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Biomedical subjects

R L Berkowitz

Publications and source records attributed to R L Berkowitz.

At least 37 records · Page 2Linked to original sources
PubMed1998

Prognostic factors and management in pregnancies complicated with severe kell alloimmunization: experiences of the last 13 years.

Because of the recent referral of an anti-Kell sensitized pregnant woman, whose fetus became severely anemic despite intensive antepartum surveillance, the prevalence and characteristics of fetal Kell isoimmunization were reviewed and analyzed. Cases with Kell and RhD alloimmunization requiring intrauterine intravascular transfusions (IUT) at the Mount Sinai Medical Center during the 13-year period ending March 1998 were compared. Thirty-six fetuses with RhD and 5 with Kell isoimmunization required IUTs. Lower fetal and neonatal hematocrit levels were observed in the RhD group. A significantly higher incidence of polyhydramnios was found among fetuses with Kell isoimmunization and the maternal serum titers were much lower than those in the RhD group. DeltaOD450 values did not reliably reflect the Kell sensitized fetus's condition. There were no intrauterine deaths or neonatal direct hyperbilirubinemia in the Kell group, and the hemolytic disease of the newborn was more severe in the RhD group. Although the course of the hemolytic disease in our cases of Kell isoimmunization showed a better prognosis than that in the RhD group, the importance of this condition should not be underestimated, and differences in the pathophysiology of Kell and RhD alloimmunization should be taken into consideration during the management of these cases.

Adult↗
PubMed1998

Ethical issues involving multifetal pregnancies.

Selective termination is a procedure in which an anomalous fetus in a multifetal pregnancy is terminated with the intent of allowing the pregnancy to continue, so that the patient delivers one or more healthy infants at term. Multifetal pregnancy reduction is the elective reduction of three or more fetuses to a smaller number in an attempt to reduce the incidence of premature delivery in these patients. The ethical issues relating to these two procedures are quite different. Data are presented relating to the efficacy and safety of each procedure, and the ethical issues relating to them are discussed.

Ethics, Medical↗
PubMed1997

Fetal alloimmune thrombocytopenia.

BACKGROUND: Alloimmune thrombocytopenia is a serious fetal disorder resulting from platelet-antigen incompatibility between the mother and fetus. The diagnosis is usually made after the discovery of unexpected neonatal thrombocytopenia. Approximately 10 to 20 percent of affected fetuses have intracranial hemorrhages, one quarter to one half of which occur in utero. We studied the correlates of thrombocytopenia in affected fetuses. METHODS: We studied 107 fetuses with alloimmune thrombocytopenia at a mean (+/-SD) gestational age of 25+/-4 weeks, before their entry into one of three treatment protocols. The fetuses were initially evaluated because an older sibling had been given this diagnosis at birth. We compared the initial platelet counts in utero in these 107 fetuses with the platelet count at birth and the history of intracranial hemorrhage in the affected sibling. RESULTS: The initial platelet count was < or =20,000 per cubic millimeter in 53 of the 107 fetuses (50 percent), including 21 of 46 fetuses (46 percent) studied before 24 weeks of gestation. The 97 fetuses with PI(A1) incompatibility had more severe thrombocytopenia than the 10 fetuses with other antigen incompatibilities. Among seven fetuses with platelet counts of more than 80,000 per cubic millimeter that were not treated initially, the counts decreased by more than 10,000 per cubic millimeter per week. Although 41 fetuses had initial platelet counts that were lower than those measured at birth in an older affected sibling, only a history of antenatal intracranial hemorrhage in the sibling predicted greater severity of thrombocytopenia in the fetus. Only one treated fetus had an intracranial hemorrhage, and the thrombocytopenia resolved after birth in all cases. CONCLUSIONS: Fetal alloimmune thrombocytopenia occurs early in gestation, is severe, and is more severe in fetuses with an older affected sibling who had had an antenatal intracranial hemorrhage.

Fetal Blood↗
PubMed1997

Twin pregnancies conceived by assisted reproductive techniques: maternal and neonatal outcomes.

