Biomedical subjects

M L Socol

Publications and source records attributed to M L Socol.

At least 37 records · Page 2Linked to original sources

PubMed1994

Tumor necrosis factor-alpha is elevated in plasma and amniotic fluid of patients with severe preeclampsia.

OBJECTIVE: Our purpose was to investigate whether markers for activation of the immune system are present in patients with preeclampsia by assessing maternal plasma and amniotic fluid for tumor necrosis factor-alpha and interleukin-1 beta. STUDY DESIGN: Twenty-one patients with severe preeclampsia composed the study group (group A). An antepartum comparison group was composed of healthy nulliparous patients not in labor and matched for gestational age (group B). Another control group consisted of term nulliparous patients in labor with uneventful pregnancies (group C). Maternal plasma samples were collected from all patients at recruitment and from patients in groups A and C immediately after delivery and again 20 to 24 hours post partum. Amniotic fluid was also collected from patients in groups A and C during labor. All samples were collectively assayed for tumor necrosis factor-alpha and interleukin-1 beta by specific enzyme-linked immunoassays. RESULTS: Before labor tumor necrosis factor-alpha was detected more frequently in the plasma of preeclamptic patients than in the plasma of patients in group B (12/16 vs 5/16, p < 0.05) and in higher concentrations (median 35 pg/ml vs median 0 pg/ml, p < 0.05). Although tumor necrosis factor-alpha was frequently detected in the plasma of patients in group C in early labor (16/20), concentrations were higher in the four preeclamptic patients first sampled in early labor (210 pg/ml vs 65 pg/ml, p < 0.05). Similarly, amniotic fluid levels of tumor necrosis factor-alpha were increased in preeclamptic patients compared with control patients. At delivery tumor necrosis factor-alpha was more likely to be identified in the plasma of preeclamptic patients and was found in higher concentrations, but by 20 to 24 hours post partum measurements in the preeclamptic and control patients were similar. There were no differences in the frequency with which interleukin-1 beta was detected or the concentration of interleukin-1 beta in any of the samples. CONCLUSIONS: Tumor necrosis factor-alpha is increased in the plasma and amniotic fluid of patients with severe preeclampsia. These data are suggestive of a role for abnormal immune activation in the pathophysiologic mechanisms of preeclampsia.

Adult↗

PubMed1993

Factors contributing to the increased cesarean birth rate in older parturient women.

OBJECTIVE: Our purpose was to determine factors contributing to the increased use of cesarean section in patients > or = 35 years old. STUDY DESIGN: Data were collected prospectively on nulliparous patients in spontaneous labor with term, singleton pregnancies and vertex presentations. Criteria for the diagnosis of labor were standardized: regular, painful uterine contractions at least once every 5 minutes in the presence of either complete cervical effacement or spontaneous rupture of membranes. The labors of women > or = 35 years old (n = 74) were compared with those of women 20 to 29 years old (n = 275). RESULTS: The cesarean section rate was significantly greater for patients > or = 35 years old (21.6% vs 10.2%, odds ratio 2.4, 95% confidence interval 1.2 to 5.1). Mean birth weights were similar in the two groups, but when birth weight was > or = 3600 gm patients > or = 35 years old were more likely to be delivered by cesarean section (36.7% vs 12.2%, odds ratio 4.0, 95% confidence interval 1.4 to 11.9). There were no differences between the two age groups in physician factors that could explain the disparate rates of cesarean delivery. Indeed, of patients delivered vaginally the older parturients received oxytocin for longer duration (6.4 +/- 2.6 vs 5.0 +/- 3.1 hours, p < 0.05) and at higher maximum doses (12.4 +/- 6.1 vs 9.8 +/- 6.2 mU, p < 0.05). After controlling for potentially confounding variables with multiple logistic regression analysis, maternal age (R = 0.125, p < 0.005), birth weight (R = 0.196, p < 0.001), the need for oxytocin (R = 0.210, p < 0.001), and epidural anesthesia (R = 0.195, p < 0.001) were found to be independently associated with the increased rate of cesarean section. CONCLUSION: We could not identify any controllable physician factors affecting the rate of cesarean section in patients > or = 35 years old. The increased oxytocin requirements and the incidence of dystocia with birth weight > or = 3600 gm suggest that maternal and fetal characteristics contribute to the increased frequency of cesarean section in older parturients.

