Search PubMed⌕ Search

Biomedical subjects

R J Wapner

Publications and source records attributed to R J Wapner.

At least 55 records · Page 3Linked to original sources
PubMed1995

A randomized multicenter trial assessing a home uterine activity monitoring device used in the absence of daily nursing contact.

OBJECTIVE: To evaluate the effectiveness of home uterine activity monitoring in the early detection of preterm labor among women with a history of preterm delivery. STUDY DESIGN: Two hundred eighteen women from four centers were prospectively randomized to routine high-risk prenatal care alone (not monitored) or to the same prenatal care with twice-daily home uterine activity monitoring without daily nursing support (monitored). All women had a history of preterm delivery. The primary study end point was cervical status as measured by cervical dilatation at the time of diagnosis of preterm labor. RESULTS: The two study group populations at entry into the study were similar in medical and demographic characteristics. Of 187 women completing the trial, 21 (24.4%) of the women in the monitored group (n = 86) and 22 (21.8%) of the women in the unmonitored (control) group (n = 101) experienced preterm labor (not significant). Mean cervical dilatation at the time of diagnosis of preterm labor was 1.7 cm in the monitored group and 2.8 cm in the unmonitored group (p = 0.004). A total of 52.4% of the women in the monitored group had a cervical dilatation of < 2 cm when preterm labor was detected, compared with 18.2% of the women in the unmonitored group (p = 0.019). The median duration of gestation after diagnosis of preterm labor was 21.0 days for the monitored group and 3.0 days for the unmonitored group (p = 0.016). CONCLUSION: The diagnosis of preterm labor for women using home uterine activity monitoring without daily nursing contact was detected with less cervical dilatation than found in those women not monitored. This earlier detection of preterm labor demonstrates the utility and effectiveness of home uterine activity monitoring devices and may lead to improved neonatal outcomes.

Adult↗
PubMed1995

Ultrasonographically guided intrauterine contraceptive device removal before chorionic villus sampling.

OBJECTIVE: Management of a retained intrauterine contraceptive device with no visible string during early pregnancy presents a dilemma. Because these devices are frequently used by multiparous women, it is not unusual that many women with retained devices are also of advanced maternal age. We describe our experience with ultrasonographically guided first-trimester retrieval of an intrauterine contraceptive device in conjunction with chorionic villus sampling. STUDY DESIGN: Patients with a first-trimester pregnancy and a retained intrauterine contraceptive device where no string was visible were offered ultrasonographically guided retrieval of the device. If the patient had genetic risks and desired prenatal diagnosis, chorionic villus sampling was offered at the same office visit. RESULTS: Six patients underwent intrauterine contraceptive device retrieval, under continuous ultrasonographic guidance, by use of an intrauterine contraceptive device hook. All patients had a posterior or fundal device. One patient had two in situ: a Lippes Loop (Ortho Pharmaceutical Corp., Raritan, N.J.) removed by its string and a Cu-7 (G.D. Searle & Co., Chicago) removed under ultrasonographic guidance. The remaining five patients had a Cu-7. Four of six patients had chorionic villus sampling performed immediately after the intrauterine contraceptive device removal and one patient had chorionic villus sampling 3 weeks later. There were two losses in our series: one after a lengthy procedure and one before documented viability. All infants were structurally normal and born at term. CONCLUSION: First-trimester ultrasonographically guided retrieval of a retained intrauterine contraceptive device may be safely performed in conjunction with chorionic villus sampling.

Adult↗
PubMed1995

Genetic diagnosis in multiple pregnancies.

A twin gestation presents unique problems in both genetic counseling and prenatal diagnosis. This article describes the specific genetic counseling concerns for a twin gestation and outlines the available techniques for genetic prenatal diagnosis. The technical aspects, risks and benefits to the pregnancy of amniocentesis and of chorionic villi sampling are compared. Although the risk of miscarriage after amniocentesis in a twin gestation is at least double that for a singleton, much of this additional risk is secondary to the inherent hazards of twins and not procedure-related. In experienced centers, chorionic villi sampling is equally safe and efficacious, and allows an earlier diagnosis that may be beneficial when discordant results are found. The aspects of serum screening unique to twin gestations are also outlined. Prenatal diagnosis by both chorionic villus sampling and amniocentesis can be safely performed in twin gestations and higher-order multiple gestations. Serum screening is also useful, but appears to have a lower sensitivity and specificity than in singletons.