OBJECTIVE: To determine whether twin pregnancies conceived by assisted reproductive techniques are at increased risk for obstetric complications or perinatal morbidity. METHODS: A computerized perinatal data base was reviewed for all twin pregnancies managed by private obstetricians and delivered between 1990 and 1995. The obstetric and neonatal outcomes of those conceived following in vitro fertilization (IVF) or gamete intrafallopian transfer (GIFT) were compared to the outcomes of those conceived spontaneously. RESULTS: There were 105 twin deliveries following IVF or GIFT and 279 following natural fertilization. Discordant birth weight and low birth weight occurred more frequently in pregnancies conceived by IVF or GIFT (adjusted odds ratio [OR] 2.11, 95% confidence interval [CI] 1.14, 3.91; OR 1.65, 95% CI 0.98, 2.79, respectively). Elective cesarean delivery was more frequent in twin pregnancies conceived after IVF GIFT (relative risk [RR] 4.02, 95% CI 1.28, 12.6). There were no statistically significant differences in the frequency of antepartum or intrapartum complications, preterm delivery, or mean gestational age at delivery. There was no statistically significant increase in the frequency of neonatal complications among infants born after IVF GIFT. CONCLUSION: Although twin pregnancies following IVF or GIFT are more likely to result in discordant birth weight infants, the perinatal outcome is comparable to that of spontaneously conceived twin pregnancies.

Adult↗
PubMed1997

One hundred consecutive cases of selective termination of an abnormal fetus in a multifetal gestation.

OBJECTIVE: To determine whether transabdominal selective termination of one or more abnormal fetuses in a multifetal pregnancy with dichorionic placentation is a safe and effective procedure. METHODS: One hundred consecutive selective termination procedures were performed by transabdominal injection of potassium chloride into the heart or umbilical vein of an anomalous fetus in a multifetal pregnancy. All of the abnormal fetuses were presumed to have dichorionic diamniotic placentas, based on an ultrasound evaluation before the procedure. Follow-up data were obtained for each patient regarding the development of postprocedural complications, laboratory or clinical evidence of a coagulopathy, maternal or neonatal morbidity, gestational age at delivery, and birth weight of the infants. RESULTS: Ninety-one sets of twins were reduced to singletons, six sets of triplets were reduced to twins, two sets of triplets were reduced to singletons, and one set of quadruplets was reduced to triplets. The anomalous fetus or fetuses were identified correctly and terminated in each case. Three patients spontaneously aborted, and one women electively terminated her pregnancy 2 weeks after the procedure. The mean gestational age at delivery of the 96 patients who delivered surviving infants was 36.8 weeks, and 85.4% delivered at 32 weeks or later. Three women developed laboratory evidence of a coagulopathy, but there were no cases of clinically evident disseminated intravascular coagulation. CONCLUSION: This procedure, performed at a single institution by a small number of operators using a common protocol, accomplished its objective in all cases, was accompanied by a low spontaneous loss rate, and resulted in the birth of healthy infants at or near term in the vast majority of cases. This series suggests that selective termination is a reasonable option to consider when one abnormal fetus is found in a multifetal pregnancy with dichorionic placentation.

Abortion, Eugenic↗
PubMed1996

Preterm delivery after selective termination in twin pregnancies.

OBJECTIVE: To determine the effect of selective termination of an abnormal twin on the rate of preterm delivery. METHODS: The study group consisted of 69 patients with twin pregnancies who underwent selective termination between 1987-1994. The comparison groups consisted of singleton (n = 42,362) and twin pregnancies (n = 825) delivered at our institution during the same period. The data were analyzed by Chi2 and Fisher exact test, as appropriate. P < .05 was considered significant. Adjusted odds ratios(OR) and 95% confidence intervals (CI) were calculated by multiple logistic regression. RESULTS: Terminating the presenting twin was associated with a significantly higher risk of delivery before 37 weeks (adjusted OR 4.1, 95% CI 1.4-12.3) and low birth weight (adjusted OR 3.8, 95% CI 1.3-11.4) compared with terminating the nonpresenting twin. When the termination was performed at or after 20 weeks' gestation, only the risk of preterm premature rupture of the membranes or preterm labor was significantly increased (adjusted OR 3.7, 95% CI 1.2-11.5). Selective termination patients had a lower rate of preterm delivery than twin pregnancies (40 versus 58%, P < .005) but higher than singleton pregnancies (40 versus 10%,P < .001). CONCLUSION: Selective termination of the presenting twin at 20 weeks or later was associated with a worse perinatal outcome than terminating the nonpresenting twin or performing the procedure before 20 weeks.

