Biomedical subjects

James N Martin

Publications and source records attributed to James N Martin.

26 records · Page 2Linked to original sources

PubMed2003

The importance of parity to major maternal morbidity in the eclamptic mother with HELLP syndrome.

OBJECTIVE: To determine if the rate of major morbidity from severe preeclampsia with/without hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome differs by parity. METHODS: Retrospective investigation of 970 gravidas with severe preeclampsia with and without HELLP syndrome analyzed according to parity. RESULTS: Altogether 609 (63%) patients were nulliparous and 361 (37%) parous. Between groups there was no significant difference in the incidence of overall major morbidity (21% vs. 19%, p=0.467), or specific morbidities including hematologic/coagulopathic (13.6% vs. 11.9%, p=0.442), cardiopulmonary (8.9% vs. 7.2%, p=0.362), CNS/visual (1.8% vs. 2.8%, p=0.319), or hepatorenal (0.8% vs. 2.2%, p=0.068). Although eclampsia was significantly more common in nulliparous (10.2%) than in parous patients (5.5%, p=0.012), the later significantly more often demonstrated major maternal morbidity associated with eclampsia (50%) than did nulliparous patients (25%, p=0.043). CONCLUSIONS: Unless parous patients with severe preeclampsia with or without HELLP syndrome develop eclampsia, their disease acuity does not differ significantly from their nulliparous counterparts.

Adolescent↗

PubMed2003

Cesarean delivery for fetal distress: rate and risk factors.

UNLABELLED: The objective of this article was to review the recent English language literature on cesarean delivery for fetal distress to determine its incidence, diagnostic tests, and the contributing factors to this obstetric complications. A PubMed search (1990-2000) with items of "cesarean, fetal distress," "cesarean, non-reassuring fetal heart rate," "cesarean, neonatal acidosis," and "cesarean, umbilical arterial pH," was undertaken. Reports, letters to the editor, focus on anomalous fetuses, and papers not specifically focused on this topic were excluded. Of the 392 articles that the search yielded, 169 met the inclusion criteria. Based on 37 reports with more than 1,000 patients each, the overall risk of prompt cesarean delivery for fetal concern was 3.1% (43,340 of 13,989,74). The risk exceeded 20% in patients with moderate/severe asthma, severe hypothyroidism, severe preeclampsia, and postterm or fetal growth restricted fetuses with abnormal Doppler studies. Use of likelihood ratios suggests that Doppler of the umbilical artery is a superior diagnostic test to amniotic fluid index in identifying parturients at risk for cesarean for non-reassuring fetal heart rate tracing. Although several risk factors increase the need for cesarean delivery for fetal distress, in general, most are unpreventable. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this article, the reader will be able to estimate the incidence of cesarean delivery for non-reassuring fetal heart rate tracing, outline potential diagnostic tests that are useful for the detection of fetal distress, and summarize medical and obstetric conditions that place patients at risk for cesarean delivery for fetal distress.

Adult↗

PubMed2003

Emergency cesarean delivery for nonreassuring fetal heart rate tracings. Compliance with ACOG guidelines.

OBJECTIVE: To review the English-language literature from 1990 to 2000 on cesarean delivery for "fetal distress" and assess compliance with American College of Obstetricians and Gynecologists (ACOG) guidelines. STUDY DESIGN: A PubMed search with the search items cesarean, fetal distress, cesarean, nonreassuring fetal heart rate, cesarean, neonatal acidosis and cesarean, umbilical arterial pH was undertaken. Excluded from the search were case reports, letters to the editor, focus on fetal anomaly, combinations with other reasons for operative delivery (either abdominally or vaginally) or absence of pertinent information. RESULTS: Among 392 articles from the search, 169 met the inclusion criteria. Three reports provided detailed information on use of scalp pH; use occurred in 5% (60/1,128) of emergency cesareans. Three reports provided data on the use of tocolytics for intrauterine resuscitation; the combined result was 16% (201/1,261). Five reports assessed the decision-to-incision interval within 30 minutes; in 59% (262/446) of cases it was achieved. Five reports contained cord pH information on 340 emergency cesarean deliveries; umbilical arterial pH was < 7.00 in 10%. CONCLUSION: Physician use of, and compliance with, ACOG guidelines for emergency cesarean deliveries is difficult to assess, and incomplete compliance appears commonplace.

Acidosis↗

PubMed2002

Markedly elevated beta-hCG levels in a normal singleton gestation with hyperreactio luteinalis.

BACKGROUND: Human chorionic gonadotropin (hCG) is produced by the trophoblast early in pregnancy and peaks at a level of approximately 100,000 IU/liter around the ninth week of gestation. Abnormally high levels are usually noted in association with multiple gestation, molar gestation, and specific ovarian or gestational malignancies. CASES: A multiparous patient in the second trimester was referred for evaluation after a maternal triple marker screen was incalculable due to a beta-hCG level of 2.1 million IU/L. Targeted sonography revealed bilateral complex adnexal masses with a solid component of the left ovary, a normal fetus, and normal placenta. The patient underwent an exploratory laparotomy at 18 weeks' gestational age. A left oophorectomy was performed. Pathology confirmed hyperreactio luteinalis. The remainder of the pregnancy was remarkable for preterm labor and delivery at 35 weeks' gestational age. At delivery, the hCG level was noted to be 24,210 IU/L, and the fetus and placenta were normal. CONCLUSION: Markedly elevated hCG levels rarely occur in normal singleton pregnancy and can be associated with hyperreactio luteinalis. When noted, a work-up to evaluate possible malignancy, molar gestation, and multiple gestation should be pursued.