Amniocentesis↗
PubMed1995

Fetal gallbladder growth and development during gestation.

This study sought to establish normal dimensions of the fetal gallbladder throughout pregnancy. The gallbladders in 300 normal fetuses between 15 and 40 weeks of gestation were measured prospectively for length, anteroposterior dimension, and transverse dimension. The gallbladder length, anteroposterior diameter, and transverse diameter have a linear relationship with gestational age between 15 weeks and 30 weeks of gestation, after which a plateau is observed. Calculated gallbladder area, volume, and sagittal perimeter have similar rates of growth in utero. The normative dimensions we have established for the fetal gallbladder throughout pregnancy can be expected to serve as a basis against which aberrant growth can be evaluated prenatally.

Anthropometry↗
PubMed1994

Efficacy of second-trimester selective termination for fetal abnormalities: international collaborative experience among the world's largest centers.

OBJECTIVE: Our goal was to develop the most comprehensive database possible to counsel patients about selective termination for fetal abnormalities, because no one center has sufficient data to assess much more than crude loss rates. STUDY DESIGN: A total of 183 completed cases of selective termination from 9 centers in 4 countries were combined (169 twins, 11 triplets, 3 quadruplets). Variables included indications, methods, (potassium chloride, exsanguination, air embolus), gestational age at procedure, pregnancies lost (< or = 24 weeks), gestational age at delivery, and neonatal outcome. RESULTS: Indications for selective termination were 96 chromosomal, 76 structural, and 11 mendelian. Selective termination was technically successful in 100% of cases. In 23 of 183 (12.6%) miscarriage occurred before 24 weeks; 2 of 37 (5.4%) occurred when the procedure done at < or = 16 weeks and 21 of 146 (14.4%) when it was done thereafter. Air embolization had a higher loss rate: 10 of 24 (41.7%) compared with 13 of 156 (8.3%) by potassium chloride (chi 2 = 117, p < 0.0001). Three cases of selective termination performed in monochorionic pregnancies all resulted in pregnancy loss. Among 183 potentially viable deliveries, 7 occurred before 28 weeks, 19 at 29 to 32 weeks, 41 at 33 to 36 weeks, and 93 at > or = 37 weeks. Gestational age at delivery was not influenced by the technique used or the indication but was negatively correlated with gestational age at the time of selective termination. No coagulopathy or ischemic damage was observed in survivors. There was no maternal morbidity. CONCLUSIONS: (1) Selective termination in experienced hands for a dizygotic abnormal twin is safe and effective when done with potassium chloride. A total of 83.8% of viable deliveries occurred after 33 weeks and only 4.3% at 25 to 28 weeks. (2) Gestational age at the procedure correlated positively with loss rate and inversely with gestational age at delivery; this emphasizes the need for early diagnosis in multifetal pregnancies. (3) Coagulopathy tests are probably unnecessary.

Abortion, Therapeutic↗
PubMed1994

The natural history of euploid pregnancies with first-trimester cystic hygromas.

OBJECTIVES: Little information is available with regard to prognosis of euploid fetuses with first-trimester nuchal hygromas. To evaluate this population, the natural history, pregnancy outcome, and pediatric implication of this lesion were determined. STUDY DESIGN: Fetuses with cystic hygromas detected in the first trimester were retrospectively identified, and karyotype results were documented. Pregnancy outcome of those fetuses having a euploid karyotype was obtained, and physical examination of the live-born neonates and infants was performed by a clinical geneticist. RESULTS: A normal karyotype was identified in 22 (51%) of these pregnancies. Eighty-two percent of the euploid pregnancies were continued, with 89% of the fetuses surviving to the third trimester. Dysmorphic sequelae were documented in three children, including Noonan syndrome in one. CONCLUSION: In the presence of a normal karyotype fetuses with a first-trimester nuchal hygroma have an excellent prognosis. Normal outcome was seen in 80% of pregnancies carried to the third trimester.

Aneuploidy↗
PubMed1994

Transabdominal versus transcervical and transvaginal multifetal pregnancy reduction: international collaborative experience of more than one thousand cases.

