insulin-dependent diabetic (IDD) and 15 healthy control women participated in a study of the relationship between glycemic control or renal function measurements and the levels of magnesium, calcium and copper in the serum and urine. In the IDD women glycosylated hemoglobin averaged 9.8 +/- 0.5% and the fasting plasma glucose was 1.89 +/- 0.19 g/L. The glomerular filtration rate, approximated from creatinine clearance, averaged 125 +/- 16 ml/min in the IDD women in comparison to 82 +/- 4 ml/min in the controls. IDD women had lower serum (p less than 0.001) and higher urinary (p less than 0.01) magnesium levels than did the controls; serum and urinary copper levels and serum ceruloplasmin levels all were higher (p less than 0.01) in the IDD women. There was no difference in either serum or urinary calcium levels between the two groups. In the IDD women serum magnesium was related to urinary glucose (r = -0.758, p less than 0.01) and to glycosylated hemoglobin (r = -0.603, p less than 0.01); none of the other measurements of serum or urinary minerals was related to measures of glucose control. Urinary calcium and copper levels, but not urinary magnesium, were correlated with the glomerular filtration rate (r = 0.476, p less than 0.05 and r = 0.554, p less than 0.05, respectively). The results of this study suggest that IDD alters the utilization of magnesium, calcium, and copper, but that these three minerals are not affected in the same way by physiological changes associated with the disease.

Adolescent↗
PubMed1988

Use of the subcutaneous terbutaline pump for long-term tocolysis.

Nine patients in preterm labor requiring long-term tocolysis were managed with subcutaneous terbutaline administered via a portable infusion pump. All had failed oral tocolytic therapy and were therefore faced with prolonged hospitalization. In this feasibility study, the patients were treated at home and monitored with portable tocodynamometers and home nursing visits. Uterine activity data were transmitted via telephone to the study center and terbutaline pump infusion rates were adjusted accordingly. Terbutaline pump therapy consisted of a combination of low-dose continuous basal infusion supplemented with intermittent high-dose boluses. Total daily drug dosage remained exceptionally low (less than 3 mg/24 hours). The mean gestational age at initiation of therapy was 29.6 +/- 3.7 weeks, and pregnancy was prolonged an average of 9.2 +/- 4.3 weeks. The minimum gestational age at delivery was 37.3 weeks. Patient tolerance was excellent and, in a total 394 patient-days of therapy, there were no significant complications. We conclude that the portable subcutaneous terbutaline pump may be a promising new method for long-term outpatient tocolysis in patients who cannot be maintained on oral therapy.

Administration, Oral↗
PubMed1987

Measurement of fetal shoulder width with computed tomography in diabetic women.

We conducted a feasibility study of the use of computed tomography (CT) to measure the width of the fetal shoulders and to predict large birth weight in infants of diabetic mothers. Computed tomography pelvimetry using low-dose digital radiographs was performed before delivery at term in 22 diabetic women. Shoulder width was estimated by direct electronic measurement on a single axial section through the shoulders of the fetus, and by orthopedic calipers within 48 hours of birth. Shoulder width by CT was 11.4-16.5 cm, and correlated significantly with postnatal measurements (r = 0.66, P = .01). Shoulder width by CT also correlated well with birth weight (r = 0.84, P less than .01), and measured more than 14 cm in all seven infants with birth weights more than 4200 g. Using 14 cm as a positive test and birth weight 4200 g as an abnormal result, the predictive value of a positive test was 78% and the predictive value of a negative test was 100%. This technique deserves further evaluation in assessing the risk of shoulder dystocia in potentially macrosomic infants.

Birth Weight↗
PubMed1986

Pregnancy following renal transplantation in class T diabetes mellitus.

Nine cases of pregnancy complicated by diabetes and prior renal transplantation are reviewed. Maternal and fetal death occurred in a patient with foot and leg ulcers associated with preexisting peripheral vascular disease. Pregnancy-induced hypertension occurred in six cases. Spontaneous weight-bearing fractures occurred in two patients. No episodes of renal allograft rejection occurred. Evidence of fetal compromise was present in six cases. All fetuses were delivered by cesarean section prior to term, with live births occurring from 31 1/2 to 36 weeks' gestation. A single case of hypospadias was the only congenital defect. Prepregnancy screening for complications of diabetes and renal transplantation is advised and euglycemia should be achieved before and during pregnancy. Advanced diabetic vascular disease puts these gestations at significant risk.