Adult↗

PubMed1993

Factors that influence route of delivery--active versus traditional labor management.

OBJECTIVE: Our purpose was to compare maternal and fetal factors that influence the route of delivery with active management of labor and a traditional labor management protocol. STUDY DESIGN: Data were collected prospectively on 346 consecutive patients receiving active management of labor and 354 patients who were managed traditionally. Within each group demographic and labor characteristics of patients undergoing cesarean section were compared with those of patients having vaginal deliveries by means of the Student t test, chi 2 analysis, and stepwise logistic regression. RESULTS: With both active management of labor and traditional labor management success in achieving vaginal delivery was related to the station of the fetal vertex at admission, the need for oxytocin augmentation of labor, the uterine response to oxytocin, the use of epidural anesthesia, and the development of chorioamnionitis. By means of multiple logistic regression analysis maternal age, height, payor status, and birth weight were also identified as risk factors for cesarean section with traditional labor management but not with active management of labor. CONCLUSIONS: Differences were identified in risk factors for cesarean section between active management and traditional labor management. Active management of labor may diminish or eliminate some patient characteristics as risk factors for cesarean birth.

Adult↗

PubMed1993

Neonatal morbidity after preterm delivery in the presence of documented lung maturity.

OBJECTIVE: Our purpose was to determine the incidence of significant neonatal morbidity in fetuses with documented pulmonary maturity delivered before 37 weeks' gestation. STUDY DESIGN: A retrospective review of 213 pregnancies with documented fetal lung maturity (lecithin/sphingomyelin ratio > or = 2.0 or phosphatidylglycerol present) and delivery before 37 weeks was performed. The incidence of neonatal respiratory distress syndrome, bronchopulmonary dysplasia, grade 3 or 4 intraventricular hemorrhage, necrotizing enterocolitis, patent ductus arteriosus, retinopathy of prematurity, infectious morbidity, hyperbilirubinemia, and admission to the special care nursery was determined for those pregnancies with intact membranes and preterm premature rupture of membranes. RESULTS: Serious neonatal morbidity declined with advancing gestational age and was less common after 32 completed weeks of pregnancy. Although the frequencies of respiratory distress syndrome, grade 3 or 4 intraventricular hemorrhage, and necrotizing enterocolitis were 19.4% (12/62), 8.1% (5/62), and 4.8% (3/62), respectively, at < or = 33 weeks' gestation, one case of respiratory distress syndrome, one case of grade 3 intraventricular hemorrhage, and one case of necrotizing enterocolitis occurred in the 151 neonates born at > or = 34 weeks' gestation. CONCLUSIONS: In spite of fetal lung maturity major neonatal morbidity was observed in our patient population. These data relating neonatal morbidity to gestational age are useful in the critical decision regarding timing of delivery.

Adult↗

PubMed1993

The efficacy of oral terbutaline after intravenous tocolysis.

OBJECTIVE: Our purpose was to investigate in a prospective, randomized study the efficacy of oral terbutaline after successful intravenous tocolysis in reducing preterm birth. STUDY DESIGN: Patients between 28 and 35 weeks' gestation with uterine contractions and change in cervical examination were treated with intravenous magnesium sulfate for 12 to 24 hours. After successful tocolysis patients were approached for study participation and randomized to receive either oral terbutaline or no therapy. The dose of terbutaline was individualized to achieve a maternal pulse > 100 beats/min, and terbutaline was continued until 36 completed weeks of gestation. Recurrent preterm labor (contractions with change in cervical examination) for either group was treated with intravenous magnesium sulfate, and subsequent treatment was based on the previous randomization. RESULTS: Fifty-five patients were enrolled (28 terbutaline, 27 no oral tocolytic). No difference was found between groups with respect to time gained (4.0 +/- 2.7 vs 4.6 +/- 3.1 weeks, p = 0.412), gestational age at delivery (35.6 +/- 2.7 vs 36.1 +/- 2.4 weeks, p = 0.562), > or = 37 weeks at delivery (nine vs 13, p = 0.291), recurrent preterm labor (10 vs four, p = 0.104), recurrent uterine contractions alone (five vs eight, p = 0.527), birth weight (2616 +/- 633 gm vs 2645 +/- 599 gm, p = 0.785), special care nursery admissions (eight vs six, p = 0.759), or neonatal respiratory distress syndrome (three vs two, p = 0.965). CONCLUSION: The use of oral terbutaline after successful parenteral tocolysis failed to reduce the rate of preterm birth.

