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Biomedical subjects

S J Kilpatrick

Publications and source records attributed to S J Kilpatrick.

At least 37 records · Page 2Linked to original sources
PubMed1996

Is there a benefit to episiotomy at spontaneous vaginal delivery? A natural experiment.

OBJECTIVE: Our purpose was to examine the association between maternal vaginal and perineal morbidity and episiotomy performed at spontaneous vaginal delivery. STUDY DESIGN: We obtained data from 17,483 consecutive spontaneous vaginal deliveries and compared the yearly rates of episiotomy, lacerations, and potential confounders with linear regression and stratified analyses. RESULTS: Between 1976 and 1994 the use of episiotomy fell significantly (86.8% to 10.4%, R2 = 0.92, p = 0.0001). This change was associated with a fall in the rate of third- and fourth-degree lacerations (9.0% to 4.2%, R2 = 0.59, p = 0.0001) and a rise in the rate of intact perinea (10.3% to 26.5%, R2 = 0.68, p = 0.0001) and vaginal lacerations (5.4% to 19.3%, R2 = 0.77, p = 0.0001). These associations held in separate analyses stratified by parity and birth weight, except for the subgroup of nulliparous women with macrosomic infants. CONCLUSION: At our institution a large reduction in the use of episiotomy in spontaneous vaginal deliveries was associated with a significant reduction in perineal trauma in all groups of women except for nulliparous women with macrosomic infants.

Episiotomy↗
PubMed1995

Head entrapment and neonatal outcome by mode of delivery in breech deliveries from twenty-four to twenty-seven weeks of gestation.

OBJECTIVES: Our purpose was to determine whether there are differences in the incidence of head entrapment and adverse neonatal outcome by mode of delivery in breech deliveries from 24 to 27 weeks of gestation. STUDY DESIGN: Charts of 132 viable consecutive singleton breech deliveries from 24 to 27 weeks' gestation were reviewed. Statistical methods used included chi 2, logistic regression, and analysis of variance. RESULTS: Head entrapment occurred in four of 43 (9.3%) vaginally delivered neonates and five of 89 (5.6%) neonates delivered by cesarean section (p = 0.17). The only identifiable risk factor for head entrapment was the birth weight category 1000 to 1249 gm (odds ratio 6.4, 95% confidence interval 1.6 to 26.1). There were no statistically significant associations between head entrapment and adverse neonatal outcomes. CONCLUSIONS: There did not appear to be a difference in the incidence of head entrapment by mode of delivery for breech infants at 24 to 27 weeks' gestation, nor did there appear to be a difference in adverse neonatal outcomes after entrapment. However, this latter conclusion has limited power because of the small number of head entrapment cases.

Analysis of Variance↗
PubMed1995

Management of term breech presentation: a protocol of external cephalic version and selective trial of labor.

OBJECTIVE: The results of a program of external version and selective trial of labor for term breech presentation are reviewed. This is a follow-up to our 1987 report describing management of singleton, term breech presentations and expands our 16-year experience to 1180 cases. STUDY DESIGN: All term breech presentations cared for in 1985 through 1992 are reviewed and outcome contrasted with those predicted in our earlier report. During these 8 years a trial of external version was offered if a breech presentation was identified after 36 completed weeks' gestation and before active labor. The criteria for allowing a trial of labor are detailed. RESULTS: Four hundred sixty-four breech presentations were identified for review. Three hundred eighty-two (82%) were diagnosed before active labor. Of these, 344 (90%) underwent an attempt at external version, of which 174 (51%) were successful. The 290 breech presentations where version either was not attempted or was unsuccessful were stratified into three groups: cesarean section without labor (147), trial of labor with cesarean section (90), and trial of labor with vaginal delivery (53). The 174 cases where version was successful were stratified into two additional groups on the basis of the eventual route of delivery. Careful review of maternal and fetal variables indicates that a trial of labor in selected patients resulted in vaginal delivery in only 37% but was achieved without an increase in fetal or maternal mortality or morbidity. Surprisingly, 54 of the 174 cases where version was successful were ultimately delivered by cesarean section. This 31% rate of cesarean delivery is significantly higher than the 15% rate observed for all cases of term, singleton vertex presentation. A higher prevalence of cases complicated by failed progress in labor and failed induction contributed to the excess. CONCLUSION: External version is successful in 51% of cases of term breech presentation. With careful selection, cases where version has failed can be allowed to labor and be delivered vaginally. The incidence of cesarean section (31%) for those cases where version had been successful was surprisingly high, largely because of an increase in labor abnormalities and failed labor inductions.

Breech Presentation↗
PubMed1995

Thalassemia in pregnancy.

