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PubMed2006

Valacyclovir prophylaxis to prevent recurrent herpes at delivery: a randomized clinical trial.

OBJECTIVE: To measure the efficacy of valacyclovir suppression in late pregnancy to reduce the incidence of recurrent genital herpes in labor and subsequent cesarean delivery. METHODS: A total of 350 pregnant women with a history of genital herpes were assigned randomly to oral valacyclovir 500 mg twice a day or an identical placebo from 36 weeks of gestation until delivery. In labor, vulvovaginal herpes simplex virus (HSV) culture and polymerase chain reaction (PCR) specimens were collected. Vaginal delivery was permitted if no clinical recurrence or prodromal symptoms were present. Neonatal HSV cultures and laboratory tests were obtained, and infants were followed up for 1 month after delivery. Data were analyzed using chi2 and Student t tests. RESULTS: One hundred seventy women treated with valacyclovir and 168 women treated with placebo were evaluated. Eighty-two percent of the women had recurrent genital herpes; 12% had first episode, nonprimary genital herpes; and 6% had first episode, primary genital herpes. At delivery, 28 women (8%) had recurrent genital herpes requiring cesarean delivery: 4% in the valacyclovir group and 13% in the placebo group (P = .009). Herpes simplex virus was detected by culture in 2% of the valacyclovir group and 9% [corrected] of the placebo group (P =.02). No infants were diagnosed with neonatal HSV, and there were no significant differences in neonatal complications. There were no significant differences in maternal or obstetric complications in either group. CONCLUSION: Valacyclovir suppression after 36 weeks of gestation significantly reduces HSV shedding and recurrent genital herpes requiring cesarean delivery. LEVEL OF EVIDENCE: I.

Acyclovir↗
PubMed1989

Improvement in airway responsiveness and asthma severity during pregnancy. A prospective study.

In the myometrium and gut, smooth muscle becomes less contractile during pregnancy, probably because of the effect of progesterone and estrogen. It is not known whether these hormones cause similar changes in airway smooth muscle, and therefore, this study examined airway responsiveness during the large hormonal changes of pregnancy and evaluated whether changes in responsiveness are associated with changes in (1) progesterone and estrogen and (2) the clinical severity of asthma. Twenty nonpregnant asthmatic women were assessed every 3 months until conception. In the 16 who conceived, assessments were repeated once during the second and third trimesters and 1 month after delivery. Data collected preconception and from those who did not conceive within 1 yr were used for control subjects. There was a 2-fold improvement in airway responsiveness during pregnancy from a preconception mean PC20 0.35 to 0.72 mg/ml during the second trimester and 0.58 mg/ml during the third (p = 0.03). Post-delivery responsiveness (0.48 mg/ml) was not significantly different from preconception. The improvements during pregnancy were greater than the 3 monthly fluctuations when not pregnant (p = 0.04) and were greatest in those who were most hyperresponsive initially (p = 0.01). There was an associated improvement in clinical asthma severity as indicated by a reduction in minimum medication requirements (p = 0.03) and this was not at the expense of good symptoms control; both symptoms and spirometry remained unchanged during pregnancy. Changes in responsiveness were not closely related to progesterone or estriol, suggesting that other nonhormonal factors may also contribute to the improvement during pregnancy and that the control of asthmatic airway smooth muscle may not be exactly the same as that of the myometrium and gut.

Adult↗
PubMed1988

[Pneumothorax in pregnancy. Apropos of 3 cases].

We report 3 cases of pneumothorax developed during pregnancy and we compare them with the 16 cases previously published. We insist on the late occurrence of pneumothorax during pregnancy and on the possibility of vaginal delivery. Data from literature and our own experience incline us to believe that pneumothorax is not rare during pregnancy but is often misdiagnosed or unreported.

Adult↗
PubMed1995

Very-low-birth-weight outcomes of the National Institute of Child Health and Human Development Neonatal Network, November 1989 to October 1990.