OBJECTIVES: Two major approaches for multifetal pregnancy reduction have been developed over the past several years: transabdominal potassium chloride by injection and pelvic procedures by either transcervical aspiration or transvaginal potassium chloride injection or by an automated spring-loaded puncture device. The purpose of this study was to create the largest database from among the world's largest centers to assess possible differences in efficacy and complication rates by transabdominal or transcervical or multifetal pregnancy reduction. STUDY DESIGN: Data on over 1000 completed pregnancies that underwent multifetal pregnancy reduction by both methods from major centers with among the highest worldwide experience were combined. Transabdominal cases were divided temporally (1986 through 1991 and 1991 through 1993). RESULTS: Transabdominal multifetal pregnancy reduction was successfully performed on 846 patients and transcervical or transvaginal on 238 patients. Transcervical or transvaginal reduction is performed earlier and starts and finishes with fewer embryos. In 12.6% of cases transcervical or transvaginal reduction left a singleton as opposed to 4.4% for transabdominal reduction. Pregnancy losses (up to 24 weeks) were observed in 13.1% of transcervical or transvaginal cases and in 16.2% of transabdominal cases early in the series and 8.8% of late transabdominal cases. Transcervical or transvaginal reduction may be safer very early in gestation and transabdominal safer later in the first trimester. Premature deliveries were comparable, with only about 5% delivered between 25 and 28 weeks. The smaller starting numbers for transcervical and transvaginal reduction may explain a slightly higher term delivery rate. The transabdominal route tends to reduce the fundal embryos and the transcervical and transvaginal the lower ones. The significance of this is not clear. CONCLUSIONS: (1) Multifetal pregnancy reduction by either method is a relatively safe and efficient method for improving outcome in multifetal pregnancies. (2) More than 84% are delivered at > 33 weeks. (3) The experience and preference of the operator are probably the key determinants for an individual patient. (4) An inverse relationship of starting and finishing number to loss rates and gestational age at delivery suggests that there still is a cost of iatrogenic multifetal pregnancies, even if multifetal pregnancy reduction can be successfully performed.

Abdomen↗
PubMed1994

Neonatal screening for sickle cell disease in a metropolitan university hospital: efficacy and problems.

OBJECTIVE: To determine the effectiveness of a screening programme to identify infants with sickle cell anaemia. SETTING: A metropolitan university hospital. METHOD: 4845 (73.3%) newborn cord blood samples from 6271 infants born in the Thomas Jefferson University Hospital over a two year period were tested for the presence of haemoglobinopathies. The patient group comprised approximately 44% white Americans and 51% African Americans. Diagnoses of haemoglobinopathies were established by cellulose acetate (pH 8.6) and citrate agar (pH 6.2) electrophoresis, and thin layer isoelectric focusing. RESULTS: 17 African American infants were suspected of having sickle cell anaemia and their families were notified and called for retesting to confirm the diagnosis. Fourteen of these families responded; retesting confirmed the diagnosis of sickle cell anaemia in 12 (86%), and the remaining two (14%) had sickle cell trait. The other three families never responded and all efforts to reach them were unsuccessful so the diagnosis could not be confirmed. The infants for whom the diagnosis of sickle cell anaemia was confirmed were treated prophylactically with penicillin and enrolled in sickle cell programmes. Of 398 infants with an abnormal haemoglobin (Hb), 170 (3.5% of all infants tested) showed sickle trait, 63 (1.3%) showed Hb C trait, and 165 samples (3.4%) showed Hb Bart's. Letters of notification were sent to those families whose infants had sickle trait or Hb C trait. Thirty three (16%) families responded and asked for additional information, counselling, or testing of other family members. Three of these families (about 0.1% of all white subjects tested) were white subjects of Italian, English, and Polish ancestry, and all of their infants had sickle trait. Additional testing on other family members showed that one black parent had Hb SC disease that had not previously been diagnosed as the subject was asymptomatic. CONCLUSIONS: A screening programme for newborns in a metropolitan hospital (a) was effective in identifying and treating infants with sickle cell anaemia with prophylactic penicillin, (b) was associated with difficulties in tracking infants and their families in about 30% of suspected cases of sickle cell disease, (c) found that sickle trait is not uncommon in white subjects, and (d) found that "silent" sickle cell disorders to occur among American black subjects.

Anemia, Sickle Cell↗
PubMed1994

Real-time ultrasonographic analysis of the normal postpartum uterus: technique, variability, and measurements.

We evaluated normal uterine involution prospectively with real-time ultrasonography in 100 women after uncomplicated term vaginal delivery. Transducers easily distorted the spongy uterus during early postpartum scanning, an effect minimized with sector transducers that are superior to linear or convex probes for accurate early postpartum uterine measurement. Long-axis measurements correcting for uterine angulation were the most reproducible and accurate, irrespective of bladder distention. Uterine contractions caused instability of particularly the transverse dimension. Increasing maternal parity was associated with slightly but significantly larger uterine dimensions up to 4 weeks post partum. The uterus reassumed nongravid dimensions by 6 to 8 postpartum weeks. Uterine involution was unrelated to infant birth weight or breast feeding.