The responsibility of the obstetrician is to identify during the first trimester women who are carriers for thalassemia. When she has been identified, the father of the baby should be screened and if he is also a carrier, the couple should be offered prenatal diagnosis. In the majority of cases, prenatal diagnosis can identify the homozygous fetus, thus allowing the family a choice in continuing the pregnancy.

Decision Trees↗
PubMed1995

Repeat external cephalic version. Is it worth the effort?

OBJECTIVE: To determine whether repeat external cephalic version subsequent to initial failed version resulted in a decreased cesarean section rate and hospital cost. STUDY DESIGN: All women who underwent repeat external cephalic version after initial failed version were identified and their charts reviewed. Data collected included success of version, mode of delivery, presentation in labor, hospital days, hospital cost, parity and birth weight. RESULTS: Thirty-six women had a repeat external cephalic version attempt from 1987 to 1992. Six, or 17%, of these were successful. All the successful versions were vertex in labor and had a vaginal delivery. Only 6, or 21%, of the failed versions had a vaginal delivery (P < or = .0002). The mean hospital stay was 2.0 and 3.0 days in the successful and failed groups, respectively. The mean hospital cost, expressed in 1992 dollars, was significantly greater in the failed group: $8,042 vs. $5,059 (P < or = .03). CONCLUSION: Repeat version was associated with a decrease in the cesarean section rate and hospital cost and should be considered in the management of nonvertex term presentations.

Cesarean Section↗
PubMed1994

Puerperal presentation of a living abdominal pregnancy.

BACKGROUND: Abdominal and heterotopic pregnancies appear to be increasing in incidence. CASE: We report a case of puerperal presentation of a living heterotopic pregnancy in an African woman. The patient presented 6 days postpartum with fever and abdominal pain. The correct diagnosis of heterotopic pregnancy was not considered, and for 9 days she was treated for presumed puerperal sepsis. It was only upon abdominal x-ray that the diagnosis was made. The patient underwent laparotomy with delivery of a living male neonate weighing 2000 g. He subsequently died of respiratory failure on day 3 of life. CONCLUSION: Although still rare, the increasing incidence of abdominal pregnancies in both developed and developing countries mandates awareness of this diagnosis, particularly in pregnant or postpartum women presenting with abdominal pain.

Female↗
PubMed1993

Characterization and ontogeny of endothelin receptors in human placenta.

Because of the potent mitogenic and vasoactive properties of endothelin-1 (ET-1) and the presence of its receptor in third trimester placenta, we postulated that ET-1 might be involved in human placental growth and vascularization during development. As an initial approach to test this hypothesis, placental ET receptors were characterized and quantified in each trimester of pregnancy. Membrane-rich particulates were prepared from first-, second-, and third-trimester villous human placenta obtained immediately after pregnancy termination or delivery. ET receptors were characterized by radioligand saturation analysis, ligand competition, and reverse transcription-polymerase chain reaction (RT-PCR) to determine the concentration, affinity, and specificity of ET binding sites, and to document the presence of specific ET-receptor subtype mRNA transcripts in placentas from each trimester. Kinetic determinations of 125I-labeled ET-1 binding yielded a Kd = 61 pM, consistent with the equilibrium determinations of 34 +/- 6 pM (n = 11). The concentration of ET receptors decreased significantly from 682 +/- 94 fmol/mg protein (n = 4) in the first trimester to 266 +/- 89 fmol/mg protein (n = 4) in the third trimester. Competition studies with unlabeled ET-1 indicated a single class of binding sites with a Ki = 49 +/- 5 pM (n = 9), whereas competition with ET-3 demonstrated binding sites with two affinities. The predominant sites had a Ki = 84 +/- 14 pM, similar to that for ET-1. The RT-PCR data confirmed that both ETA and ETB receptors mRNA transcripts are expressed in human placenta.(ABSTRACT TRUNCATED AT 250 WORDS)

Base Sequence↗
PubMed1993

Maternal hydration increases amniotic fluid index in women with normal amniotic fluid.

