Group B streptococcal infections: an obstetrical viewpoint.
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Carrier State↗
Biomedical subjects
S L Dooley
Publications and source records attributed to S L Dooley.
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↗
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↗
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↗
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↗
The influence of demographic and phenotypic heterogeneity on the prevalence of gestational diabetes mellitus.
In order to explore the influence of demographic and phenotypic characteristics on the prevalence of gestational diabetes mellitus (GDM), data were analyzed from 3744 consecutive patients who underwent universal screening with a 50 g glucose load at 24-28 weeks gestational age. Those with a 1-h plasma glucose greater than or equal to 130 mg/dl underwent a 3-h, 100-g oral glucose tolerance test following dietary preparation. The population was 39.1% White, 37.7% Black, 19.8% Hispanic and 3.4% Oriental/other. The overall prevalence of GDM was 3.5 cases/100. Significant inter-racial differences in maternal age and prepregnant percent ideal body weight (PIBW) were observed, with White patients being older and leaner than Blacks and Hispanics. By multiple logistic regression, Black and Hispanic race, maternal age and PIBW were found to have significant independent effects on the prevalence of GDM. Controlling for age and PIBW, the adjusted relative risk of GDM was significantly higher in Black (1.81, 95% CI 1.13-2.89) and Hispanic (2.45, 95% CI 1.48-4.04) patients compared to White. We conclude that demographic and phenotypic characteristics of populations need to be taken into consideration in future studies of prevalence of GDM, perinatal implications and therapeutic approaches to the disease.
Adult↗
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↗
Northwestern University Twin Study X: Outcome of twin gestations complicated by gestational diabetes mellitus.
Existing data concerning the effect of gestational diabetes on perinatal outcome in twin pregnancies is scant. We hypothesized that altered carbohydrate metabolism would worsen perinatal outcome in twin gestation in a manner similar to singleton gestation. Thirteen twin pregnancies complicated by gestational diabetes mellitus were matched by gestational age at delivery to 13 twin pregnancies unaffected by gestational diabetes. Comparing infants of diabetic mothers to infants of control mothers, there was a trend of greater likelihood of respiratory distress syndrome, hyperbilirubinemia, and prolonged neonatal intensive care nursery admissions. Our experience suggests that altered carbohydrate metabolism in multiple gestations increases the potential for neonatal morbidity.
Adult↗
Gestational diabetes mellitus. Influence of race on disease prevalence and perinatal outcome in a U.S. population.
We explore whether racial differences in a United States population influence disease prevalence and perinatal outcome in gestational diabetes mellitus (GDM). The data presented are based on 3744 consecutive patients who underwent universal screening at 24-28 wk gestation; those with a 1-h plasma glucose greater than or equal to 7.2 mM underwent a 100-g 3-h oral glucose tolerance test (OGTT). The overall prevalence of GDM was 3.5 cases/100 with the standard O'Sullivan-Mahan diagnostic criteria derived for plasma, whereas use of the Carpenter-Coustan modification of the O'Sullivan-Mahan criteria yielded a prevalence of 5.5. The population was 39.1% white, 37.7% black, 19.8% Hispanic, and 3.4% Oriental/other. For those patients with a nondiagnostic test, mean plasma glucose at each time point of the OGTT was similar for all racial groups. Because of demographic and phenotypic heterogeneity between different racial groups, the influence of these different variables on the prevalence of GDM was tested by multiple logistic regression. Black and Hispanic race, maternal age, and percentage ideal body weight were found to have significant independent effects on the prevalence of GDM (P less than 0.05, 0.001, 0.001, and 0.001, respectively). The adjusted relative risk of GDM was significantly higher in black (1.81, 95% confidence interval [CI] 1.13-2.89, P less than 0.05) and Hispanic (2.45, 95% CI 1.48-4.04, P less than 0.001) patients compared with whites. The influence of race on infant birth weight was examined in the 92 patients with GDM controlled with diet.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
The role of ultrasonography in the management of diabetic pregnancy.
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Congenital Abnormalities↗
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↗
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↗
Awaiting cervical change for the diagnosis of preterm labor does not compromise the efficacy of ritodrine tocolysis.
We retrospectively studied 209 patients treated with ritodrine hydrochloride to determine whether change in cervical effacement or dilatation during a period of observation before therapy would result in decreased efficacy of ritodrine, as measured by delivery delays of 48 hours, 1 week, or until greater than or equal to 37 weeks' gestation; neonatal intensive care unit admission; and neonatal respiratory distress syndrome. Patients who were greater than or equal to 3 cm dilated on admission were at high risk of therapy failure by all outcome measures compared with patients less than 3 cm dilated. For patients less than 3 cm dilated on admission, there was no difference in outcome when patients treated for contractions only were compared with those treated after change in effacement or dilatation had been documented. We conclude that awaiting change in cervical effacement or dilatation to be more certain of the diagnosis of preterm labor will not compromise the efficacy of ritodrine tocolysis.
Adult↗
Infants of diabetic mothers with accelerated fetal growth by ultrasonography: are they all alike?