OBJECTIVE: Our purpose was to describe the neonatal outcomes of 1804 very-low-birth-weight (< or = 1500 gm) infants delivered between November 1989 and October 1990 in the participating centers of the National Institute of Child Health and Human Development Neonatal Research Network. STUDY DESIGN: In an observational study sociodemographic, pregnancy, and delivery data were collected soon after birth, and neonatal and outcome data at discharge, at 120 days, or at death. RESULTS: Maternal and birth weight characteristics included 64% black, 29% white; 71% single mothers; 18% no prenatal care; 17% antenatal steroids; and 12% multiple gestations. Birth weight distributions included 18% weighing 501 to 750 gm, 23% 751 to 1000 gm, 28% 1001 to 1250 gm, and 31% 1251 to 1500 gm. Survival was 39% at < 751 gm birth weight, 77% at 751 to 1000 gm, 90% at 1001 to 1250 gm, and 93% at 1251 to 1500 gm. Survival was 15% to 18% at < or = 23 weeks' gestation, 54% at 24 weeks, 59% at 25 weeks, and 71% at 26 weeks. Surfactant was administered to 45% of the 56% of infants with respiratory distress syndrome. Morbidity, including intraventricular hemorrhage (40%), septicemia (24%), symptomatic patent ductus arteriosus (22%), and necrotizing entercolitis (8%), increased with decreasing birth weight. Oxygen was administered for > or = 28 days to 82% of < 751 gm infants, 49% of 751 to 1000 gm infants, and 10% of > 1001 gm infants. Steroids were administered to 28% of infants who required oxygen for > or = 28 days. Mean hospital stay was 62 days for survivors and 18 days for infants who died. There were large intercenter variations in mortality and morbidity. CONCLUSION: Mortality and morbidity in very-low-birth-weight infants improved in 1989 to 1990 without an increase in morbidity or length of hospital stay. The threshold of the improved survival was > or = 24 weeks and 601 to 700 gm. Although such data are reassuring, the rate of major morbidity in < 1001 gm birth weight infants continues to be high.

Birth Weight↗
PubMedDate not supplied

Visualizing Internet routing changes.

Today's Internet provides a global data delivery service to millions of end users and routing protocols play a critical role in this service. It is important to be able to identify and diagnose any problems occurring in Internet routing. However, the Internet's sheer size makes this task difficult. One cannot easily extract out the most important or relevant routing information from the large amounts of data collected from multiple routers. To tackle this problem, we have developed Link-Rank, a tool to visualize Internet routing changes at the global scale. Link-Rank weighs links in a topological graph by the number of routes carried over each link and visually captures changes in link weights in the form of a topological graph with adjustable size. Using Link-Rank, network operators can easily observe important routing changes from massive amounts of routing data, discover otherwise unnoticed routing problems, understand the impact of topological events, and infer root causes of observed routing changes.

Algorithms↗
PubMed2001

Correlation between prenatal and neonatal birth order in twin pregnancy.

Little data is available correlating the in utero order of presentation and the birth order of twins. Our objective was to determine whether birth order in twin pregnancies corresponds to the order of presentation early in pregnancy. All twin pregnancies in which amniocentesis was performed from 1996 to 1998 were identified. Those with discordant genders that delivered at our hospital were included. Order of presentation was documented by ultrasound at the time of amniocentesis. Delivery data were obtained from review of medical records. Statistical comparison was done using two-tailed Fisher's exact test, Student's t-test, and Mann-Whitney U test. Sixty patients met inclusion criteria. Birth order corresponded to the order at the time of amniocentesis in 55 of 60 cases (91.7%). There was no difference in the rate of concordance of prenatal and neonatal birth order in twins delivered vaginally compared with those delivered abdominally (90.9 vs. 91.8%, p = 1.0). Cases with discordant prenatal and neonatal birth order had similar maternal ages, gestational ages at amniocentesis and delivery, and fetal presentation at delivery as cases with concordant birth orders. In dichorionic twin pregnancies, birth order is established early in gestation in >90% of cases regardless of route of delivery.

Birth Order↗
PubMed2003

Impact of sociodemographic and hospital factors on attempts at vaginal birth after cesarean delivery.