Adult↗
PubMed1986

Erythropoiesis in infants of diabetic mothers.

Neonatal polycythemia is a well-established perinatal complication in infants of diabetic mothers (IDM). To investigate the regulation of erythropoiesis in these infants, we measured cord blood erythropoietin (EP) levels by a sensitive radioimmune assay and examined the growth of erythroid progenitor colonies in a series of IDM and control infants. Fifteen of 18 diabetic mothers were managed on a protocol emphasizing careful glycemic control throughout pregnancy; 10 had glycosolated hemoglobin values within the normal, nondiabetic range during the third trimester. Cord blood EP was elevated in one of 18 IDM and in two of 13 controls (p = NS). In IDM, cord blood EP values were higher in infants delivered following maternal labor and were inversely correlated with umbilical artery pH (r = -0.72; p = 0.006). Growth of burst forming units-erythroid was similar in IDM and controls in the presence of 0.1 to 2.0 U of exogenous EP per ml of methylcellulose medium. Individual infants tended to respond consistently over the entire range of EP doses tested. The number of burst forming units-erythroid observed did not correlate with cord blood EP, birth weight, or neonatal hematocrits. We conclude that: umbilical cord blood EP levels are generally normal in IDM delivered by mothers in whom good glycemic control is maintained throughout gestation, cord blood EP values are strongly influenced by perinatal events, and the response of erythroid progenitors to EP is intrinsically normal in IDM. These data suggest that polycythemia is an adaptive response in IDM and is not associated with a primary abnormality in erythropoiesis.(ABSTRACT TRUNCATED AT 250 WORDS)

Blood Glucose↗
PubMed1985

Continuous long-term intravenous beta-sympathomimetic tocolysis.

This report concerns the clinical course and outcome of 16 patients treated by continuous long-term intravenous beta-sympathomimetic tocolysis (greater than or equal to 1 week's intravenous therapy). Half of the patients received such therapy for at least 5 weeks. Intravenous tocolysis was adjusted to decrease uterine activity and maintain a satisfactory pulse and blood pressure. Parenteral tocolysis was continued until there was a successful transition to oral therapy, until fetal maturity, or until maternal/fetal indications for delivery were noted. Data indicate that the cardiovascular and metabolic effects were pronounced mostly during the first 3 to 4 days of therapy and then returned toward pretreatment values. In none of the study patients was the treatment discontinued because of drug-related problems, electrocardiogram changes, chorioamnionitis, or fever. The experience indicates that, in a selected group of patients and under close supervision, continuous long-term intravenous beta-sympathomimetic tocolysis may be considered a safe therapeutic modality able to prolong pregnancy with a more desirable outcome.

Administration, Oral↗
PubMed1985

Continuous subcutaneous insulin therapy during early pregnancy.

Intensive metabolic control of diabetes is probably important during formation of the embryo early in pregnancy. The purpose of this study was to determine the efficacy and complications of continuous subcutaneous insulin infusion therapy during the fifth to the tenth week of gestation. Twenty-four insulin-dependent subjects were trained to use blood glucose self-monitoring and the Auto Syringe portable insulin infusion pump (AS6C). Regular insulin was administered as a basal infusion of 18 +/- 8 U/24 hours (+/- SD) (12.2 +/- 3.9 mU . kg-1 . h-1) and as bolus injections of 6 +/- 3 U before meals and 1.2 +/- 1 U before snacks. Reasonable control of fasting (119 +/- 30 mg/dL) and postprandial (133 +/- 34 mg/dL) hyperglycemia was achieved, accompanied by an average of 2.2 +/- 1.5 symptomatic hypoglycemic episodes per week. The frequency of complications with this new therapy declined as the authors gained experience in teaching the system. The persistence of good diabetic control in many of the subjects after they returned to conventional insulin therapy points to the need for a controlled trial of continuous subcutaneous insulin infusion therapy versus intensive conventional therapy in pregnancy.

Blood Glucose↗
PubMed1984

Ultrasonography in preterm labor.

A prospective study was conducted with ultrasonography in a group of 48 patients who presented with significant premature uterine activity. The study attempted to characterize the ultrasonographic signs exhibited by the cervix and lower uterine segment in conjunction with preterm labor. These signs, their frequency of occurrence, and possible clinical significance are described.

Cervix Uteri↗