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Biomedical subjects

J N Martin

Publications and source records attributed to J N Martin.

At least 145 records · Page 8Linked to original sources
PubMed1991

The natural history of HELLP syndrome: patterns of disease progression and regression.

Despite much recent interest in HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count), there is little published information about the natural history of this unique form of severe preeclampsia-eclampsia. The time course and pattern of laboratory abnormalities for 158 patients with HELLP syndrome managed in a single tertiary referral center between 1980 and 1989 were studied retrospectively. Despite considerable patient variation, most gravid women with HELLP syndrome had decreasing platelet counts until 24 to 48 hours after delivery. Conversely, lactate dehydrogenase concentrations usually peaked 24 to 48 hours post partum. In all patients who recovered, a platelet count greater than 1,000,000/mm3 was spontaneously achieved by the sixth postpartum day or within 72 hours of platelet nadir. An upward trend in platelet count and a downward trend in lactate dehydrogenase concentrations should be apparent in patients without complications by the fourth postpartum day. These data provide baseline information against which the course of individual patients can be compared and the infrequent, atypical case identified for interventive therapy.

Analysis of Variance↗
PubMed1991

Acute gestational pyelonephritis: the impact on colloid osmotic pressure, plasma fibronectin, and arterial oxygen saturation.

Acute gestational pyelonephritis infrequently leads to nonhydrostatic permeability pulmonary edema known clinically as acute respiratory distress syndrome (ARDS). In this form of ARDS, sepsis is considered the primary cause of pulmonary dysfunction. Decreases in colloid osmotic pressure, plasma fibronectin, and arterial oxygen saturation are associated with a worsening prognosis in septic conditions. We sought to investigate the changes in these parameters with acute gestational pyelonephritis to gain insight into the factors that may place the patient at risk for sepsis-related morbidity. Colloid osmotic pressure, plasma fibronectin, and arterial oxygen saturation via pulse oximetry were prospectively measured during the inpatient treatment of 17 pregnant patients with acute gestational pyelonephritis. All three parameters achieved their nadir within 24 hours of hospitalization and the initiation of therapy. Although no patient developed significant pulmonary dysfunction, we believe that patient susceptibility for pulmonary edema and general morbidity could be maximal in the first 24 hours after therapy. Future studies using a larger number of patients may identify one or more of these laboratory parameters as helpful in identifying gravid patients who are at risk of developing gestational ARDS.

Acute Disease↗
PubMed1991

Pregnancy after Fontan repair of tricuspid atresia.

We have described a patient who had a cyanotic congenital heart disease (type Ib tricuspid atresia), with initial palliation accomplished in childhood via a Glenn procedure. In 1985, she had a Fontan repair with the Bjork modification; 3 years later she achieved her first pregnancy at age 27. Maternal Doppler echocardiography in early pregnancy showed good flow through the constructed conduit, with normal left ventricular size and function. Fetal echocardiography at 22 weeks' gestation via two-dimensional, M-mode, pulsed Doppler, and color flow mapping revealed no evidence of fetal cardiac disease. At 25 weeks' gestation recalcitrant preterm labor developed, and the infant was delivered spontaneously. Labor, delivery, and puerperium were uncomplicated, and the newborn (though too premature to survive) was of appropriate weight for gestational age, without evidence of congenital heart disease or other anomalies. We believe this is the first report of pregnancy and spontaneous delivery in a patient who has had Fontan repair of a congenital heart defect.

Adult↗
PubMed1991

Cordocentesis (funipuncture) by maternal-fetal fellows: the learning curve.

One hundred cordocenteses were attempted at the University of Mississippi Medical Center between July 1, 1989, and June 1, 1991. There were 1.3 attempts for each successful umbilical blood sampling. The overall success rate was 94%. The first-year fellows-in-training attempted 61 procedures with a 90.2% success rate within two attempts and an overall success rate of 95.1%. Second-year fellows attempted 32 procedures with a 93.8% success rate within two attempts and an overall success rate of 93.8%. Procedure-related complications included five episodes of fetal bradycardia (one resulting in a stillbirth at 20 weeks) and a single case of chorioamnionitis. Of the three perinatal deaths, two were associated with severe congenital anomalies resulting in a corrected procedure-related mortality rate of 1%. The morbidity and mortality associated with cordocentesis appears to be relatively low and fellows-in-training can perform such procedures with no apparent increase in complications if appropriately supervised.