OBJECTIVE: To estimate the clinical and nonclinical factors associated with whether a patient attempts a trial of labor after previous cesarean delivery or elects to have a repeat cesarean delivery. METHODS: We conducted a retrospective, cohort study comparing all women with previous low transverse cesarean delivery who attempted a trial of labor with those who elected to have a repeat cesarean delivery. Data from 17 hospital sites for the period 1995-1998 were included, for a total of 15,172 patients. Bivariate, site-adjusted, and multivariable logistic regression analyses were used. RESULTS: Odds of trial of labor by hospital were not uniform in the unadjusted or adjusted analyses. The odds of trial of labor decreased significantly with increasing age, gravidity, and number of previous cesarean deliveries. Medicaid patients had higher odds of trial of labor than did privately insured patients (odds ratio [OR] 1.37 [95% confidence interval (CI) 1.20, 1.55]). Patients with nonrecurrent indication for previous cesarean delivery had generally higher odds of trial of labor than did those with a recurrent indication. Black women were more likely to attempt trial of labor than were white women (OR 2.17 [95% CI 1.83, 2.56] for those with a nonrecurrent indication). CONCLUSION: Clinical and nonclinical factors influence rates of attempted vaginal birth after cesarean delivery.

Adult↗
PubMed2002

Evidence of intrapartum hypoxia-ischemia is not present in the majority of cases of neonatal seizures.

OBJECTIVE: To determine the extent to which neonatal seizures are associated with intrapartum hypoxia-ischemia. METHODS: In this case-control study, all neonates diagnosed with seizures at a single institution from 1988 to 1999 were compared to a control group without seizures matched in a 2:1 fashion for gestational age at delivery, birth weight and mode of delivery. Data were abstracted from the maternal and neonatal charts. Parametric variables were compared using an independent samples t test, and non-parametric variables were compared using a Fisher exact test, with p < 0.05 being considered significant. RESULTS: There were 13 cases of neonatal seizures identified, of which one was chromosomally abnormal and excluded from further analysis. For the cases, the mean gestational age at delivery was 34.8 +/- 6.9 weeks, with four preterm and eight term deliveries. The mean birth weight for the cases was 2684 +/- 1369 g (range 590-4350 g). For both cases and controls, 83% were delivered vaginally and 17% by Cesarean section. For term neonates with seizures, the mean length of stay was 11.6 +/- 5.0 days, as compared to 2.5 +/- 0.9 days in the control group (p < 0.001). A 1-min Apgar score of < 7 was found in six of 12 (50%) cases and seven of 24 (29%) controls, and a 5-min Apgar score of < 7 was found in four of 12 (33%) cases and four of 24 (17%) controls (non-significant). In the controls, the mean base excess was -2.8 +/- 2.6 mEq/l, and the mean umbilical arterial pH was 7.28 +/- 0.09. In the case group, two infants born at 24 weeks did not have an umbilical arterial blood gas obtained; in the remaining cases, the mean base excess was -7.6 +/- 6.9 mEq/l (p = 0.02), and the mean cord pH was 7.17 +/- 0.23 (p = 0.065), with only three of ten (30%) having a pH < 7.00 (p = 0.02). CONCLUSION: Clinically significant acidosis was found in only 30% of neonates who developed seizures, and only one of 12 cases (8%) could possibly have met the criteria of the American College of Obstetricians and Gynecologists for neurological morbidity linked to intrapartum asphyxia. The majority of cases of neonatal seizures were not associated with evidence of intrapartum hypoxia-ischemia.

Acidosis↗
PubMed2004

[Pregnancy and delivery outcomes after loop electrosurgical excision procedure of cervical intraepithelial neoplasia].

OBJECTIVE: To investigate the effects of loop electrosurgical excision procedure (LEEP) on pregnancy and delivery outcomes of patients with cervical epithelial neoplasia (CIN). METHOD: The delivery data of 27 pregnant women who had LEEP from May 1995 to April 2002 were retrospectively collected and analysed. RESULTS: The mean age of the 27 women was 30.3 years (range 23 approximately 40 years). Ten women underwent artificial abortion. One ectopic pregnancy and two spontaneous miscarriages occurred at 6 to 8 weeks of gestation. There were 14 term pregnancies, 9 of them via vaginal delivery and 5 via caesarean section. The birth weight of newborns ranged from 2905 to 4000 g. All of newborns had a high Apgar score. No asphyxia occurred. CONCLUSIONS: LEEP is a safe and effective treatment for patients with CIN. It will not increase the risk of pregnancy and delivery of the patients.

