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Biomedical subjects

T M Goodwin

Publications and source records attributed to T M Goodwin.

At least 37 records · Page 2Linked to original sources
PubMed1999

Clinical Implications of Perinatal Depression.

The evaluation of the depressed newborn as a possible role in intrapartum asphyxia must be based on the objective findings of the fetal heart rate tracing, umbilical cord blood gas, and newborn neurologic function. Using these points as a basis for long-term followup, the following principles have been elucidated: Intrapartum asphyxia is an uncommon cause of childhood neurologic disfunction, the intrapartum insult necessary to cause long-term neurologic dysfunction is profound, and the child who does not manifest encephalopathy in the newborn period will not suffer long-term neurologic dysfunction that can be attributed to intrapartum asphyxia.

Acid-Base Imbalance↗
PubMed1998

The efficacy of methylprednisolone in the treatment of hyperemesis gravidarum: a randomized, double-blind, controlled study.

OBJECTIVE: The study compared the efficacy of methylprednisolone with that of promethazine for the treatment of hyperemesis gravidarum. STUDY DESIGN: Patients with a normal-appearing intrauterine pregnancy of < or = 16 weeks' gestation with hyperemesis gravidarum (persistent vomiting and large ketonuria despite outpatient therapy) were admitted to the hospital for continuous intravenous hydration and offered participation in the study. Patients meeting study criteria were randomly assigned to receive (from identical-appearing dispensers packaged in advance with a 2-week supply) oral methylprednisolone, 16 mg 3 times daily, or oral promethazine, 25 mg 3 times daily. After 3 days the methylprednisolone was tapered completely during the course of 2 weeks whereas the promethazine was continued without change for 2 weeks. For patients who continued to vomit after 2 days the study medication was discontinued. Patients receiving study medication at discharge continued to take the remainder of the assigned medication from the packaged pill dispensers. Patients were followed up weekly. The study outcomes, as established in advance, were (1) improvement of symptoms within 2 days of starting therapy and (2) readmission for hyperemesis within 2 weeks of starting the study. RESULTS: Forty patients were enrolled in the course of 11 months (20 per group). There were no significant differences between the groups with respect to maternal age, gravidity, parity, gestational age at entry, number of previous admissions, or > 5% body weight loss. Three patients in the methylprednisolone group and 2 in the promethazine group failed to stop vomiting within 2 days. One patient from the promethazine group was unavailable for follow-up. No patient from the methylprednisolone group but 5 of the 17 patients receiving promethazine were readmitted for hyperemesis within 2 weeks of discharge (P = .0001). There were no adverse effects noted for either drug. CONCLUSION: A short course of methylprednisolone is more effective than promethazine for the treatment of hyperemesis.

Adult↗
PubMed1998

Stillbirth evaluation: what tests are needed?

OBJECTIVE: We sought to investigate what aspects of the stillbirth evaluation are considered to be essential and what tests can potentially be eliminated. STUDY DESIGN: A retrospective analysis of 745 stillbirths occurring from January 1990 to December 1994 was conducted. A stillbirth was defined by an estimated gestational age >20 weeks' gestational age or fetal weight >500 gm. We attempted to arrive at an apparent cause for each stillbirth after evaluation of genetic or chromosomal abnormalities, obstetric history, maternal medical illnesses, laboratory tests, autopsy findings, and placental pathologic conditions. RESULTS: We found that the most important aspects of stillbirth evaluation were placental pathologic conditions and autopsy. When the placenta was examined, a significant abnormality was detected in 30% (160 of 529) of the cases. When autopsy was performed, only 31% of fetal deaths (142 of 462) were unexplained; however, when no autopsy was performed, 44% (125 of 283) were unexplained (p = 0.0002). The following laboratory evaluations that were routinely performed were found to yield little definitive information: antinuclear antibody testing, Kleihauer-Betke test, and screening for congenital infections (toxoplasmosis, other viruses, rubella, cytomegalovirus, and herpes simplex virus). Overall, 36% (267 of 745) of stillbirths still remained unexplained despite a thorough evaluation in most cases. CONCLUSION: The causes of stillbirth are many and varied, with a large proportion having no obvious cause. As this study demonstrates, certain laboratory tests can be eliminated in the workup of fetal death. In the evaluation of stillbirth a complete systematic method that incorporates placental pathologic conditions, as well as autopsy findings, should prove to be beneficial.