We studied longitudinal ultrasonographic growth patterns (abdominal circumference, biparietal diameter) initiated early in gestation in 52 pregnancies complicated by pregestational diabetes mellitus and 19 controls. Three predominant patterns of growth were ascertained including a heretofore unrecognized pattern characterized by accelerated abdominal circumference growth (greater than 90th percentile) before 24 weeks' gestational age. Maternal and neonatal anthropometric and metabolic parameters were contrasted for the three patterns. The findings suggest that in some cases of diabetic macrosomia that can be recognized before 24 weeks' gestation, augmented growth may be influenced by factors other than fetal hyperinsulinism.
Amniotic Fluid↗
Amniotic fluid prolactin in the third trimester of pregnancies complicated by gestational or pregestational diabetes mellitus.
Amniotic fluid concentrations of immunoreactive prolactin were measured during the third trimester in 184 diabetic gravidas and correlated with concurrent levels of prolactin in maternal plasma. Prolactin measurements concorded with previously published estimates in normal gravid women and averaged 825 +/- 32 ng/mL (mean +/- SEM) in amniotic fluid and 168 +/- 6.5 ng/mL in simultaneously sampled plasma. Cross-sectional and longitudinal analyses indicated that the prolactin levels in amniotic fluid of pregnant diabetics declined significantly between weeks 32 and 40 of gestation, whereas plasma levels did not change consistently during the same interval. Mean values for amniotic fluid prolactin did not correlate with simultaneous prolactin concentrations in plasma, nor with maternal age, clinical estimates of polyhydramnios, amniotic fluid creatinine content, or lecithin/sphingomyelin (L/S) ratios or subsequent birth weight of the offspring. Clear-cut correlations with overall maternal glucose regulation could not be demonstrated. However, subtle effects may be operative since amniotic fluid prolactin displayed weak but significant correlations with concurrent levels of maternal plasma glucose, and mean values for hemoglobin A1c (HbA1c) but not with mean values for fasting plasma glucose (FPG). Amniotic fluid prolactin concentrations were significantly greater in patients with pregestational diabetes (White classes C, D, and F) than in women with gestational diabetes mellitus (GDM) (our classes A1, A2, and B1). The differences could not be accounted for by differences in metabolic regulation, maternal age, or weights of these two populations.(ABSTRACT TRUNCATED AT 250 WORDS)
Amniotic Fluid↗
Effects of intravascular, intrauterine transfusion on prenatal and postnatal hemolysis and erythropoiesis in severe fetal isoimmunization.
In an investigation of the effects of intrauterine, intravascular transfusions (IUT) on fetal and neonatal hemolysis and erythropoiesis, 12 fetuses who received IUT for treatment of severe isoimmunization had serial measurements of hemoglobin concentration, Kleihauer-Betke stains to detect fetal hemoglobin-containing erythrocytes, and determination of plasma erythropoietin (EPO) concentration before each IUT, at birth, and postnatally. Reticulocyte counts and sensitizing antibody titers were measured in five fetuses. Mean values before the first IUT, before the final IUT, and at birth were as follows: hemoglobin level, 6.1, 9.1, and 11.3 gm/dl; reticulocyte count, 22.7%, 0.5%, and 0.9%; fetal hemoglobin-containing erythrocytes, 100%, 1.6%, and 1.5%; and EPO level, 12, 56, and 756 mU/ml, respectively. Only one neonate required exchange transfusion. In the first month postnatally, all infants had a profound anemia. All but one infant required simple blood transfusions postnatally. Before the first postnatal transfusion, mean hemoglobin concentration was 6.2 gm/dl, mean reticulocyte count was 0.8%, mean erythropoietin concentration was 23 mU/ml, and the sensitizing antibody titer remained markedly elevated. Except for the surge of EPO at birth, EPO levels did not rise prenatally or postnatally unless marked anemia (hemoglobin level less than 5 gm/dl) occurred. These observations suggest that the intrauterine and postnatal anemia in fetuses who receive IUTs may be explained both by hemolysis of newly formed erythrocytes by circulating antibody, which typically persisted for more than a month after birth, and by suppressed erythropoiesis.
Anemia, Neonatal↗
Amniotic fluid insulin concentration as a predictor of obesity.
Longitudinal correlations were obtained between amniotic fluid insulin concentration at 32 to 38 weeks' gestation and anthropometric characteristics at the age of 6 years in 56 children of diabetic mothers. The prospective studies indicated that at the age of 6 years, as at birth, the greatest increase in weight in relation to height (relative obesity) was seen in children who experienced the greatest exposures to insulin in the uterus (as judged by amniotic fluid insulin concentration). Significant correlations between amniotic fluid insulin and relative obesity at the age of 6 years were found after adjustment for maternal obesity and macrosomia at birth. The highest amniotic fluid insulin values are clustered in the subgroup of 14 children who were obviously obese by the age of 6 years. These findings are consistent with the hypothesis that there is an association between anthropometric development and intrauterine metabolism, and suggest that premature and excessive exposure to insulin during gestation may predispose to obesity in childhood. The amniotic fluid insulin concentration may predict this eventuality.
Amniotic Fluid↗
The search for a lower cesarean rate goes on.
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Cesarean Section↗