Adult↗
PubMed1996

Pregnancy outcome at age 40 and older.

OBJECTIVE: To examine pregnancy outcome among women age 40 years and older. METHODS: A retrospective cohort study, including 1404 pregnant women at least 40 years of age and 6978 controls age 20-29 years, was conducted. The two groups were stratified, according to parity, to facilitate separate analysis. Associations between maternal age and pregnancy outcomes were assessed with the contingency chi 2 or two-tailed Fisher exact test. Multiple logistic regression was used to evaluate these associations and allowed for calculation of adjusted odds ratios (OR). RESULTS: Older gravidas were more likely to develop gestational diabetes (nulliparas: OR 2.7, 95% confidence interval [CI] 1.9-3.7; multiparas: OR 3.8, 95% CI 2.7-5.4), preeclampsia (nulliparas: OR 1.8, 95% CI 1.3-2.6; multiparas: OR 1.9, 95% CI 1.2-2.9), and placenta previa (nulliparas: OR 13.0, 95% CI 4.8-35.0; multiparas: OR 6.4, 95% CI 2.6-15.6). Older women were also at increased risk for cesarean delivery (nulliparas: OR 3.1, 95% CI 2.6-3.7; multiparas: OR 3.3, 95% CI 2.6-4.1), operative vaginal delivery (nulliparas: OR 2.4, 95% CI 1.9-2.9; multiparas: OR 1.5, 95% CI 1.2-1.9), and induction of labor (nulliparas: OR 1.5, 95% CI 1.2-1.8; multiparas: OR 1.4, 95% CI 1.1-1.7). Older nulliparas had an increased incidence of abnormal labor patterns (OR 1.4, 95% CI 1.2-1.7), neonatal intensive care unit admissions (OR 1.6, 95% CI 1.2-2.2), and low 1-minute Apgar scores (OR 2.3, 95% CI 1.1-4.9). Older multiparas were more likely to experience fetal distress (OR 2.0, 95% CI 1.4-2.8), antepartum vaginal bleeding (OR 1.8, 95% CI 1.1-3.1), and preterm premature rupture of membranes (OR 1.7, 95% CI 1.1-2.9). CONCLUSION: Although maternal morbidity was increased in the older gravidas, the overall neonatal outcome did not appear to be affected.

Adult↗
PubMed1996

Antenatal management of alloimmune thrombocytopenia with intravenous gamma-globulin: a randomized trial of the addition of low-dose steroid to intravenous gamma-globulin.

OBJECTIVES: Our purposes were to investigate maternal infusions of intravenous gamma-globulin, to prevent intracranial hemorrhage, and to determine whether 1.5 mg dexamethasone and 60 mg prednisone per day add to the effect of intravenous gamma-globulin. STUDY DESIGN: Fifty-four women with alloimmune thrombocytopenia and thrombocytopenic fetuses were randomized to intravenous gamma-globulin 1 gm/kg per week with or without dexamethasone. Nonresponders after 4 to 6 weeks received continued intravenous gamma-globulin plus 60 mg of prednisone per day ("salvage"). RESULTS: Dexamethasone did not add to the effect of intravenous gamma-globulin. Overall, there was a mean platelet increase from the first to the second fetal blood sampling of 36,000/microliters (n = 47) and from the first fetal blood sampling to birth of 69,000/microliters (n = 54). A total of 62% to 85% of fetuses responded. There were no intracranial hemorrhages. "Salvage" increased the platelet count in 5 of 10 nonresponders to intravenous gamma-globulin. CONCLUSION: Intravenous gamma-globulin treatment is appropriate for thrombocytopenic fetuses with alloimmune thrombocytopenia before use of weekly in utero platelet transfusions, even in severe thrombocytopenia.

Cerebral Hemorrhage↗
PubMed1996

The current status of multifetal pregnancy reduction.