Adolescent↗
PubMed1998

Obstetric maneuvers for shoulder dystocia and associated fetal morbidity.

OBJECTIVE: We sought to determine the fetal injury rate associated with shoulder dystocia and to determine whether there is a higher rate of brachial plexus injury or bone fracture when fetal manipulation techniques are required for delivery. STUDY DESIGN: A retrospective review of 285 cases of shoulder dystocia that occurred between January 1991 and December 1995 was performed. The type, sequence, and combination of obstetric maneuvers used to relieve the shoulder dystocia were noted. These cases were divided into two groups, as follows: (1) those resolved with McRoberts' maneuver, suprapubic pressure, or proctoepisiotomy or a combination of these and (2) those that required the addition of direct fetal manipulative maneuvers (Woods, posterior arm, or Zavanelli). Fetal injury was defined as the occurrence of brachial plexus palsy, clavicular fracture, humeral fracture, or fetal death caused by asphyxial complications. RESULTS: The fetal injury rate was 24.9% (71/285), including 48 (16.8%) brachial plexus palsies, 27 (9.5%) clavicular fractures, and 12 (4.2%) humeral fractures. Sixteen infants had both nerve injury and bone fracture. Four (8.9%) brachial plexus palsies had documented persistence at 1 year of follow-up. One neonatal death occurred at age 3 months after an episode of hypoxic ischemic encephalopathy. The incidence of bone fracture was not higher when direct fetal manipulation was required: 21 of 127 (16.5%) versus 18 of 158 (11.4%), p = 0.21. The incidence of brachial plexus palsy was also similar in both groups (27/127 vs 21/158, p = 0.1). CONCLUSIONS: Direct fetal manipulation techniques used to alleviate shoulder dystocia are not associated with an increased rate of bone fracture or brachial plexus injury.

Adult↗
PubMed1998

Spontaneous vaginal delivery: a risk factor for Erb's palsy?

OBJECTIVE: Our purpose was to determine whether Erb's palsies occurring in the absence of shoulder dystocia differ from those occurring after shoulder dystocia. STUDY DESIGN: We compared the time course of resolution and incidence of persistent injury at 1 year of age in 17 cases of Erb's palsy without shoulder dystocia and 23 cases associated with shoulder dystocia. RESULTS: The rate of persistence at 1 year was significantly higher in those Erb's cases without identified shoulder dystocia, 7 of 17 (41.2%) versus 2 of 23 (8.7%), p = 0.04. These cases of Erb's palsies also took longer to resolve (6.4 +/- 0.9 vs 2.6 +/- 0.7 months, p = 0.002), had a higher rate of associated clavicular fracture (12 of 17 vs 5 of 23, p = 0.006), and were more likely to occur in the posterior arm (10 of 15 vs 4 of 21, p = 0.009). CONCLUSIONS: Erb's palsy occurring without shoulder dystocia may be a qualitatively different injury than that occurring with shoulder dystocia.

Adult↗
PubMed1998

Symphyseal separation and transient femoral neuropathy associated with the McRoberts' maneuver.

Many authors have recommended the McRoberts' maneuver as the initial technique in the management of shoulder dystocia. There have been, however, no reported adverse maternal outcomes associated with this technique. We report a case of symphyseal separation and transient femoral neuropathy associated with the McRoberts' maneuver. An overly exaggerated lithotomy position and thigh abduction stretches the articular surfaces of the symphysis pubis and places increased pressure on the femoral nerve by the overlying inguinal ligament.