Blood Specimen Collection↗
PubMed1991

Imitators of preeclampsia and HELLP syndrome.

The key to the differential diagnosis of these related conditions is knowledge of the natural history of each disease process; an awareness of how this usually translates in each instance into clinical and laboratory parameters; an appreciation for the wide spectrum of findings for each of these conditions, which are more aptly considered disease syndromes rather than single diseases; and the good fortune to encounter the patient early enough or midway in the course of her disease, prior to terminal stages when all subtle differences among disease syndromes almost disappear in a blur of grossly abnormal physiology and multiple organ failures.

Autoimmune Diseases↗
PubMed1990

Plasma exchange for preeclampsia. I. Postpartum use for persistently severe preeclampsia-eclampsia with HELLP syndrome.

The postpartum use of plasma exchange with fresh-frozen plasma was assessed in a group of seven women with severe preeclampsia-eclampsia and HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count) that persisted greater than 72 hours after delivery. During the study interval in which a total of 107 gravid women with HELLP syndrome were seen in our referral center, these seven patients (6.5%) demonstrated persistent thrombocytopenia (platelet count usually less than 30,000/mm3), rising lactic dehydrogenase (greater than 1000 IU/L) and evidence of multiorgan dysfunction. The seven case histories emphasize the variety of clinical and laboratory profiles that can be encountered in this small group of gravid women at risk for severe morbidity or mortality. Up to three 3 L plasma exchanges were required to effect permanent disease arrest and reversal. Utilization of the IBM 2997 Cell Separator system permitted bedside performance of procedures with enhanced convenience and optimal medical management. Successful plasma exchange was associated with (1) sustained increases in the mean platelet count at 24, 48, and 72 hours that were 2.2, 3.6, and 4.5 times the preexchange platelet counts and (2) a decreasing trend in lactic dehydrogenase concentrations below 1000 IU/L within 48 hours of exchange plasmapheresis. The current series of patients supports our recommendation that a trial of plasma exchange(s) with fresh-frozen plasma be considered for treatment of the infrequent postpartum case of HELLP syndrome that fails to abate within 72 hours of delivery and in which other evidence develops of an ongoing, widespread, and life-threatening thrombotic microangiopathy.

Adolescent↗
PubMed1990

Pregnancy complicated by preeclampsia-eclampsia with the syndrome of hemolysis, elevated liver enzymes, and low platelet count: how rapid is postpartum recovery?

The rapidity of postpartum disease recovery for severe preeclampsia associated with hemolysis, elevated liver enzymes, and low platelet count (HELLP syndrome) has not been well studied. Between January 1980 and March 1989, 158 pregnancies with preeclampsia-eclampsia complicated by HELLP syndrome were managed at the University of Mississippi Medical Center. The 70 patients with platelet nadir below 50,000/microL (class 1 HELLP syndrome) required as long as 11 days for all members to achieve a platelet recovery concentration of more than 100,000/microL, whereas all 88 gravidas with platelet nadir between 50,000-100,000/microL (class 2 HELLP syndrome) exceeded this platelet concentration by the sixth postpartum day, a statistically significant difference (P less than .0001). The interval between delivery and the onset of diuresis (mean +/- SD) was significantly longer in class 1 than in class 2 patients with milder disease (22.7 +/- 18.9 compared with 15.9 +/- 11.1 hours). Significantly more postpartum days were required in class 1 than in class 2 HELLP parturients for the lactic dehydrogenase (LDH) concentration to decrease below 500 IU/L (4.2 +/- 4.9 compared with 3.2 +/- 2.7 days). No women in the class 2 group required plasma exchange therapy to effect disease arrest and reversal, but 11 of 58 severely ill women in class 1 were treated with this modality. We conclude that the platelet count and LDH serum concentration, as indicators of HELLP severity and recovery, are clinically useful tools and that a more protracted postpartum recovery period should be expected for progressively severe expressions of HELLP syndrome.