OBJECTIVE: To test the hypothesis that maternal oral hydration would increase the amniotic fluid (AF) index in pregnancies with normal AF. METHODS: Forty women with a normal AF index (7.0-24.0 cm) were randomized to either the control or hydration group. Women in the hydration group drank 2 L of water and returned for the post-treatment AF index in 4-6 hours, whereas women in the control group drank only 100 mL of water during the same time period. The investigator performing the AF index was blinded to the subject's group. The pre- and post-treatment AF indexes and maternal urine specific gravities were compared between the groups. RESULTS: The mean AF index in the hydration group increased significantly by 3.0 +/- 2.4 cm (P < or = .0001) whereas it declined significantly by 1.5 +/- 2.7 cm in the control group (P < or = .02). The maternal urine specific gravities also changed significantly in the expected direction, with those in the hydration group decreasing and those in the control group increasing (P < or = .0001). There was a regression coefficient of -0.6 (P < or = .0001) between the change in urine specific gravity and the change in AF index. The mean time between the pre- and post-treatment AF indexes was not different between the groups. CONCLUSIONS: Maternal oral hydration increased the AF index by approximately 16%, whereas fluid restriction decreased the AF index by 8% in women with normal AF. These findings support previous data that maternal hydration increased the AF index by 31% in women with decreased AF and suggest that maternal fluid volume or osmolality may have a role in maintaining the AF volume.

Amniotic Fluid↗
PubMed1993

Maternal and neonatal outcomes after prolonged latent phase.

OBJECTIVE: To examine the association of prolonged latent phase with cesarean risk, subsequent labor abnormalities, and other adverse maternal and neonatal outcomes. METHODS: Patients with prolonged latent phase were compared to patients with normal latent phase. We studied 10,979 singleton vertex deliveries of at least 37 weeks' gestation. Patients with risk factors for adverse outcome known before labor were excluded from the analysis. RESULTS: Seven hundred thirteen patients (6.5%) had prolonged latent phase. Subsequent labor abnormalities were more frequent among patients with prolonged latent phase (42.9 versus 16.3%; P < .05), as was cesarean delivery (24.4 versus 6.9%; P < .05). Need for neonatal resuscitation, thick meconium, maternal fever, low 5-minute Apgar score, intensive care nursery admission, lengthened maternal and newborn hospital stays, and higher estimated blood loss were all significantly more frequent in patients with prolonged latent phase after controlling for mode of delivery. Multivariate linear logistic regression models were created to determine whether these risks actually reflected the prolonged latent phase. The first model controlled for other labor abnormalities, parity, epidural use, and macrosomia and showed prolonged latent phase to be associated with an increased risk for cesarean delivery (relative risk [RR] 1.65, 95% confidence interval [CI] 1.32-2.06). The second model controlled for other labor abnormalities, postdates, thick meconium, mode of delivery, and prolonged rupture of membranes and showed that both the need for newborn resuscitation and 5-minute Apgar scores less than 7 were significantly more frequent in association with a prolonged latent phase (RR 1.37 and 1.97, 95% CI 1.15-1.64 and 1.23-3.16, respectively). CONCLUSIONS: Prolonged latent phase is independently associated with an increased incidence of subsequent labor abnormalities, need for cesarean delivery, depressed Apgar scores, and need for newborn resuscitation. The presence of prolonged latent phase should alert the clinician to an increased risk for further problems during the labor.

Adult↗
PubMed1993

The role of velamentous cord insertion in the etiology of twin-twin transfusion syndrome.

OBJECTIVE: To evaluate the prevalence of velamentous cord insertion in twin-twin transfusion using the hypothesis that such insertions may contribute to the etiology of the condition. METHODS: All cases of placentas referred for pathologic evaluation at the University of California at San Francisco from 1984-1992 were reviewed for the citation of diamniotic-monochorionic placentation, including the presence of velamentous cord insertions. Maternal and infant records were studied for findings consistent with twin-twin transfusion syndrome. RESULTS: Thirty-eight cases of monochorionic-diamniotic twins were identified, 11 of which showed twin-twin transfusion syndrome. The prevalence of velamentous cord insertion in the transfusion syndrome subset was 63.6%, compared with 18.5% in those without (significant difference at P < .01). Twin-twin transfusion syndrome pregnancies with velamentous insertions were delivered at a significantly earlier gestational age; they also had fewer surviving infants and were more likely to have been treated prenatally than transfusion syndrome pregnancies without velamentous insertion, although these latter two findings were not significantly different. CONCLUSIONS: Velamentous cord insertions are more common in twin-twin transfusion syndrome pregnancies and may contribute to the development of profound disparity in fluid volume because the membranously inserted cord can be easily compressed, reducing blood flow to one twin. Large-volume amniocentesis may reduce this compressive force on the cord insertion, thus explaining the success of this mode of intervention.

Female↗
PubMed1992

Obstetric patients requiring critical care. A five-year review.

