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R K Freeman

Publications and source records attributed to R K Freeman.

At least 37 records · Page 2Linked to original sources
PubMed1992

A randomized, placebo-controlled trial of betamethasone for the prevention of respiratory distress syndrome at 24 to 28 weeks' gestation.

Previous randomized controlled studies of corticosteroids for the reduction of respiratory distress syndrome have failed to demonstrate benefit in very early premature gestational age groups. A randomized, double-blind, placebo-controlled clinical trial of betamethasone given to mothers with intact membranes and threatened premature delivery between 24 and 28 weeks of pregnancy was conducted. Thirty-six patients were randomized to receive betamethasone, two doses of 12 mg, 24 hours apart, and 41 received placebo. No difference was found in the overall incidence of respiratory distress syndrome between the two groups (betamethasone vs placebo 0.55 vs 0.66) or in the incidence of respiratory distress syndrome in babies delivered between 1 and 7 days after the first dose of drug (betamethasone vs placebo 0.78 vs 0.88). Nor were there any differences observed in any measure of severity of respiratory distress syndrome between the groups. The neonatal death rates were also similar (betamethasone vs placebo 0.25 vs 0.24). The only difference seen was an unexpected reduction in the betamethasone group in the incidence of grades 3 and 4 intraventricular hemorrhage (betamethasone vs placebo 1/31 vs 9/36, p = 0.01). Therefore this study was unable to demonstrate any beneficial effect of corticosteroids in reducing respiratory distress syndrome at less than 28 weeks' gestation in spite of a sample size that had an 80% likelihood of detecting a 50% reduction in the incidence of respiratory distress syndrome with p = 0.05, which is the minimum reduction seen in virtually all randomized trials in other gestational age groups.

Adult↗
PubMed1992

How frequently should the amniotic fluid index be repeated?

OBJECTIVE: Our objective was to determine the most appropriate interval for assessing amniotic fluid volume with amniotic fluid index. STUDY DESIGN: In a retrospective analysis amniotic fluid indexes performed every 3 to 4 days in antepartum testing patients were compared with their follow-up values. Of 10,742 amniotic fluid indexes there were 7393 with follow-up values within 4 days. The results were stratified by current amniotic fluid index, gestational age, and concurrent nonstress test results. The groups were compared with chi 2 analysis. RESULTS: Patients with normal amniotic fluid index (> or = 8 cm) had a 0.54% chance of oligohydramnios developing in the next 4 days. Those patients with low normal amniotic fluid indexes (5 to 8 cm) had a 5% chance of oligohydramnios developing within the next 4 days, and patients with low amniotic fluid indexes (< or = 5 cm) had a 59% chance of persistent oligohydramnios 4 days after the index examination. Subdividing by gestational age demonstrated that patients > or = 41 weeks' gestation had a 2.6% chance of oligohydramnios developing within 4 days if current amniotic fluid index was between 8 and 15 cm. Results of concurrent fetal heart rate findings did not appear to change the risk for development of oligohydramnios. CONCLUSION: In patients < 41 weeks' gestation with normal amniotic fluid indexes, a repeat amniotic fluid index is not necessary for 7 days.

Amniotic Fluid↗
PubMed1991

Antepartum testing in the hypertensive patient: when to begin.

Antepartum testing has been recommended for patients whose pregnancies are complicated by hypertension. Although this is considered accepted practice, there are little data available to help the clinician know when to start testing. To help answer this question in patients with chronic hypertension and nonproteinuric pregnancy-induced hypertension, we reviewed the results of all antepartum tests between 1976 and 1987 in patients with these diagnoses. The primary mode of surveillance in the majority of our patients was the contraction stress test. We determined when patients first had positive contraction stress test results and when intervention occurred because of an abnormal antepartum test result. There were a total of 917 patients tested with these diagnoses. Fifty-three (5.8%) of these patients had at least one positive contraction stress test result. Twenty-two patients were delivered of infants before 35 weeks' gestation because of abnormal antepartum test results. Those with early intervention (less than 35 weeks' gestation) could not be differentiated from those with later intervention (greater than or equal to 35 weeks' gestation) by maternal age, diastolic blood pressure, or systolic blood pressure at the time of testing. The majority of patients who were delivered of infants before 35 weeks' gestation had a concomitant diagnosis of systemic lupus erythematosus, intrauterine growth retardation, diabetes mellitus, or superimposed preeclampsia. On the basis of when compromise was evident, patients with these diagnoses may require testing to be started as early as the fetus is considered viable. However, in those without these diagnoses, the clinician may delay the beginning of testing until 33 weeks' gestation without significant risk of pregnancy loss before testing.