Adult↗

PubMed2002

Pregnancy after classic cesarean delivery.

OBJECTIVE: To describe maternal and perinatal outcomes after a prior classic cesarean delivery. METHODS: A retrospective review was performed including all patients from 1990-2000 whose most recent pregnancy was preceded by classic cesarean delivery. RESULTS: During the 11-year period, there were 37,863 deliveries and 157 patients (0.4%) underwent classic cesarean operations. In the next pregnancy, one case of uterine rupture (0.6%, 95% confidence interval 0.1, 3.5) occurred at 29 weeks without preterm labor and resulted in fetal death. The prevalence of asymptomatic dehiscence was 9% (95% confidence interval 5, 15). There was no significant difference between patients with uterine dehiscence (n = 15) and patients with intact uteri (n = 141) with regard to maternal demographics, duration of labor, cervical dilatation at time of surgery, transfusion of packed red cells, bowel injury, postpartum endometritis, wound breakdown, thrombophlebitis, or umbilical arterial pH less than 7.00 (P >.05). Duration of labor, cervical dilatation, and gestational age at repeat cesarean delivery were poor predictors for uterine rupture or dehiscence. CONCLUSION: Among patients with prior classic cesarean delivery, uterine rupture and dehiscence are neither predictable nor preventable. One in four patients will experience some form of maternal morbidity. Uterine rupture, although infrequent, can be fatal to the fetus. Uterine dehiscence, however, does not increase neonatal or peripartum maternal morbidity.

Cesarean Section↗

PubMed2002

Subcutaneous stitch closure versus subcutaneous drain to prevent wound disruption after cesarean delivery: a randomized clinical trial.

OBJECTIVE: The purpose of this study was to compare a subcutaneous stitch closure and subcutaneous drain placement for the risk of wound disruption after cesarean delivery. STUDY DESIGN: This was a prospective randomized clinical trial that evaluated subcutaneous stitch closure, placement of a subcutaneous drain, or no closure for subsequent wound disruption risk in women with subcutaneous depth at >or=2 cm. RESULTS: The maternal demographics and intrapartum risk factors for postoperative wound disruptions were similar among the 964 study subjects, who were divided into 3 groups. Wound disruptions that required opening of the wound, irrigation, debridement, packing, and/or secondary delayed closure occurred in 9.7% of the women with no closure, 10.4% of the women in the stitch closure group, and 10.3% of the women in the closed drain group (P =.834). CONCLUSION: There appears to be no difference in the subsequent risk of wound complications when no closure of the subcutaneous tissue layers occurs versus suture closure or a closed drainage system.

Adult↗

PubMed2002

Intra-operative haemorrhage by blunt versus sharp expansion of the uterine incision at caesarean delivery: a randomised clinical trial.

OBJECTIVE: To determine whether the method used to expand the uterine incision for caesarean delivery affects the incidence of intra-operative haemorrhage. DESIGN: A prospective randomised study of women undergoing a low segment transverse caesarean delivery. Participants were assigned to have their uterine incision either sharply or bluntly expanded. PARTICIPANTS: Between June 1998 and June 2000, 470 women drew assignments to the sharp expansion group and 475 to the blunt group. RESULTS: The maternal demographics of age, race, nulliparity, and body mass index as well as pre-operative haematocrit were similar between groups. Compared with the blunt group, the estimated blood loss (886 versus 843mL, P = 0.001), change in the mean haematocrit (6.1% versus 5.5%, P = 0.003), incidence of postpartum haemorrhage (13% versus 9%; relative risk = 1.23, 95% CI 1.03, 1.46) and need for a transfusion (2% versus 0.4%; relative risk = 1.65, 95% CI 1.25, 2.21) were significantly greater in the sharp group. CONCLUSION: In caesarean delivery, sharply expanding the uterine incision significantly increases intra-operative blood loss and the need for subsequent transfusion.

Adult↗

PubMed2002

Preeclampsia: pathophysiology and practice considerations for the consulting nephrologist.

Abnormal placental implantation presumed to be secondary to maternal genetic susceptibility or immune maladaptation is considered to be fundamental to the pathogenesis of preeclampsia. The reduced placental perfusion resulting in placental ischemia is hypothesized to cause the known endothelial dysfunction, which leads to the clinical manifestations of this disease. Oxidative stress is a postulated linking factor, an aberration that possibly has its genesis via cytokines released from the abnormally implanted and perfused placenta. Clearly the maternal pathophysiologic changes that subsequently produce what is recognized as preeclampsia are present long before the disease makes its clinical appearance.

Cytokines↗