Administration, Oral↗

PubMed1993

Perinatal factors influencing survival at twenty-four weeks' gestation.

OBJECTIVE: Our objective was to identify those obstetric and neonatal factors associated with survival in infants delivered at 24 weeks' gestation. STUDY DESIGN: The obstetric and pediatric data bases from the two hospitals in our perinatal center were examined to ascertain all infants delivered between 1987 and 1989 whose gestational age was 24 weeks to 24 weeks 6 days. This time interval was chosen to coincide with the introduction of prophylactic exogenous surfactant. Data were abstracted from the maternal antepartum and intrapartum records and the neonatal records, with specific attention to objective risk factors related to survival. RESULTS: Forty-five pregnant patients were identified and delivered of 52 infants. Seventeen newborn infants survived (33%). Univariate comparisons between survivors and nonsurvivors revealed more aggressive intrapartum care in the former cohort as represented by the frequencies of internal fetal heart rate monitoring (p = 0.005), maternal oxygen therpay (p = 0.003), and maternal position change to remediate decelerations (p = 0.001). Planned exclusion of cesarean delivery was more common in those pregnancies that ended in fetal or neonatal death (29/35 vs 7/17; p = 0.006). Although a greater proportion of infants delivered by cesarean section survived (6/11 vs 11/41), this difference was not significant (p = 0.17). With the use of logistic regression, the best predictor of survival was gestational age at delivery. Neonatal care was more aggressive among survivors, as measured by the relative frequencies of resuscitation and surfactant administration. Respiratory distress syndrome was either absent (n = 6) or mild (n = 6) in a majority of the survivors, and respiratory insufficiency was the major cause of neonatal death. CONCLUSION: Perinatal outcome at 24 weeks' gestation appears most dependent on gestational age at delivery. The intensity of intrapartum care and neonatal support, as well as clinical biases regarding survivability, may also influence outcome.

Birth Weight↗

PubMed1993

Reducing cesarean births at a primarily private university hospital.

OBJECTIVE: The rise in cesarean birth at Northwestern Memorial Hospital in 1986 to 27.3% prompted implementation of three initiatives to reverse the escalating cesarean section rate. STUDY DESIGN: First, vaginal birth after cesarean section was more strongly encouraged. Second, after the 1988 calendar year the cesarean section rate of every obstetrician was circulated annually to each attending physician. Third, on completion of a prospective, randomized trial of the active management of labor in early 1991, this protocol was recommended as the preferred method of labor management for term nulliparous patients. RESULTS: The total, primary, and repeat cesarean section rates declined from 27.3%, 18.2%, and 9.1% in 1986 to 16.9%, 10.6%, and 6.4%, respectively, in 1991. At the same time the perinatal mortality dropped from 19.5 to 10.3. Significant reductions in abdominal deliveries occurred for both private patients (30.3% to 19.1%, p < 0.0001) and clinic patients (20.8% to 11.5%, p < 0.0001). A decline in operative deliveries for dystocia and an increase in vaginal birth after prior cesarean section were the principal factors contributing to the lower cesarean section rates. However, in 1991 individual private physicians still had wide variations in primary cesarean section rates (4.6% to 21.1%) and use of vaginal birth after prior cesarean section (5.3% to 90%). CONCLUSION: The cesarean section rate has been significantly reduced for both private and clinic patients. Differences in population demographics and individual physician practice patterns contributed to a higher incidence of cesarean birth on the private service.

Birth Weight↗

PubMed1993

Placenta accreta is associated with elevated maternal serum alpha-fetoprotein.