Alanine Transaminase↗
PubMed1990

Biochemical assessment and prediction of gestational well-being.

It is apparent from this brief review of serum markers that there is no ideal biochemical screen available to either assure fetal well-being or reliably predict fetal compromise. At present, MSAFP has become the dominant serum marker, but much work needs to be done to refine its usefulness as a screen and its utility in association with other measurements of fetoplacental well-being. The trend in modern obstetric management is toward an array of biophysical tests of fetal well-being, particularly in the last trimester of pregnancy. Biochemical screening in early gestation is used increasingly to assess future fetoplacental status and to predict risk for later pregnancy complications. Combinations of these biochemical and biophysical modalities will likely achieve the greatest predictive success in assessing fetal and placental well-being.

Atrial Natriuretic Factor↗
PubMed1990

Angiographic arterial embolization and computed tomography-directed drainage for the management of hemorrhage and infection with abdominal pregnancy.

Hemorrhage during or after surgery, pelvic abscess, bowel obstruction, and prolonged febrile morbidity can complicate the puerperal course of the gravida after removal of an extrauterine fetus with nondisturbance of the extrauterine placenta. In this report we describe the successful angiographic arterial gelfoam embolization of the placental vascular bed to control heavy postoperative hemorrhage in a mother suffering adult respiratory distress syndrome after removal of the fetal portion of her abdominal pregnancy. Six weeks later, computed tomography (CT)-directed drainage by catheter of a placental abscess was performed. Selective angiographic transcatheter embolization with gelfoam is a useful tool for the control of hemorrhage in the gravida who is an unfavorable operative candidate or who may present technical hemostasis problems peculiar to the placenta with abdominal pregnancy. Later use of CT-directed catheter drainage of the infected residual placental mass provided a nonoperative means of treatment.

Abscess↗
PubMed1990

Successful pregnancy outcome following mid-gestational uterine rupture and repair using Gore-Tex soft tissue patch.

The first reported gestational use of the Gore-Tex soft tissue patch (expanded polytetrafluoroethylene) for uterine repair and support is presented in a pregnant woman whose partially dehisced, congenitally abnormal uterus was operated upon at 19 weeks' gestation. Use of the expanded polytetrafluoroethylene Gore-Tex soft tissue patch for assisted uterine integrity in combination with a program of uterine tocolysis and close maternal/fetal surveillance averted a pregnancy loss.

Abruptio Placentae↗
PubMed1990

Uterine activity among a diverse group of patients at high risk for preterm delivery.

In this study, 98 patients with early premature rupture of membranes (PROM), postoperative recuperation, placenta previa, or blunt abdominal trauma were assessed for uterine contractions with an ambulatory uterine activity monitor. Uterine irritability manifested by low-amplitude, high-frequency contractions of 30 seconds' duration or less was prevalent in all groups but decreased as the patients were stabilized and diminished or disappeared in those who did not develop preterm labor. In the 18 women who developed preterm labor, daily uterine activity monitoring detected contractions 24-48 hours before clinical symptoms of preterm labor and/or vaginal bleeding occurred. A number of patients with early PROM and placenta previa had low-amplitude, high-frequency contractions, and the majority occurred in those who subsequently developed preterm labor.

Abdominal Injuries↗
PubMed1990

Postpartum eclampsia: a recurring perinatal dilemma.