The number of women conceiving three or more fetuses has increased dramatically as a result of successful infertility therapy with ovulation-inducing agents and assisted reproductive technology. Higher-order multiple gestations have an increased risk of premature delivery and its attendant sequelae of increased neonatal mortality or irreversible morbidity. Multifetal pregnancy reduction is a procedure designed to decrease the increased propensity to deliver very prematurely in these patients by reducing the number of live fetuses they are carrying. The procedure has proved to be both safe and effective, and pregnancies reduced to twins proceed as if that were the number of fetuses originally conceived. Nevertheless, this invasive procedure does have the potential to result in loss of the entire pregnancy and causes considerable emotional distress for some couples who view it as their "least bad" alternative. The medical benefits of performing multifetal pregnancy reduction in women with four or more fetuses seem fairly well established, but this is less true for triplets. Serious attention should be paid to reducing the number of higher-order multiple pregnancies resulting from infertility therapy. In the meantime, when three or more fetuses have been conceived, multifetal pregnancy reduction offers a reasonable option to patients whose only choices in the past were either to accept the risk of delivering extremely prematurely or to terminate the entire pregnancy.

Ethics↗
PubMed1996

The clinical outcome of preterm premature rupture of membranes in twin versus singleton pregnancies.

The purpose of this study was to determine the clinical outcome of preterm premature rupture of the membranes (PPROM) in twin versus singleton pregnancies at less than or equal to 36 weeks' gestation. A retrospective cohort study was conducted in 116 twin pregnancies with PPROM at less than or equal to 36 weeks' gestational age and 116 matched singleton pregnancies. The two groups were analyzed for differences in maternal demographics and perinatal and neonatal outcome. Perinatal and neonatal outcomes were similar in the two groups. The median latency period, however, was significantly decreased in the twin group (11.4 hours, Inter Quartile Range: 6.3-26.4) versus the singleton group (19.5 hours, Inter Quartile Range: 10.2-49.3, p < 0.05). The latency period in each group was notably longer when PPROM occurred at less than 30 weeks' gestation, but was still shorter in the twin pregnancies (27.6 hours, Inter Quartile Range: 20-307 versus 75.1 hours, Inter Quartile Range: 15-189, p < 0.05). Twin pregnancies with PPROM at less than or equal to 36 weeks' gestational age have a decreased latency period when compared to matched singletons. The perinatal and neonatal outcomes, however, are similar.

Adult↗
PubMed1995

Fetal and maternal plasma endothelin levels during the second half of pregnancy.

OBJECTIVE: Our objective was to evaluate maternal and fetal endothelin concentrations in uncomplicated pregnancies across the second half of pregnancy. STUDY DESIGN: Paired (n = 64) maternal venous and fetal umbilical venous or arterial samples were obtained during cordocentesis. In addition, eight neonatal umbilical vein samples were obtained immediately after delivery. Samples were assessed for hematocrit and pH, and concentrations of endothelin were measured by sensitive enzyme immunoassay. RESULTS: No significant correlation was found between either fetal or maternal endothelin levels and gestational age (r = 0.01, p = 0.91 and r = 0.07, p = 0.5, respectively). Fetal plasma endothelin concentrations were significantly lower than neonatal umbilical vein endothelin levels [median 2.5 pg/ml (range 0.9 to 5.73) vs 15.77 pg/ml (8.12 to 19.58), respectively; p < 0.0001] but significantly higher than maternal levels [1.3 pg/ml (0.8 to 3.25); p < 0.0001]. In addition, endothelin values were higher in the umbilical artery than in the umbilical vein, but this difference failed to achieve statistical significance [2.89 pg/ml (1.61 to 5.73) vs 2.29 pg/ml (0.9 to 5.70), respectively; p = 0.06]. No correlation was noted between fetal and maternal endothelin levels (r = 0.12, p = 0.36). CONCLUSION: Fetal endothelin levels were significantly higher than maternal levels, but neither correlated with gestational age across the second half of pregnancy.

Endothelins↗
PubMed1995

Alloimmune thrombocytopenia: fetal and neonatal losses related to cordocentesis.

OBJECTIVE: This report describes the increased risks of cordocentesis in fetuses affected with alloimmune thrombocytopenia. STUDY DESIGN: As part of a multicenter treatment study clinical and laboratory data from five pregnancies with alloimmune thrombocytopenia in which there was a fetal or neonatal loss associated with cordocentesis were reviewed. The fetal or neonatal deaths were all thought to be a result of exsanguination. These fetuses were compared with a group of 44 affected fetuses who underwent the same procedure but who survived. The data were analyzed by the Wilcoxon rank-sum test and the two-tailed Fisher's exact test. A p value < 0.05 was considered significant. RESULTS: The mean platelet count at cordocentesis was significantly lower in the cases than in the controls (5.8 vs 32.8 x 10(9)/L, p = 0.005). The incidence of antenatal intracranial hemorrhage in the untreated sibling of the prior affected pregnancy was significantly greater in the cases than in the controls (two of five vs one of 42, p = 0.02). CONCLUSION: Fetuses affected with alloimmune thrombocytopenia are at increased risk for fatal exsanguination associated with cordocentesis.

