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Biomedical subjects

J M Thorp

Publications and source records attributed to J M Thorp.

At least 37 records · Page 2Linked to original sources

Determinants of participation in an epidemiological study of preterm delivery.

We describe the study design and patterns of participation for a cohort study of preterm delivery, focused on genital tract infections, nutrition, tobacco use, illicit drugs and psychosocial stress. Women are recruited at 24-29 weeks' gestation from prenatal clinics at a teaching hospital and a county health department. We recruited 57% of the first 1843 eligible women; 29% refused and 8% could not be contacted. White women were somewhat more likely to participate than African-American women (61% vs. 54% respectively). More notable differences were found comparing teaching hospital and health department clinics (71% vs. 47% participation respectively), with the health department clinic having a greater proportion refuse (24% vs. 33%) and more women who could not be contacted (4% vs. 11%). Participation was affected only minimally by day or timing of recruitment, but inability to contact diminished substantially as the study continued (13-0%). Refusals were largely unrelated to patient attributes. Lower education predicted inability to contact. Risk of preterm delivery was 14% among recruited women, 10% among women who refused, and 15% among women whom we were not able to contact, demonstrating that, overall, risk status was not lower among recruited women.

Adolescent↗

Race/ethnicity, vaginal flora patterns, and pH during pregnancy.

OBJECTIVES: To investigate the relationship between bacterial vaginosis during pregnancy and black race/ethnicity. STUDY DESIGN: Gram staining was used to evaluate vaginal flora in 842 women at 24 to 29 weeks' gestation. RESULTS: Overall, 22.3% of blacks and 8.5% of whites had bacterial vaginosis. Vaginal pH and flora differed significantly by race/ethnicity; blacks were more likely to have pH > or = 4.5, no lactobacilli, small gram-variable and -negative rods, and Mobiluncus compared with whites (odds ratios 1.6, 1.5, 1.4, and 10.6, respectively). Quantity of morphotypes also differed, especially for Mobiluncus. Among women with Mobiluncus present (12.0% of blacks and 1.3% of whites), 73.3% of blacks compared with 40.0% of whites had the highest level. Adjustment for sociodemographics, sexual activity, sexually transmitted diseases, health behavior, and sexual hygiene did not explain these differences. CONCLUSION: We observed race/ethnicity differences in vaginal flora ecology. These differences may ultimately play a role in the larger proportion of preterm deliveries among black women compared with white women.

Adolescent↗

Comparison of once-daily and twice-daily dosing of 0.75% metronidazole gel in the treatment of bacterial vaginosis.

BACKGROUND AND OBJECTIVES: Bacterial vaginosis is the most common cause of vaginal symptoms in women and has potential complications. Efforts to improve treatment of this disease process are warranted. GOAL OF THIS STUDY: The goal of this study was to compare the safety and efficacy of once-daily intravaginal administration of 0.75% metronidazole gel for 5 days to the established twice-daily regimen in the treatment of bacterial vaginosis. STUDY DESIGN: Nonpregnant women with bacterial vaginosis diagnosed by accepted clinical criteria at 14 geographically diverse general gynecology clinics were enrolled in this prospective, randomized, investigator-blind, parallel study. They were treated with either once-daily or twice-daily 0.75% metronidazole gel 5 g intravaginally for 5 days and were reevaluated at 7 to 12 days and 28 to 35 days after completing treatment. Efficacy was determined by clinical criteria. Adverse drug reactions were monitored. RESULTS: Of the 514 evaluable women enrolled, bacterial vaginosis was cured at the first return visit among evaluable patients in 153 of 199 (77%) of those who received the once-daily and in 157 of 196 (80%) of those who received the twice-daily administration. Bacterial vaginosis was cured among evaluable patients at the final visit in 104 of 180 (58%) of those who received once-daily and 109 of 178 (61%) of those who received the twice-daily regimen. Intent-to-treat analysis showed cure at 1 month in 118 of 207 (57%) of those treated once daily and 129 of 209 (62%) of those treated twice daily. Side effects were mild, and none caused treatment discontinuation. CONCLUSIONS: Once-daily dosing of 0.75% metronidazole gel 5 g for 5 days yields efficacy, safety, and tolerance equivalent to the currently used twice-daily dosing in the treatment of bacterial vaginosis, adding another competitive choice to the available therapeutic options for this condition.

Adult↗

Predictors of urinary tract infection at the first prenatal visit.