Because identification of patients at risk and preventive therapies are imperfect, eclamptic seizures continue to occur occasionally during the puerperium. During an 18-year span in a single tertiary medical center, 36 of 254 patients with eclampsia (14.2%) experienced postpartum seizures at a mean gestational age of 35.6 weeks. Early (before 48 hours) postpartum eclampsia was experienced by 72% of patients, and 28% had late (after 48 hours) postpartum eclampsia. Prospectively only 67% of patients were correctly diagnosed, and retrospectively only 83% could be considered to have had preeclampsia before seizure. Hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome was present in 30% of the affected patients. Seven patients were receiving magnesium sulfate by controlled infusion when an eclamptic seizure occurred. The presence or absence of diuresis was unrelated to seizure occurrence. Preeclampsia recurred in 38.5% of subsequent gestations. It appears that HELLP syndrome may be a predisposing factor for eclampsia.

Blood Pressure↗
PubMed1989

Use of prostaglandin E2 vaginal suppositories in third-trimester fetal demise.

A retrospective analysis of eight cases of third-trimester fetal demise managed with prostaglandin E2 vaginal suppositories (PGE2) is presented. Management included laminaria insertion prior to induction and an initial lower dosage of PGE2. No cases of uterine rupture or cervicovaginal lacerations were encountered. A summary of the literature as it relates to PGE2 vaginal suppository use in third-trimester fetal demise is included.

Adolescent↗
PubMed1989

Cost effectiveness of ambulatory uterine activity monitoring.

A cost analysis is presented comparing 34 patients who received uterine activity monitoring versus 33 patients who attempted to detect uterine activity by palpation. All patients were at high risk for preterm delivery and were given the same educational information and prenatal care regarding signs and symptoms of preterm labor. The results revealed an increase in newborn days (640) and cost to those patients who were in the self-palpation group ($13,364) compared to monitored parturients (268 days and $8,633). The difference was attributed to neonatal morbidity from an increased number of preterm deliveries greater than 26 weeks but less than 37 weeks (P = 0.04). The increase in NICU days was significant (P = 0.03). No difference in normal newborn costs for infants delivered after greater than 33 weeks could be detected between the two groups, but morbidity was increased among control infants delivering between 34 and 36 weeks. Uterine activity monitoring to prevent preterm birth appears to be medically effective and reduces cost.

Cost-Benefit Analysis↗
PubMed1989

Perinatal aspects of abdominal surgery for nonobstetric disease.

Surgical interventions for nonobstetric reasons during pregnancy are reported to occur in 0.2% to 2.2% of all gestations with obvious perinatal implications. In this retrospective study, 57 parturients were identified who underwent nonobstetric abdominal surgery. Thirty-one patients underwent exploratory celiotomy for suspected appendicitis, 16 for adnexal disease other than ectopic pregnancy, six for cholecystectomy, three for intestinal disorders, and one with a pheochromocytoma. Alterations in disease expression are related to the severity of the disease and advancing gestational age, being more important in cases of appendicitis. Preterm labor reflecting fetal morbidity relates to the presence of peritonitis and then only during the third trimester. In this retrospective study, tocolysis with intravenous magnesium sulfate had an uncertain effect on the incidence of preterm delivery. Prospective studies will be required to assess the indications and limitations of tocolysis for nonobstetric abdominal surgical conditions.

Abdomen↗
PubMed1989

Utilization of hydralazine or alpha-methyldopa for the management of early puerperal hypertension.

Despite the importance of pregnancy-induced hypertension (PIH), there are few published investigations of therapeutic approaches for the postpartum management of such patients. Twenty-six gravida patients with PIH were prospectively studied during the first 24 hours after delivery while receiving intravenous magnesium sulfate. Each study subject was randomly assigned to a group also systemically administered either hydralazine or methyldopa. During the study interval, hourly measurements of blood pressure, pulse, fluid intake, and urine output were recorded. Hydralazine was found to be superior in its ability to effect more rapidly a lower mean arterial blood pressure. No significant differences in urine output or time until onset of diuresis were noted among treatment groups. No serious side effects were encountered with the use of either antihypertensive agent. Based on these preliminary findings, it appears that hydralazine is the less costly and more effective medication to lower mean arterial blood pressure in the immediate postpartum period.

Blood Pressure↗