Antigens, Human Platelet↗
PubMed1995

First-trimester multifetal pregnancy reduction: acute and persistent psychologic reactions.

OBJECTIVE: Our purpose was to determine acute and persistent psychologic impacts of multifetal pregnancy reductions and patients' ability to cope with fetal loss while simultaneously bonding to surviving infants. STUDY DESIGN: The first 100 women to undergo a multifetal reduction were invited to participate in a retrospective telephone study assessing their emotional reactions and attitudes toward multifetal reduction. The semistructured interview elicited demographic and obstetric data and contained scales used in previous studies of reproductive loss, which assessed repetitive thoughts about reduced fetuses, catastrophic fears, and lingering depressive feelings. RESULTS: More than 65% of the sample recalled acute feelings of emotional pain, stress, and fear during the reduction procedure. Mourning for the lost fetuses was reported by 70% of women, but most grieved for only 1 month. Thoughts about reduced fetuses occurred moderately frequently after the reduction but rarely at follow-up. Persistent depressive symptoms were mild, although moderately severe levels of sadness and guilt continued for many. Nonetheless, 93% would make the same decision again. Emotional reactions of patients who miscarried differed little. The small subsample who continued to be most affected were younger (p < 0.02), were more religious (p < 0.003), and had viewed the multifetal pregnancy on ultrasonography more often (p < 0.009). CONCLUSIONS: Multifetal reductions, although highly stressful psychologically, are well tolerated. Sadness and guilt may persist, especially for an identifiable subgroup. Normal maternal bonding and achievement of parenthood goals facilitate grief resolution. The large majority were reconciled to the termination of some fetuses to perserve the lives of a remaining few.

Abortion, Spontaneous↗
PubMed1995

The effect of multifetal pregnancy reduction on serum relaxin.

OBJECTIVE: To determine the effect of multifetal pregnancy reduction on circulating relaxin levels. METHODS: Patients with multifetal pregnancies had relaxin levels determined on the day of multifetal pregnancy reduction, after the procedure, and late in pregnancy. RESULTS: Forty-eight women (26 presenting with three fetuses and 22 with four or more) were studied. All pregnancies followed some form of ovulation induction. All pregnancies (except for one, which was reduced to a singleton) were reduced to twins. Pre-procedure, post-procedure and late-pregnancy relaxin levels were significantly higher in the in vitro fertilization (IVF)-gamete intrafallopian transfer (GIFT) group compared with the human menopausal gonadotropin (hMG)-alone group (P < .05). The initial number of fetuses had no significant effect on relaxin levels. Although post-procedure relaxin levels were significantly lower than pre-procedure levels (P = .002), relaxin levels continued to decrease throughout pregnancy, as evidenced by even lower levels later on (P = .0001). CONCLUSIONS: Serum relaxin levels were significantly higher in the IVF-GIFT group than in the hMG-alone group, which probably reflects more aggressive ovulation induction in the former. Because relaxin levels continued to decrease throughout pregnancy, the difference observed between pre- and post-procedure levels are not considered to be due to the procedure itself.

Female↗
PubMed1995

Multifetal pregnancy reduction and selective termination.

The incidence of multifetal pregnancies has increased dramatically since the advent of assisted reproductive technologies. Preterm delivery accounts for most of the mortality associated with multifetal pregnancies. Multifetal pregnancy reduction is a safe and effective procedure designed to decrease the adverse outcomes associated with very preterm deliveries. The increased incidence of multifetal pregnancies combined with reliable techniques for prenatal diagnosis of genetic and structural fetal anomalies have led to an increase in the diagnosis of abnormal fetal conditions in parents carrying multiple gestations. The development of the procedure of selective termination has provided prospective couples the option of selective termination of the abnormal fetus and continuation of the pregnancy.

Chorion↗