We identified maternal demographic, behavioral, and medical history factors that predict bacteriuria (that is, symptomatic and asymptomatic urinary tract infection) at prenatal care initiation. We applied logistic regression modeling to data from all prenatal care recipients who delivered during 1990-1993 and resided in selected North Carolina counties (N = 8037), omitting those with diabetes mellitus, human immunodeficiency virus, or structural urologic abnormalities. The two strongest predictors of bacteriuria at prenatal care initiation were an antepartum urinary tract infection prior to prenatal care initiation (for whites, adjusted prevalence odds ratio (POR) = 2.5, 95% CI 0.6-9.8; for blacks, POR = 8.8, 95% CI 3.8-20.3) and a pre-pregnancy history of urinary tract infection (POR = 2.1, 95% CI 1.4-3.2). For white women only, education beyond high school and age > or =30 years were inversely associated (POR < or = 0.6). Sickle cell hemoglobin nearly doubled the prevalence odds for bacteriuria among African-Americans (POR = 1.9, 95% CI 1.0-3.5), whereas African-Americans with normal hemoglobin had reduced prevalence odds compared with whites (POR = 0.6, 95% CI 0.4-0.9). This study suggests predictors not considered before, including race controlling for sickle cell disease or trait and antepartum urinary tract infections prior to prenatal care.

Adolescent↗

First-trimester diagnosis of placenta previa percreta by magnetic resonance imaging.

Placenta previa percreta with bladder involvement is a rare but devastating complication of pregnancy. Antepartum diagnosis of this serious condition allows the obstetrician to alter his or her management of abdominal delivery and minimize the magnitude of bleeding. We report a case in which magnetic resonance imaging was able to detect placenta percreta in the first trimester. If further research demonstrates usefulness of this diagnostic modality, magnetic resonance imaging may prove to be useful in caring for patients with this condition.

Adult↗

Does epidural analgesia cause dystocia?

STUDY OBJECTIVE: To analyze the effects of epidural analgesia for labor when dystocia occurs. DESIGN: Retrospective cohort study. SETTING: Academic health center. PATIENTS: 641 low risk, nulliparous women in spontaneous labor. INTERVENTIONS: 406 (63%) women received epidurals analgesia and 253 (37%) did not. Sixty women (9.4%) required an abdominal delivery for dystocia. MEASUREMENTS AND MAIN RESULTS: Women receiving epidural analgesia were more likely to be white, receive care from an attending physician, need labor augmentation, and deliver a heavier infant. Multivariate analysis identified five variables predictive of dystocia and abdominal delivery: pitocin augmentation odds ratio (O.R.) = 3.9 (2.0 to 7.6), duration of labor more than 20 hours O.R. = 2.4 (1.3 to 4.4), high epidural dose O.R. = 2.2 (1.2 to 4.1), birthweight over 4,000 grams O.R. = 2.0 (1.0 to 4.2), and early placement of epidural O.R. = 1. 9 (1.0 to 3.5). Repeating the regression after excluding the 20 women who developed abnormal labor prior to epidural placement (18 of 20 women had protracted dilatation) demonstrated that pitocin augmentation O.R. = 4.0 (1.8 to 4.), high epidural dose O.R. = 3.0 (1.9 to 6.2), duration of labor greater than 20 hours O.R. = 2.7 (1.3 to 5.7), and birthweight over 4,000 grams O.R. = 2.1 (0. 9 to 4.8) were associated with dystocia. CONCLUSION: Epidural analgesia appears to be a marker of abnormal labor rather than a cause of dystocia. High concentration anesthetics and epinephrine should be avoided, as they may influence labor. Randomized, controlled trials of this technique will be difficult to do; our work should reassure patients and their clinicians that epidural analgesia does not adversely affect labor.

Adult↗

Category generation testing in the search for implicit memory during general anaesthesia.

We gave auditory examples of two semantic categories through headphones to 100 surgical patients anaesthetized with propofol and enflurane. This presentation was made during certain stages of the procedure, potentially associated with arousal, and during steady-state anaesthesia. Postoperative review using category generation tests showed successful priming in a pre-induction group but no evidence of implicit memory in the anaesthetized groups. These results suggest that timing an auditory input to coincide with surgical stimulation does not increase the probability of retrieval of information by this type of testing.

Acoustic Stimulation↗

Traumatic vulvar hematomas: conservative versus surgical management.

BACKGROUND: Vulvar hematomas are relatively uncommon and usually result from blunt trauma. They are more commonly diagnosed in postpartum patients, but hematomas after straddle-type injuries, coitus, or physical assault have been reported. Conservative and surgical management have both been advocated as the appropriate initial treatment. METHODS: In this study, we have done a retrospective review to obtain data that might indicate a clinical benefit for either conservative or surgical management. We reviewed the charts of patients treated for vulvar hematomas at the University of North Carolina Hospitals between 1975 and 1991. Cases were separated into obstetric and nonobstetric and conservatively and surgically managed groups. RESULTS: Of the 29 cases reviewed, 19 were classified as obstetric and 10 were nonobstetric. All 13 obstetric hematomas and 3 of 7 nonobstetric hematomas managed conservatively resolved without subsequent surgical intervention. CONCLUSION: In the absence of acute hematoma expansion, conservative management was often successful.