OBJECTIVE: To determine whether placenta accreta/percreta/increta is associated with elevation of second-trimester maternal serum alpha-fetoprotein (MSAFP) levels. METHODS: We reviewed the medical records of 44 women who had emergency cesarean hysterectomy. Twenty women had placenta accreta/percreta/increta (study group) and 24 underwent cesarean hysterectomy for other indications (control group). Pertinent maternal and neonatal variables were abstracted from the prenatal records and hospital charts. Chi-square and Fisher exact tests were used to analyze categorical variables. Student t test was used to analyze continuous variables. RESULTS: Nine of 20 patients (45%) with placenta accreta/percreta/increta and none of 24 subjects in the control group had an elevated MSAFP value (P < .001). Maternal estimated blood loss was also significantly greater in the study group (4469 +/- 1851 versus 1885 +/- 1113 mL; P < .0001), as was the number of blood units transfused (7.7 +/- 4.7 versus 3.0 +/- 2.2; P < .001). None of the other examined variables were different between the groups. CONCLUSIONS: A significant association exists between placenta accreta/percreta/increta and elevated MSAFP values. Patients with an unexplained elevation of MSAFP may have an increased risk for placenta accreta and associated blood loss at cesarean hysterectomy.

Adult↗

PubMed1993

Iatrogenic respiratory distress syndrome following elective repeat cesarean delivery.

OBJECTIVE: To determine the incidence of iatrogenic respiratory distress syndrome (RDS) following elective repeat cesarean delivery and to identify whether it was associated with departures from accepted management guidelines. METHODS: Between January 1986 and March 1991, there were 23,125 deliveries at Northwestern Memorial Hospital, of which 1207 were repeat cesarean births without labor. During this period, 18 neonates of 37 weeks' gestation or greater or 2500 g or greater who were delivered by elective repeat cesarean were admitted to the neonatal intensive care unit (NICU) for respiratory difficulties. RESULTS: Five of the 18 neonates admitted to the NICU with respiratory difficulty following elective repeat cesarean delivery met the criteria for RDS. This represents an incidence of 0.41% (five of 1207), or one case of RDS for every 241 repeat cesarean deliveries without labor. Four of the five neonates required mechanical ventilation for an average of 6.8 days. The average NICU stay was 11.2 days. Complications included pneumothorax (one) and pulmonary hemorrhage (one). Departures from accepted management guidelines included a discrepancy between ultrasound and menstrual dates (two), no confirmation of menstrual dates (one), and delivery before 39 weeks' gestation (two). CONCLUSION: Iatrogenic RDS continues to occur in the setting of elective repeat cesarean delivery and is associated with a failure to adhere to clinical protocols.

Cesarean Section↗

PubMed1992

A controlled trial of a program for the active management of labor.

BACKGROUND: Over the past two decades, the rate of cesarean section in the United States has risen from 5 percent to 25 percent of deliveries, primarily because of the increased frequency of dystocia (arrest of labor). One strategy that has been proposed for increasing the rate of vaginal delivery is a program of active management of labor that encourages early amniotomy, early diagnosis of slow progress in labor, and the use of higher than usual doses of oxytocin; the efficacy and safety of this approach are uncertain, however. METHODS: We conducted a randomized trial in which nulliparous women in spontaneous labor at term were randomly assigned to either active management of labor or traditional management. With active management, amniotomy was performed within one hour of the diagnosis of labor, and when the rate of cervical dilation was less than 1 cm per hour, oxytocin was infused at an initial rate of 6 mU per minute. The dose was increased by 6 mU per minute every 15 minutes (to a maximum of 36 mU per minute) until there were seven contractions every 15 minutes. RESULTS: For the women assigned to active management (n = 351), the cesarean-section rate was 10.5 percent, as compared with 14.1 percent for those assigned to traditional management (n = 354, P = 0.18). The 26 percent reduction in the cesarean-section rate was due primarily to a decrease in dystocia. After we controlled for potential confounding variables, the reduction in the rate of delivery by cesarean section was statistically significant (odds ratio for women given active as compared with traditional management, 0.57; 95 percent confidence interval, 0.36 to 0.95). With active management, the average length of labor was shortened by 1.66 hours, principally because of earlier amniotomy and earlier use of oxytocin. There was no increase in maternal or neonatal morbidity, and there were significantly fewer infectious complications in the mothers. CONCLUSIONS: The program we studied for the active management of labor reduces the incidence of dystocia and increases the rate of vaginal delivery without increasing maternal or neonatal morbidity.