Adult↗
PubMed1998

Experience with oral methylprednisolone in the treatment of refractory hyperemesis gravidarum.

OBJECTIVE: Our purpose was to describe the effect of oral methylprednisolone on the course of refractory hyperemesis gravidarum. STUDY DESIGN: Patients with intractable hyperemesis gravidarum were candidates for oral methylprednisolone. Forty-eight milligrams per day was given for 3 days followed by a tapering dose over 2 weeks. If vomiting recurred after 2 weeks of therapy or during tapering, the medication was restarted or extended but not longer than 1 month total. RESULTS: Seventeen of 18 patients (94%) were free of vomiting and were able to tolerate a regular diet within 3 days. Seven did not have further symptoms during their pregnancies. Nine vomited during or after tapering, but 7 of these responded to extension or reinstitution of therapy. Four of 6 patients on total parenteral nutrition at the start of therapy had a complete response within 3 days. CONCLUSIONS: A short course of oral methylprednisolone appears to be a reasonable therapeutic alternative for intractable hyperemesis.

Adolescent↗
PubMed1998

Umbilical arteriovenous PO2 and PCO2 differences and neonatal morbidity in term infants with severe acidosis.

OBJECTIVE: In term infants umbilical cord gas analysis is a poor predictor of immediate newborn complications associated with intrapartum asphyxia, unless the umbilical arterial pH is less than 7.00. We investigated whether umbilical arteriovenous blood gas differences may better predict asphyxia-related complications. STUDY DESIGN: The study population consisted of 82 term, nonanomalous, singleton, live-born infants with severe umbilical acidosis (pH < 7.00). Umbilical arteriovenous pH, PCO2, and PO2 differences were correlated with Apgar scores and the presence of seizures, hypoxic-ischemic encephalopathy, cardiopulmonary and renal dysfunction, and abnormal development in the neonatal period. RESULTS: Umbilical arteriovenous pH, PCO2, and PO2 differences were interrelated (p < 0.0001), but these parameters correlated only weakly with 1-minute and 5-minute Apgar scores. An arteriovenous PCO2 difference > 25 torr was a highly sensitive and specific parameter in identifying asphyxiated infants with seizures, hypoxic-ischemic encephalopathy, cardiopulmonary and renal dysfunction, and abnormal development in the neonatal period. Arteriovenous PO2 differences were less sensitive in the detection of neonatal morbidity than arteriovenous PCO2 differences. CONCLUSION: Umbilical cord blood arteriovenous PCO2 differences provide a new tool to predict neonatal morbidity and permanent neurologic injury in term infants with perinatal asphyxia.

Acidosis↗
PubMed1998

Decision making in multifetal pregnancy reduction for triplets.

The objective of this article is to examine the literature that forms the basis for counseling couples with higher order multiple gestation with regard to multifetal pregnancy reduction and present the data on expectant management of multiple gestations and multiple gestations managed with multifetal pregnancy reduction. The data sources for this article are computer-assisted search of the literature. Eighty-three articles, mainly published after 1989, and reporting on the natural history, management, and outcome of multifetal pregnancies, were reviewed. We analyze and present the data on expectant management of multiple gestations and multiple gestations managed with reduction to twins and then use the hypothetical patient-oriented questions listed below to organize the data. There is a general consensus that reducing triplets to twins results in significant secondary benefits: lower cost and fewer days in hospital and a decrease in a variety of moderate morbidities associated with prolonged hospitalizations and preterm delivery for mother and baby. However, it is not clear that couples are more likely to take home a healthy baby, if they undergo multifetal pregnancy reduction.

Decision Making↗
PubMed1998

Shoulder dystocia.

Shoulder dystocia continues to represent a largely unpredictable and potentially disastrous obstetric emergency. Recent attention has been focused on the effectiveness of obstetric maneuvers employed to alleviate shoulder dystocia. Reports have also questioned the traditional thinking that brachial plexus injury is caused by application of excessive lateral traction to the fetal head. Rather, in-utero forces may underlie a significant portion of these injuries.