Adolescent↗

Transdermal nicotine replacement in pregnancy: maternal pharmacokinetics and fetal effects.

OBJECTIVE: Our purpose was to measure any short-term effects that the transdermal nicotine replacement system may have in pregnancy and to verify salivary nicotine and cotinine levels during patch placement. STUDY DESIGN: After customary smoking cessation efforts had failed, six prenatal patients between 28 and 37 weeks' gestation who smoked between one and two packs per day were enrolled in this prospective study. The patients were admitted to the General Clinical Research Center for a period of 21 hours. During hospitalization we performed maternal and fetal assessments including vital signs, biophysical profile and electronic fetal monitoring, amniotic fluid index, and umbilical artery Doppler examinations. Salivary samples for cotinine and nicotine levels were collected at standard intervals. RESULTS: There were no measurable differences in fetal or maternal well-being. During patch use salivary nicotine levels increased as expected, to a mean value of 19.0 +/- 13.5 micrograms/L at 480 minutes. Salivary cotinine concentrations remained low (approximately 50 micrograms/L) and varied little during the 480-minute period that the patch was worn. Overall, patients were satisfied with the transdermal patches. CONCLUSION: There were no adverse maternal or fetal effects from the transdermal nicotine replacement system over the 6-hour period. Salivary nicotine concentrations were consistent with those seen in nonpregnant adults. Surprisingly, salivary cotinine concentrations were much lower than those seen in smoking nonpregnant adults.

Administration, Cutaneous↗

Fetal fibronectin as a predictor of preterm birth in patients with symptoms: a multicenter trial.

OBJECTIVE: Our aim was to determine whether the presence of fetal fibronectin in vaginal secretions of patients with symptoms suggestive of preterm labor predicts preterm delivery. STUDY DESIGN: Patients who were examined at the hospital between 24 weeks' and 34 weeks 6 days' gestation with intact membranes, no prior tocolysis, symptoms suggestive of preterm labor, and cervical dilation < 3 cm were recruited at 10 sites. Swabs of the posterior fornix were assayed for the presence of fetal fibronectin by monoclonal antibody assay, with a positive result defined as > or = 50 ng/ml. Results were not available to the managing physicians. Tocolysis was used when clinically indicated after specimen collection. RESULTS: A total of 763 patients had fetal fibronectin results and pregnancy outcome data available for analysis. Fetal fibronectin was detected in specimens from 150 (20%) patients. Compared with patients who had negative results, patients who had positive results for fetal fibronectin were more likely to be delivered within 7 days (relative risk 25.9 [95% confidence interval 7.8 to 86]), within 14 days (relative risk 20.4 [95% confidence interval 8.0 to 53]), and before 37 completed weeks (relative risk 2.9 [95% confidence interval 2.2 to 3.7]). The negative predictive values for delivery within 7 days, within 14 days, and at < 37 weeks were 99.5%, 99.2%, and 84.5%, respectively. When we used multiple logistic regression analysis to control for potential confounding variables among singleton pregnancies, only the presence of fetal fibronectin (odds ratio 48.8, 95% confidence interval 7.4 to 320), prior preterm birth (odds ratio 8.3, 95% confidence interval 1.5 to 46.6), and tocolysis (odds ratio 4.1, 95% confidence interval 1.0 to 16.0) were associated with birth within 7 days; fetal fibronectin (odds ratio 3.6, 95% confidence interval 2.2 to 5.9), prior preterm birth (odds ratio 2.5, 95% confidence interval 1.4 to 4.4), cervical dilatation > 1 cm (odds ratio 2.9, 95% confidence interval 1.6 to 5.2), and tocolysis (odds ratio 4.5, 95% confidence interval 2.8 to 7.2) were all independently associated with delivery before 37 weeks. CONCLUSION: In a population of patients with symptoms, the presence of fetal fibronectin in vaginal secretions best defines a subgroup at increased risk for delivery within 7 days; the high negative predictive value of fetal fibronectin sampling supports less intervention for patients with this result.

Adult↗

Central hemodynamic effects of oxytocin and interaction with magnesium and pregnancy in the isolated perfused rat heart.