Only one study has examined the clinical issues presented by critically ill obstetric patients with respect to medical indications for intensive care unit (ICU) admission and fetal and maternal morbidity and mortality. Therefore, a review of all obstetric patients admitted to a medical-surgical ICU in a large tertiary referral center over a five-year period was conducted. Obstetric, ICU-related, and diagnostic data were recorded for each patient. The diagnosis of the disease responsible for the patient's critical illness was categorized as obstetric or nonobstetric. The diagnosis that prompted ICU admission was determined for each patient and was categorized as respiratory failure, hemodynamic instability, or neurologic dysfunction. There were 32 obstetric admissions representing 0.4 percent of all deliveries during this time period. There was a predominance of postpartum admissions and obstetric diagnoses responsible for the patient's critical illness. Preeclampsia was the single most common diagnosis representing 22 percent of all patients. Hemodynamic instability was never the cause of antepartum ICU admission in patients with a viable fetus. In contrast, hemodynamic instability accounted for 52 percent of postpartum ICU admissions. Of the eight women admitted with viable pregnancies to the ICU, seven were delivered during the ICU stay and all fetuses survived. There was a high incidence of acute lung injury (25 percent) that was associated with nonpulmonary or pulmonary infection in all eight cases. However, the mortality was only 25 percent.

Adolescent↗
PubMed1991

Maternal hydration increases amniotic fluid index.

Although adequate amniotic fluid (AF) volume is considered an important aspect of fetal well-being, the etiology of decreased AF volume is not well understood. A randomized blinded trial was designed to examine our hypothesis that maternal hydration would increase the AF index in women with low AF indexes. Women seen in our testing centers were randomized into control or hydration groups. The control group was instructed to drink their normal amount of fluid; the hydration group was instructed to drink 2 L of water, in addition to their usual amount of fluid, 2-4 hours before the post-treatment AF index. The women returned for the post-treatment AF index the same or following day. The mean post-treatment AF index was significantly greater in the hydration group (6.3 versus 5.1; P less than .01), as was the mean change in AF index (post-treatment AF index--pre-treatment AF index: 1.5 versus 0.31; P less than .01). These findings suggest that maternal oral hydration increases AF volume in women with decreased fluid levels.

Amniotic Fluid↗
PubMed1989

Characteristics of normal labor.

The length of the first and second stages of labor was evaluated in 6991 women with singleton gestations at 37-42 weeks with vertex presentation. All patients delivered spontaneously without the use of oxytocin. Four study groups were created based on parity and whether conduction anesthesia was used. The mean lengths and limits (95th percentile) for the first stage of labor, respectively, were as follows: nulliparas: no anesthesia--8.1 and 16.6 hours, conduction anesthesia--10.2 and 19.0 hours; multiparas: no anesthesia--5.7 and 12.5 hours, conduction anesthesia--7.4 and 14.9 hours. Similar data for the second stage were as follows: nulliparas: no anesthesia--54 and 132 minutes, conduction anesthesia--79 and 185 minutes; multiparas: no anesthesia--19 and 61 minutes, conduction anesthesia--45 and 131 minutes. These statistical parameters are useful for defining when a labor becomes abnormal and intervention should be considered.

Anesthesia, Conduction↗
PubMed1987

Misclassification of environmental tobacco smoke exposure: its potential influence on studies of environmental tobacco smoke and lung cancer.

The effects of selection, confounding, misclassification and bias must be eliminated from case-control studies of 'passive smoking' and lung cancer before a meaningful interpretation can be made. Misclassification includes the misclassification of the subject's non-smoking status, of the disease status or of the spouse's smoking habits. This paper shows that inflation of the amount smoked by the husbands of female lung cancer cases may have accounted for the apparent 'dose-response' relationships in 3 widely referenced case-control studies.

Environmental Exposure↗
PubMed1986

Surgical oncology in university departments of surgery in the United States.

Data on surgical oncology and multidisciplinary cancer program activity were obtained from 124 of 126 university surgery departments in the United States. Most of these institutions have American College of Surgeons-approved cancer programs (84%) as well as divisions of medical (95%), radiation (94%), pediatric (76%), and gynecologic (79%) oncology. Only 47 departments (38%) have formal divisions of surgical oncology. There are no major staffing or activity differences in surgical departments with or without such divisions, but multidisciplinary cancer program activity is greater in those institutions with a surgical oncology focus. Peer-reviewed cancer research grants are more frequent in departments of surgery with a surgical oncology division (68% vs 47%). The activities of the existing 47 divisions of surgical oncology are mainly operative, with breast cancer, melanoma, and soft-tissue sarcomas being the major clinical responsibilities. Chemotherapy is also frequent (81%). Cancer education for undergraduate and postgraduate surgical trainees is a major responsibility of most divisions, but only a small proportion (28%) have postresidency surgical oncology training programs. In contrast to the growth of some oncologic specialties, the establishment of surgical oncology within university departments has been slow, and the manpower needs appear modest.

Academic Medical Centers↗