Delivery, Obstetric↗
PubMed1998

Oxytocin receptor antagonists. Update.

For over three decades, scientists in a number of different laboratories have worked to design peptide analogues of oxytocin (OT) selective for the oxytocin receptor. Although there has been some interest in their use for treatment of dysmenorrhea, the principal clinical venue for such agents has been thought to lie in treatment of preterm labor. A major difficulty in identifying the clinical role for an OT antagonist had been our incomplete understanding of the role of OT in both term and preterm labor. This article begins with a review of the current understanding of the role of OT in the initiation and maintenance of labor in the human.

Drug Design↗
PubMed1997

Brachial plexus palsy associated with cesarean section: an in utero injury?

OBJECTIVE: Brachial plexus injury may be unrelated to manipulations performed at the time of delivery, occurring in the absence of shoulder dystocia and in the posterior arm of infants with anterior shoulder dystocia. To further support the hypothesis that some of these nerve injuries appear to be of intrauterine origin, we present a series of brachial plexus palsies associated with atraumatic cesarean delivery among fetuses presenting in the vertex position. STUDY DESIGN: We performed a computerized search of all deliveries from 1991 to 1995 for the discharge diagnoses of brachial plexus injury and cesarean section. Inclusion criteria included cephalic presentation at the time of delivery and the absence of traumatic delivery. RESULTS: We noted six cases of Erb's palsy, with four palsies in the anterior shoulder and two in the posterior arm. Among those five patients undergoing cesarean section because of labor abnormalities, two had uterine cavity abnormalities whereas one had a prolonged second stage of labor. One brachial plexus palsy occurred in the absence of active labor. All nerve injuries were persistent at age 1 year. CONCLUSIONS: Brachial plexus palsy can be associated with cesarean delivery. Such palsies appear to be of intrauterine origin and are more likely to persist.

Adult↗
PubMed1997

Catastrophic shoulder dystocia and emergency symphysiotomy.

We present three cases of shoulder dystocia unrelieved by standard maneuvers, including cephalic replacement. Symphysiotomy was performed in an effort to preserve fetal life. All three infants sustained severe neurologic injury and later died. Maternal morbidity including urinary incontinence was significant but responded to treatment. Symphysiotomy may be the only method of relieving some cases of shoulder dystocia, but its role remains unclear because of operator inexperience and maternal morbidity.

Adult↗
PubMed1997

Idiopathic thrombocytopenic purpura in pregnancy treated with pulsed high-dose oral dexamethasone.

Idiopathic thrombocytopenic purpura in pregnancy is usually treated with prednisone or intravenous immune globulin. Because of the fetal risk, there are few good alternatives for women who do not respond. We report a case of refractory idiopathic thrombocytopenic purpura successfully treated with pulsed high-dose oral dexamethasone, which offered ease of administration, low cost, and low risk.

Adult↗
PubMed1997

Clinical risk factors for placenta previa-placenta accreta.

OBJECTIVE: Our purpose was to define the clinical risk factors associated with placenta previa-placenta accreta. STUDY DESIGN: Hospital records were reviewed of all cases of placenta accreta confirmed histologically between January 1985 and December 1994. Additionally, we reviewed the records of all women with placenta previa and all those undergoing cesarean hysterectomy during the same period. Multiple logistic regression analysis was used to identify independent clinical risk factors for placenta accreta. RESULTS: Among 155,670 deliveries, 62 (1/2510) were complicated by histologically confirmed placenta accreta. Placenta accreta occurred in 55 of 590 (9.3%) women with placenta previa and in 7 of 155,080 (1/22,154) without placenta previa (relative risk 2065, 95% confidence interval 944 to 4516, p < 0.0001). Among women with placenta previa, advanced maternal age (> or = 35 years) and previous cesarean delivery were independent risk factors for placenta accreta. Placenta accreta was present in 36 of 124 (29%) cases in which the placenta was implanted over the uterine scar and in 4 of 62 (6.5%) cases in which it was not (relative risk 4.5, 95% confidence interval 1.68 to 12.07). Among women with placenta previa, the risk of placenta accreta ranged from 2% in women < 35 years old with no previous cesarean deliveries to almost 39% in women with two or more previous cesarean deliveries and an anterior or central placenta previa. CONCLUSION: Placenta accreta occurs in approximately 1 of 2500 deliveries. Among women with placenta previa, the incidence is nearly 10%. In this high-risk group advanced maternal age and previous cesarean section are independent risk factors.