Female↗
PubMed1990

The contraction stress test.

The contraction stress test has long been used to assess fetal wellbeing in the antepartum period. The CST continues to be a valuable tool for practicing obstetricians when interpreted and managed according to previously published guidelines. More recent data have further defined the level of compromise at which the CST becomes abnormal. When compared to similar reports using the NST or biophysical profile, we are better able to define the capabilities of these various antepartum testing methods. Consequently, we were able to align antepartum testing schemes for the specific clinical situation as opposed to using one method for all patients.

Female↗
PubMed1988

Quantitation of uterine activity preceding preterm, term, and postterm labor.

To assess uterine activity before labor in patients delivering preterm, at term, and postterm, the maximum spontaneous contraction frequency per 10-minute window during the initial portion of antepartum fetal heart rate monitoring was analyzed. Patients with multiple gestation, third trimester bleeding, polyhydramnios, or premature rupture of membranes and those already diagnosed with preterm labor were eliminated from the study. Of the 2446 remaining patients (7247 antepartum fetal heart rate tests) who went into spontaneous labor, 237 did so before 37 completed weeks of gestation, 1077 entered labor at term (38 to 42 completed weeks), and 1132 did so after 42 weeks. There was a significant increase in maximum uterine activity per 10-minute window from 30 to 44 weeks of gestation (average 4.7% per week; r = 0.97, p less than 0.0001). When compared with patients delivering spontaneously at term, average maximum uterine activity per 10-minute window was greatest in the preterm labor group (p less than 0.05) and least in the postterm labor group (p less than 0.05). These differences were present for several weeks preceding the onset of spontaneous labor. All three groups showed a surge of uterine activity during the 3 days before the onset of spontaneous labor.

Female↗
PubMed1987

A randomized trial of ritodrine tocolysis versus expectant management in patients with premature rupture of membranes at 25 to 30 weeks of gestation.

Expectant management was compared with similar management plus ritodrine tocolysis in a randomized controlled trial in patients with premature rupture of membranes at 25 to 30 weeks of gestation. In the tocolysis group intravenously administered ritodrine was instituted at the onset of labor and then changed to the oral form if successful. Tocolysis was discontinued or not instituted after 31 weeks of gestation. Seventy-nine patients were randomized over a 4-year period, 39 in the tocolysis group and 40 in the expectant group. Twenty-three patients in the tocolysis group actually received ritodrine. No difference between the two groups was demonstrated in the interval between premature rupture of membranes and delivery or in reaching 32 weeks of gestation. No statistical difference was seen in maternal morbidity. Birth weights and gestational ages at delivery were similar between the two groups as were the incidences of neonatal morbidities caused by prematurity and infection and in the duration of neonatal hospital stays. Despite being conducted in those gestational ages in which prolongation of pregnancy might be expected to be of most benefit, no difference could be demonstrated with the addition of tocolytic therapy over expectant management alone.

Adult↗
PubMed1987

The breast-stimulated contraction stress test.

A method was developed for using breast stimulation to induce uterine contractions for a contraction stress test (BSCST). Six hundred fifty-seven patients made 1,484 attempts with the BSCST and were successful in 1,072 trials (72.2%). A lower success rate was observed only in gestations less than or equal to 34 weeks. The distribution of test results (positive, negative, equivocal) by BSCST was unchanged from that of contraction stress tests performed with exogenous oxytocin (oxytocin challenge test [OCT]). The incidence of false-positive tests was similar to that in previous reports. The corrected perinatal mortality rate for the study population was 1.5 per 1,000 births. The time required for an adequate uterine response was 23.8 +/- 15.2 minutes, with 87.5% of patients responding in less than 30 minutes. The BSCST appears to be a reasonable alternative to the OCT, with elimination of the intravenous line and oxytocin administration and with a shorter testing time.

Breast↗
PubMed1986

Management of postdate pregnancy.

Management of the problems associated with pregnancies that extend beyond 294 days of amenorrhea has become increasingly important in obstetrics. This article outlines some of the methods that minimize the risks to the mother, fetus, and neonate in postdate pregnancy. A brief description of the definitions, incidence, and impact of postdate pregnancy is given for a baseline on which to base management decisions. The current management techniques are then given for the following aspects: diagnosis, antepartum surveillance, timing of delivery, and intrapartum management. Finally a synopsis of research areas that may change management is given.