Adult↗

PubMed1992

Interlaboratory variation in antiphospholipid antibody testing.

OBJECTIVE: Because of the widespread use of antiphospholipid antibody testing in the evaluation of patients with recurrent pregnancy loss, we evaluated the consistency of results among laboratories testing for anticardiolipin antibody and the lupus anticoagulant. STUDY DESIGN: A questionnaire regarding methods used and samples of blood from 20 patients were sent to five university-based and five commercial facilities for antiphospholipid antibody testing. RESULTS: The responses of the participating laboratories to the questionnaires revealed significant differences in methods, standardization, and units of reporting. For anticardiolipin antibody, the number of specimens found to be positive for any isotype (immunoglobulin G, M, or A) varied considerably among laboratories, with a range of 5 to 13. All laboratories were in agreement (i.e., at least one isotype was present or all were absent) for only 5 of 20 specimens (25%). In contrast, lupus anticoagulant results were more reproducible, although one facility reported results markedly discordant from the other four laboratories. CONCLUSION: These observations suggest that significant interlaboratory variation exists in antiphospholipid antibody, and particularly anticardiolipin antibody, testing and might lead to unnecessary therapeutic interventions.

Antibodies↗

PubMed1992

Antepartum management of triplet gestations.

OBJECTIVE: We evaluated an alternative approach to the management of triplet gestations that did not include home uterine monitoring, prophylactic tocolysis, or routine antepartum hospitalization. STUDY DESIGN: Fifteen patients were managed over a 42-month period by an antepartum protocol that emphasized patient education regarding signs and symptoms of preterm labor, weekly prenatal visits after 24 weeks' gestation with cervical examination, and increased rest in an outpatient setting. Tocolytic therapy was only used for regular uterine contractions when cervical change was documented. RESULTS: Nine of 15 (60%) patients with management in this uniform manner were delivered at > or = 35 weeks' gestation, and six patients (40%) completed 37 weeks of pregnancy. Only five patients (33%) received tocolytic therapy. The mean birth weight was 1957 +/- 488 gm, and only 19 of 45 neonates (42%) were admitted to the intensive care nursery. CONCLUSION: This management scheme was effective in reducing preterm delivery and thereby optimizing perinatal outcome.

Birth Weight↗

PubMed1991

Absence of hyperinsulinemia in isoimmunized fetuses treated with intravascular transfusion.

We serially sampled blood from fetuses of five severely isoimmunized pregnancies at the time of each intrauterine intravascular transfusion and at birth. We were unable to demonstrate either an elevation in the plasma insulin/glucose ratio or a relationship between the insulin/glucose ratio and hemoglobin concentration at any time period. Plasma total glutathione concentration, however, decreased dramatically from the initial to the second transfusion (323 +/- 114 to 43 +/- 9 ng/ml; t = -5.06, p less than 0.01). We speculate that intrauterine transfusion may modify or prevent the previously reported fetal pancreatic beta-cell hyperplasia and hyperinsulinemia associated with isoimmunization by decreasing red blood cell hemolysis and thereby circulating glutathione.

Anemia↗

PubMed1991

Shoulder dystocia and birth trauma in gestational diabetes: a five-year experience.

Over a 5-year period, 210 patients with gestational diabetes mellitus were delivered of offspring weighing greater than or equal to 3500 gm. Only three primary cesarean sections were performed electively because of suspected macrosomia. One hundred twenty patients were delivered vaginally. There were 15 shoulder dystocias but only one permanent brachial plexus injury. Seven of the 15 shoulder dystocias occurred in offspring weighing less than 4000 gm. Of variables examined, only the use of forceps was clearly associated with an increased risk of shoulder dystocia (odds ratio, 5.1). A policy to deliver by cesarean section all fetuses estimated to weigh greater than 4000 gm would considerably increase the number of cesarean sections with minimal fetal benefit.