Adult↗
PubMed1997

The McRoberts' maneuver for the alleviation of shoulder dystocia: how successful is it?

OBJECTIVE: Our purpose was to determine the rate of success of the McRoberts' maneuver as the initial treatment for shoulder dystocia and to compare the rate of maternal and neonatal morbidity with those cases of shoulder dystocia requiring additional obstetric maneuvers. A secondary goal was to assess those factors associated with successful McRoberts' maneuvers. STUDY DESIGN: A retrospective review of shoulder dystocia cases occurring between 1991 and 1994 was performed. The identified cases were divided into two groups on the basis of the maneuvers used to relieve the shoulder dystocia. The first group comprised cases in which the McRoberts' maneuver was used as the sole treatment and the second group consisted of cases in which additional maneuvers were subsequently used. Exclusion criteria included lack of documentation concerning the maneuvers used or cases in which the McRoberts' maneuver was not the initial technique used. The two groups were compared with respect to various antepartum, intrapartum, and neonatal characteristics. RESULTS: During the study period we identified 250 cases of shoulder dystocia among 44,072 vaginal deliveries, for an incidence of 0.57%. Of these, 236 cases (94%) fulfilled entry criteria. The McRoberts' position alone successfully alleviated the shoulder dystocia in 98 cases (42%). In the group of cases where the McRoberts' maneuver was the sole maneuver used, there were significantly lower mean birth weights (p = 0.008), shorter durations of the active phase of labor (p = 0.009), and shorter second stages (p < 0.0001). In the group of cases that required additional maneuvers to relieve the shoulder dystocia, there was a trend toward an increased incidence of postpartum hemorrhage and brachial plexus injury (p = 0.07). CONCLUSIONS: These data suggest that the McRoberts' maneuver is associated with a significant degree of success in relieving shoulder dystocia and may be associated with decreased morbidity compared with other maneuvers. On the basis of these findings, we recommend the McRoberts' maneuver as the initial technique for disimpaction of the anterior shoulder.

Adult↗
PubMed1997

Intrapartum rupture of the unscarred uterus.

OBJECTIVE: To examine risk factors and maternal and neonatal outcomes in ten cases of intrapartum rupture of the unscarred uterus. METHODS: Uterine ruptures in women without previous cesarean deliveries were identified from an ongoing log for a 12-year period beginning January 1, 1983. Detailed information was obtained by review of hospital records. RESULTS: From January 1, 1983, through December 31, 1994, we identified 13 uterine ruptures in women without previous cesarean deliveries. Three resulted from motor vehicle accidents and were excluded from analysis. Ten occurred during labor and are the subjects of our report. The incidence of intrapartum rupture of an unscarred uterus was 1 in 16,849 deliveries. Associated factors included oxytocin use (four cases), prostaglandin use (three cases), use of vacuum or forceps (three cases), grand multiparity (two cases), and malpresentation (two cases). Intervention was prompted by fetal heart rate decelerations in seven cases and by severe hemorrhage in three. Uterine rupture was associated with acute abdominal pain in six cases, maternal tachycardia in five, and severe hypotension in two. Neonatal outcomes were normal in nine cases. There were no maternal or perinatal deaths. CONCLUSION: Intrapartum rupture of the unscarred uterus is a rare obstetric emergency. Maternal and perinatal outcomes are optimized by awareness of risk factors, recognition of clinical signs and symptoms, and prompt surgical intervention.

Adult↗