OBJECTIVE: Our purpose was to determine the cardiac effects of oxytocin in the isolated perfused rat heart model and to see whether pregnancy or pharmacologic levels of magnesium modifies the hormone's action. STUDY DESIGN: Hearts were excised from 30 female Sprague-Dawley rats (15 pregnant, 15 nonpregnant) and attached to a Langendorf's apparatus. Heart rate, left ventricular systolic pressure, and contractility were measured. Hearts were exposed serially to 2, 4, and 6 mU/ml concentrations of oxytocin. The experiment was repeated in 15 pregnant animals at a magnesium level of 5 mEq/L. RESULTS: Hearts from pregnant rats had lower heart rates than did hearts from nonpregnant animals. Oxytocin exposure diminished heart rate but increased left ventricular systolic pressure and contractility in a dose-dependent manner. Pregnancy did not alter this response. Magnesium levels of 5 mEq/L reversed the effects of oxytocin on contractility and left ventricular systolic pressure. CONCLUSION: Oxytocin is a negative chronotropic and positive inotropic agent in hearts from pregnant and nonpregnant rats. Magnesium reserves the positive inotropic effects of oxytocin.

Animals↗

Predictors of positivity for fetal fibronectin in patients with symptoms of preterm labor.

OBJECTIVE: Identifying patients at risk for preterm delivery continues to be difficult. We analyzed fetal fibronectin immunoassays in 763 subjects with threatened preterm delivery from 10 clinical sites. STUDY DESIGN: Symptomatic women between 24 weeks 0 days and 34 weeks 6 days with intact amniotic membranes and cervical dilatation <3 cm were included. Specimens were obtained from the posterior vaginal fornix and concentrations of fetal fibronectin were measured by enzyme-linked immunosorbent assay. A total of 150 (20%) patients had positive results for the fetal fibronectin immunoassay. The simultaneous effects of multiple variables on predicting positive fetal fibronectin immunoassay results were analyzed with use of logistic regression models. Variables included were patient age (mean 24.2 years), race (40% white), gravidity (29% primigravid), history of previous premature infants (15%), sexual activity within 24 hours of sample collection (66/763 or 9%), cervical examination within 24 hours of sample collection (107/763 or 14%), vaginal bleeding (118/759 or 16%), uterine contractions (192/750 or 26% with three or more in 1 hour), cervical dilatation (94/763 or 12% with dilatation between 1 and 3 cm), estimated gestational age at sampling (mean 30 weeks 2 days). RESULTS: Regardless of the variable selection process (e.g., forward, backward, or stepwise), the reduced model showed five significant variables in predicting positive fetal fibronectin: cervical dilatation (chi2 33.5, p = 0.0006), sexual activity within 24 hours of sample collection (chi2 22.9, p < 0.0001), presence of vaginal bleeding (chi2 17.0, p < 0.0001), cervical examination within 24 hours of sample collection (chi2 11.6, p < 0.0006), and uterine contractions (chi2 6.8, p = 0.01). Deletion of the true positive subset did not change these variables or the magnitude of risk. CONCLUSION: Cervical dilation or manipulation predicts positive fetal fibronectin assays and may serve to explain some of the false-positive results generated by the test.

False Positive Reactions↗

Influence of gestational age on the time from spontaneous rupture of the chorioamniotic membranes to the onset of labor.

Our goal was to assess the influence of gestational age on the timing of labor onset following spontaneous rupture of the chorioamniotic membranes. The 24,831 patients in the Nova Scotia Atlee perinatal database from 1986 to 1992 whose membranes ruptured prior to labor onset and had live births were analyzed using life-table analysis methods. The probability of labor onset at specified intervals following rupture was markedly lower when rupture occurred earlier in gestation. Pregnancies of < 33 weeks' gestation were less than half as likely as term pregnancies to proceed to labor within 24 hours and pregnancies of 33-36 weeks' gestation were 50-75% as likely as term pregnancies to progress within that period. These data provide clear evidence that the earlier in gestation the rupture occurs, the less likely labor onset is within specified time periods. This pattern supports the contention that preterm rupture of membranes is etiologically distinct from preterm labor.

Amnion↗

Vaginal delivery is associated with occult disruption of the anal sphincter mechanism.

Childbirth is thought to be an important cause of pelvic floor dysfunction. Heretofore, this has been thought due to pudendal denervation. Endovaginal sonography allows thorough assessment of the anorectum and in this study was used to assess nulliparous women and women before and after delivery. Two groups were studied. Thirty-two nulliparous subjects without complaints of incontinence were studied once. Thirty-four pregnant women were studied before and after delivery. Endovaginal sonography was used to assess integrity of internal and external anal sphincters, thickness of the levator bundle, internal and external sphincters, anal length, and the angle between the levator bundles. Delivery was associated with disruption of the internal and external sphincters. No nulliparous women (nonpregnant or pregnant) had sphincter disruption demonstrated. Episiotomy in the index delivery was associated with increased thickness in the external sphincter and a smaller angle between the levator bundles. Vaginal delivery is associated with occult disruption of the anal sphincters.

Adult↗

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↗