Female↗
PubMed1986

The current role of daily serum estriol monitoring in the insulin-dependent pregnant diabetic woman.

This retrospective analysis of the use of serum estriol levels for antenatal assessment was performed in an effort to determine if routine, late third-trimester, daily serum estriol monitoring of insulin-dependent pregnant diabetic women can still be justified. Estriol profiles of 170 diabetic pregnancies, managed under a consistent protocol of weekly contraction stress tests and daily serum estriol assessments, were reviewed. A total of 4612 estriol determinations were performed. Nearly 4% of the estriol determinations showed a 35% fall from the mean of the previous three highest consecutive values. Forty-seven percent of the patients had at least one fall of this magnitude. Eighty-five percent of the fetal heart rate tests performed in association with an estriol fall were normal. A fall in estriol was not found to be associated with a higher risk of having a positive contraction stress test, either at the time the estriol fall was recognized or at any time during the patient's antepartum course. Although use of this strict protocol combining the use of weekly contraction stress tests and daily serum estriol determinations provided a safe method of antepartum assessment, there is little evidence to support the routine use of daily serum estriol monitoring in insulin-dependent pregnant diabetic women.

Adult↗
PubMed1986

Fetal maturity cascade: a rapid and cost-effective method for fetal lung maturity testing.

One hundred ninety-three amniotic fluid samples were tested for fetal lung maturity using a maturity cascade scheme involving the sequential use of, in order, the shake test, fluorescence polarimetry, and lecithin: sphingomyelin (L:S) ratio. If any of these tests indicated maturity, the sequence was terminated and no further test was performed, and the fetus was considered mature. Seventy percent of the tests yielded mature values and of these, 85 (63%) required a shake test only, 37 (27%) had a shake test and a fluorescence polarimetry, and only 14 (10%) required all three tests. From these 193 amniocenteses, 111 patients delivered within 72 hours of the procedure. One of 94 infants had respiratory distress syndrome after a mature test (1% false maturity) and ten of 17 had respiratory distress syndrome after an immature cascade (41% falsely immature). This approach saves time and cost and by confirming immaturity with multiple tests only when necessary and may improve predictability of neonatal respiratory distress syndrome.

Amniocentesis↗
PubMed1985

Prophylactic intrapartum amnioinfusion in patients with preterm premature rupture of membranes.

Patients with preterm premature rupture of the membranes are at increased risk to develop intrapartum variable decelerations and fetal distress. Short-term saline solution amnioinfusion may be of benefit in the treatment of variable or prolonged decelerations once they appear. In an effort to assess the benefit of prophylactic amnioinfusion, patients with preterm premature rupture of the membranes were studied during a 1-year period in a prospective randomized manner. Patients receiving prophylactic amnioinfusion had significantly decreased incidence and severity of variable decelerations in the first stage of labor (p less than 0.005). In the second stage of labor, the incidence of severe (p less than 0.005) and total (p less than 0.001) decelerations was also decreased in the treatment group. The umbilical arterial pH at delivery was significantly lower (p less than 0.001) as was the umbilical venous pH (p less than 0.005) in the newborn infants of control patients compared with those of patients receiving amnioinfusion. This suggests that prophylactic intrapartum amnioinfusion is of significant benefit in reducing the incidence of variable decelerations and improving the metabolic state in newborn infants born to women with preterm premature rupture of the membranes.

Adult↗
PubMed1985

Advanced maternal age: the mature gravida.

A 3-year study of women ages 35 years and older who were delivered at Women's Hospital of Long Beach from January 1, 1981, to December 31, 1983, was performed to study the risks involved with advanced maternal age. The study group included 1023 women who were 35 years and older, and they were divided into parous and nulliparous groups. A control group consisting of 5343 women aged 20 to 25 years was used for comparison. Each group was analyzed for the following parameters: pregnancy complications, labor complications, delivery factors, and neonatal outcome. The results show very few statistical differences in the factors analyzed. On the basis of this 3-year study it appears that pregnancies in women of advanced maternal age in the 1980s who are delivered in a modern tertiary care center may be of no higher risk for adverse outcome than pregnancies in younger parturients.

Adult↗
PubMed1985

Perinatal events and intraventricular/subependymal hemorrhage in the very low-birth weight infant.