Anthropometry↗
PubMed1994

Incidence of bacteremia associated with chorionic villus sampling.

OBJECTIVE: To assess the frequency of transient bacteremia among women undergoing transabdominal and transcervical chorionic villus sampling (CVS). METHODS: One hundred fourteen women undergoing CVS consented to participate in a university review board-approved study protocol. Exclusion criteria included known cardiac valve anomaly or replacement (or other prosthetic) and antibiotic use within the preceding 21 days. Blood cultures (aerobic and anaerobic) were drawn by a single operator on all patients, before CVS and within 15 minutes after completing CVS. Either the catheter tip or needle tip aspirate from each procedure was also sent for culture. RESULTS: Post-procedure bacteremia was detected in two (1.8%) of the patients undergoing CVS. These two patients both had their procedures performed transcervically, resulting in a 4.1% (two of 49) bacteremia rate after transcervical CVS, compared to none (zero of 65) in the transabdominal group (P = .36). The incidence of positive cultures from sampling instruments was also higher in the transcervical group (16.3 versus 0%; P = .003), but did not result in comparable rates of bacteremia among patients with positive instrument cultures. CONCLUSIONS: In this study, CVS was associated with a low rate of bacteremia, regardless of the procedure route. Recommendations for antibiotic prophylaxis in women with abnormal cardiac valves should parallel those for spontaneous vaginal delivery and other comparable genitourinary procedures.

Bacteremia↗
PubMed1993

Multifetal reduction of triplets to twins improves perinatal outcome.

OBJECTIVE: Our purpose was to compare the perinatal outcome of triplet pregnancies reduced to twins with the outcomes of continuing triplet pregnancies and twin pregnancies. STUDY DESIGN: Pregnancy outcomes of triplet pregnancies reduced to twins delivered between July 1988 and July 1992 were compared with pregnancy outcomes of continuing triplet and twin pregnancies delivered over the same time period. RESULTS: The mean gestational age at delivery for the reduced triplets was 35.6 weeks, compared with 31.2 weeks in the nonreduced triplets (p = 0.002). The perinatal mortality rate was 30 per 1000 births in the reduction group and 210 per 1000 births in the nonreduced triplets (p < 0.0001). There were no statistically significant differences between the reduced and nonreduced twins. CONCLUSION: Multifetal pregnancy reduction of triplets to twins yields an improved perinatal outcome compared with nonreduced triplets and a similar outcome compared with nonreduced twins.

Abortion, Therapeutic↗
PubMed1993

First-trimester simple hygroma: cause and outcome.

OBJECTIVE: First-trimester fetuses with simple nuchal hygromas represent a population that is different from midgestation nuchal cystic hygroma in terms of karyotype abnormalities and long-term prognosis. STUDY DESIGN: Sixty-eight consecutive fetuses diagnosed with simple nuchal hygromas between 10 and 14 weeks' gestation were evaluated ultrasonographically and karyotyped. Those with normal chromosome complements were ultrasonographically monitored throughout the remainder of the pregnancy for resolution of their hygromas. RESULTS: Twenty-three of 27 fetuses with normal karyotypes resolved their hygromas within 4 weeks of diagnosis and were phenotypically normal at birth. Forty-one fetuses were karyotypically abnormal, with trisomy 21 being the most common abnormality. CONCLUSIONS: Fetuses with first-trimester simple nuchal hygromas are at high risk for aneuploidy and should be offered prenatal testing. Such fetuses with normal karyotypes will likely resolve their hygromas by 18 weeks' gestation, and most will be phenotypically normal at birth.

Chromosomes, Human, Pair 21↗
PubMed1993

Prenatal diagnosis in twin gestations: a comparison between second-trimester amniocentesis and first-trimester chorionic villus sampling.