Birth Injuries↗

PubMed1991

Perinatal outcome following intravascular transfusion in severely isoimmunized fetuses.

Twenty-six severely isoimmunized pregnancies managed exclusively with ultrasonographically guided intravascular fetal transfusions are reported. The mean gestational age plus and minus one standard deviation (+/- SD) was 26.3 +/- 3.6 weeks and the mean hematocrit (+/- SD) prior to initial transfusion was 20.6 +/- 6.7%. Four of seven hydropic fetuses and 9 of 19 without hydrops were less than or equal to 26 weeks gestation at the first transfusion. Overall survival was 85% (22/26). Survival was similar whether or not fetal hydrops was present (6/7 vs. 16/19) and whether or not the first transfusion was administered at less than or equal to 26 weeks gestation (10/13 vs. 12/13).

Blood Transfusion, Intrauterine↗

PubMed1990

Is intrauterine transfusion associated with diminished fetal growth?

Studies in animal models and human pregnancies suggest that severe fetal anemia and/or replacement of fetal with adult blood result in decreased pH, increased base deficit, and hyperlactacidemia. Similar changes have been noted in growth-retarded, nonanemic fetuses, and we therefore hypothesized that isoimmunized fetuses requiring intrauterine transfusions might have diminished growth. We longitudinally studied growth patterns in 17 isoimmunized fetuses by noting biparietal diameter and head and abdominal circumference measurements at each transfusion. The distributions of these measurements above and below the 25th, 50th, and 75th percentiles derived from our general obstetric population were compared at the initial transfusion and the last ultrasonogram performed before delivery. Birth weights also were noted and their distribution around the 25th, 50th, and 75th percentiles was compared to the expected distribution. For each ultrasonographic parameter, the distribution of measurements at the last ultrasonogram before delivery was not significantly different from the distribution at the initial ultrasonogram. The birth weight distribution also was not significantly different than the expected distribution. Thus we were unable to demonstrate slowing of fetal growth in our severely isoimmunized pregnancies.

Anemia↗

PubMed1990

The tap test: confirmation of a simple, rapid, inexpensive, and reliable indicator of fetal pulmonary maturity.

The tap test was previously described, and preliminary experience suggested it might be a rapid, inexpensive, and reliable indicator of fetal lung maturity. In this expanded series of 332 patients delivered of infants within 72 hours of amniotic fluid analysis, the predictive values for mature test results at 2, 5, and 10 minutes were 98.9% (182 of 184), 97.4% (221 of 227), and 97.1% (233 of 240), respectively. Predictive values for immature test results were 41.2% (61 of 148), 54.3% (57 of 105), and 60.9% (56 of 92). For the phospholipid profile the predictive value was 96.9% (186 of 192) for a mature test result and 40.7% (57 of 140) for an immature result. These observations, coupled with its methodologic simplicity, make the tap test a good first step in a cascade scheme of tests for fetal lung maturity and a valuable test in a facility where the phospholipid profile is not available 24 hours a day.

Amniotic Fluid↗

PubMed1990

The prevalence of substance abuse in patients with suspected preterm labor.

Premature labor is a recognized complication of substance abuse in pregnancy. However, the prevalence of substance abuse in patients first seen with symptoms of preterm labor and who deny use of illicit drugs is unknown. Between July 1, 1988, and December 15, 1988, 141 patients first seen at Northwestern Memorial Hospital in suspected preterm labor and a comparison group of 108 uncomplicated laboring term patients had urine toxicology screening performed to detect substance abuse. Positive urine toxicology screenings were found in 24 of 141 (17.0%) patients with suspected preterm labor and in 3 of 108 (2.8%) patients in the comparison group. The most common substance identified was cocaine (14/24 and 1/3, respectively). Of those patients in suspected preterm labor, 22 of 86 (25.6%) clinic patients had positive urine toxicology screenings as did 2 of 55 (3.6%) private patients. On the basis of our observations, we recommend that patients admitted in possible preterm labor be encouraged to submit to screening for substance abuse so that appropriate counseling and prenatal and neonatal care become available for these high-risk patients.

Adolescent↗