One hundred nineteen very low-birth weight infants were studied to see whether intrapartum fetal distress with or without acidosis correlated with the development of intraventricular and subependymal hemorrhage. Of 112 infants studied prospectively, 24% (27/112) had intraventricular/subependymal hemorrhage documented by real-time ultrasound studies shortly after birth; only 4.4 (5/112) had severe hemorrhage (grade 3/4). Ominous fetal heart rate patterns occurred in 50% of monitored infants with severe intraventricular/subependymal hemorrhage compared to 8% of matched controls (p less than 0.01). Reassuring fetal heart rate patterns were more predominant in infants without intraventricular/subependymal hemorrhage (p less than 0.05). Neonatal depression and the need for assisted ventilation beyond the immediate delivery period were more frequent in infants who developed intraventricular/subependymal hemorrhage. Antepartum and intrapartum complications, fetal presentation, cesarean section, duration of labor, hyaline membrane disease, and volume expansion appeared to play no role in the incidence of intraventricular/subependymal hemorrhage. Preliminary data presented here suggest that intrapartum fetal distress and acidosis may be significant factors in predicting which very low-birth weight infant will develop intraventricular/subependymal hemorrhage. The condition of the infant at birth may be more significant with respect to the extent of intraventricular/subependymal hemorrhage than a variety of obstetric variables. Aggressive management of appropriately selected patients and judicious resuscitation of the very low-birth weight infant may keep the incidence of severe intraventricular/subependymal hemorrhage at a minimum, thereby optimizing neurological outcome for this high-risk group.

Acidosis↗
PubMed1985

The significance of a previous stillbirth.

Among 7052 patients studied between 1976 and 1982 in a collaborative project on antepartum fetal heart rate monitoring, 337 patients had a previous stillbirth as a reason for testing. Overall a previous stillbirth history significantly increased the risk of having a positive result on a contraction stress test, primarily among hypertensive patients. Patients with a previous stillbirth also had a significantly higher incidence of respiratory distress syndrome in their neonates attributable to premature intervention for maternal indications (primarily among hypertensive women and patients with clinical intrauterine growth retardation). Low Apgar scores were found to be significantly increased in diabetics with previous stillbirths primarily due to neonates with congenital malformations. Premature intervention by labor induction or cesarean section was more common among patients with a previous stillbirth for both maternal indications and abnormal antepartum fetal heart rate studies. Previous stillbirth would appear therefore to be a significant risk factor primarily when associated with a diagnosis of hypertension or clinical intrauterine growth retardation.

Apgar Score↗
PubMed1985

Maternal herpes infection complicated by prolonged premature rupture of membranes.

Three cases of patients who developed genital herpes virus infections after prolonged, premature rupture of membranes (PROM) at 28-31 weeks gestation are reported. These patients were expectantly managed without immediate intervention at the time of diagnosis of the genital herpes virus infection. In all three cases, there was no evidence of neonatal herpes virus infection at the time of delivery or before hospital discharge. The spectrum of decisions facing the physician managing a patient with prolonged PROM and a genital herpes virus infection is discussed, and a rational approach to management presented.

Adult↗
PubMed1984

Nonreactive contraction stress test: clinical significance.

Between September 1, 1976, and December 31, 1980, there were 4629 contraction stress tests performed at Women's Hospital, Memorial Hospital Medical Center of Long Beach, California. Forty-four (1.0%) of these tests were completely nonreactive. Eight of 3367 negative contraction stress tests (0.2%), 19 of 1124 equivocal contraction stress tests (1.7%), and 17 of 63 positive contraction stress tests (27.0%) were nonreactive. When compared with patients who had reactive tests, only those patients with a nonreactive, positive contraction stress test had significantly increased perinatal mortality and infants with low Apgar scores. Twelve percent of patients with nonreactive contraction stress tests had fetuses with congenital anomalies. Eighteen percent of patients with nonreactive tests were taking phenobarbital or other sedative drugs, and 45% of patients with nonreactive tests were hypertensive. Excluding anomalous fetuses, there were no perinatal deaths and no Apgar scores below 7 at five minutes in patients with nonreactive negative, or nonreactive equivocal, contraction stress tests as the worst test result. The hypothesis that the completely nonreactive negative contraction stress test as the worst test result is associated with increased perinatal mortality and morbidity could not be substantiated. Standardization of criteria for reactivity and interpretation of the contraction stress test using the entire testing period is desirable.

Apgar Score↗