OBJECTIVE: To evaluate prospectively the relative risks and accuracy of first-trimester chorionic villus sampling (CVS) and second-trimester amniocentesis in the genetic evaluation of twin gestations. METHODS: Between March 1984 and August 1990, patients presenting for prenatal diagnosis of a twin gestation of less than 12 weeks were offered sampling by either first-trimester CVS or amniocentesis at 16-18 weeks' gestation. Selection was based solely on patient preference and was obtained before ultrasound identification of placental position. Women presenting beyond 12 weeks' gestation were sampled by amniocentesis. Clinical and laboratory outcomes were evaluated. RESULTS: Eighty-one women had amniocentesis (nine of whom also had CVS), and 161 women had CVS. All fetuses in both groups were successfully sampled and karyotyped; 85.3% of the amniocentesis patients and 75.8% of the CVS patients were sampled in two or fewer passes (P = not significant). There were three cases of twin-twin villus contamination following CVS; one of these led to incorrect gender assignment because of erroneous laboratory interpretation. Loss of the entire pregnancy from the time of sampling until the 28th week of gestation followed amniocentesis in 2.9% of the cass and CVS in 3.2%. The total fetal loss rates were 9.3% for amniocentesis and 4.9% for CVS (P = not significant). When pregnancies having mosaic or abnormal karyotype results are excluded, the total amniocentesis loss rate remained 9.3% and the CVS loss rate became 3.9% (P < .05). CONCLUSION: In the hands of experienced operators, CVS is at least as safe and effective as amniocentesis for the prenatal diagnosis of twin gestations.

Abortion, Eugenic↗
PubMed1993

Efficacy of transabdominal multifetal pregnancy reduction: collaborative experience among the world's largest centers.

OBJECTIVE: To evaluate the safety and efficacy of transabdominal multifetal pregnancy reduction (MFPR) in the management of iatrogenic and spontaneous multifetal pregnancies. METHODS: Data were combined from 463 completed pregnancies that underwent MFPR at major worldwide centers. RESULTS: Multifetal pregnancy reduction was performed with a 100% technical success rate (there were no failed procedures); 83.8% had delivery of potentially viable fetuses (defined as 24 weeks' gestation or later), and 83.5% of these viable pregnancies delivered at 33 weeks or later. The risk of fetal loss was 3.9% at 2 weeks or less post-procedure, 4.6% at 4 weeks or less, and 16.2% at less than 24 weeks of gestation. Gestational age at delivery varied principally with the number of fetuses remaining, with 7.1% delivering prematurely at less than 28 weeks, and 9.4% at 29-32 weeks. The incidence of obstetric and medical complications appeared to be unaffected, and there was no increase in congenital malformations. CONCLUSIONS: Multifetal pregnancy reduction is an efficient and safe way of improving outcome in multifetal pregnancies, unambiguously for quadruplets or more, and arguably for triplets. However, particularly at higher starting numbers, there are still suboptimal outcomes. We cannot answer the question of whether MFPR should be offered to women with triplets or twins. The only major risk appears to be fetal loss per se, and because the procedure itself does not damage the survivors, parental autonomy should be given a higher priority in the decision process than previously. However, to obviate the need for this procedure, infertility specialists must continue to be vigilant in the use of fertility drugs.

Abortion, Induced↗
PubMed1992

Selective termination to a singleton pregnancy is ethically justified.

Consensus presently opposes selective termination of a multifetal pregnancy to a singleton. We reject this consensus because the arguments made in defense of it are deficient. We show that these arguments rely on the indefensible assumption that the previable fetus possesses independent moral status. We conclude that, since selective termination of a multifetal pregnancy of any order to a singleton is ethically justifiable, a pregnant woman's request for selective termination to a singleton from twins or a higher-order multiple gestation should be respected and implemented. Physicians who object to selective termination to a singleton in private conscience should not feel compelled to perform the procedure but are obligated to make an appropriate referral.

Journal Article↗
PubMed1992

Chorionic mosaicism: association with fetal loss but not with adverse perinatal outcome.

Cytogenetic data from the United States NICHD collaborative study of chorionic villus sampling (CVS) were used to evaluate the clinical significance of chorionic mosaicism. The 10,754 patients with normal cytogenetic results were compared with 108 patients (1.0 per cent) with placental mosaicism and 181 patients (1.6 per cent) with pseudo-mosaicism. Of the pregnancies intended to continue, the pregnancy loss rate was significantly greater in patients with placental mosaicism than in the cytogenetically normal cohort (8.6 vs. 3.4 per cent, p less than 0.05). However, there was no difference in the frequencies of abruptio placenta, preterm labour or delivery, small-for-gestational-age newborns, pregnancy-induced hypertension, or neonates with Apgar scores less than 7.

Abortion, Spontaneous↗