Adult↗
PubMed1993

Amniotic fluid index in hospitalized hypertensive patients managed expectantly.

OBJECTIVE: To determine the relationship between low amniotic fluid (AF) index and fetal growth retardation (FGR), fetal distress, and cesarean delivery in patients hospitalized for hypertensive disease, and to describe changes in AF status in relation to the severity of maternal disease. METHODS: The AF index in 142 hospitalized hypertensive patients was followed per an inpatient protocol with semi-weekly testing; medical records were reviewed to obtain delivery data. RESULTS: Fetal growth retardation was significantly associated with an AF index of 5.0 cm or less or 7.0 cm or less (P < .001) at initial assessment, with positive predictive values of 86 and 52%, respectively. However, the sensitivity of an AF index of 5.0 cm or less or 7.0 cm or less to detect FGR was limited (21 and 46%, respectively). Fetal distress and cesarean delivery were not associated with an AF index of 5.0 cm or less or 7.0 cm or less throughout observation in this cohort. Based upon a definition of oligohydramnios as an AF index of 7.0 cm or less, the AF status worsened from an initial normal value in 39% of patients whose final diagnosis was severe preeclampsia, versus only 14% of patients who were diagnosed as having mild disease. The AF index also normalized in ten patients who were originally diagnosed with oligohydramnios and admitted for expectant management. Only one of these women was diagnosed with severe preeclampsia. CONCLUSIONS: 1) Depending on the definition, the incidence of oligohydramnios ranges from 10-30% in hypertensive patients requiring hospitalization; 2) an AF index of 5.0 cm or less at initial evaluation predicts FGR but lacks sensitivity; 3) the AF status frequently changes with serial assessment, and these changes appear to be related to the severity of hypertensive disease; and 4) the frequency of the obstetric complications studied depends more upon the severity of hypertensive disease than on its potential effect of inducing oligohydramnios.

Cesarean Section↗
PubMed2006

The effect of amniotomy on the outcome of spontaneous labour in uncomplicated pregnancy.

The objective of this study is to determine the effect of amniotomy on the outcome of spontaneous labour in uncomplicated pregnancy. A prospective randomised study of low-risk parous women with spontaneous onset of labour at term with singleton fetus in cephalic presentation and intact amniotic membranes and a cervical dilatation between 4 and 5 cm were randomly assigned to have amniotomy (Case) or no amniotomy (Control) during the course of labour. Maternal demographics, labour-delivery data and newborn outcome were compared. A total of 128 women were studied. The duration of labour was significantly shorter in the amniotomy group than the control group (208 vs 292 min; p < 0.05) with the only difference being in the first stage of labour. There was however no difference on the oxytocin requirement for labour augmentation, caesarean section rate, incidence of suspected fetal distress or instrumental delivery in both groups. Newborn outcome measured by Apgar scores at 1 and 5 min showed no significant difference. In conclusion, amniotomy significantly reduced the duration of the first stage of labour without affecting the oxytocin requirement, the rate of caesarean section and newborn outcome.

Adult↗
PubMed1997

A critical review of the relationship between gestational weight gain and preterm delivery.

OBJECTIVE: To review the relationship between gestational weight gain and preterm delivery. DATA SOURCES: We identified published studies through Medline searches (for the period 1980-1996), and we reviewed bibliographies from published articles. METHODS OF STUDY SELECTION: We excluded non-English-language articles and articles that used total weight gain, unadjusted for gestational age. Thirteen articles were identified for review. TABULATION, INTEGRATION AND RESULTS: Eleven of the 13 studies reported a significant association between maternal weight gain and risk of preterm delivery, and most reported that inadequate rate of maternal weight gain was associated with an increased risk (approximately 50-100%) of preterm delivery. Studies examining pattern of gain noted that a low rate of gain during the latter part of pregnancy (but not early pregnancy) was associated with an increased risk of preterm delivery (also approximately 50-100%). The studies' findings were relatively consistent, despite the use of diverse samples, study designs, and analytic strategies. CONCLUSION: The evidence suggests that a lower rate of weight gain during pregnancy is associated with an increased risk of preterm delivery, and that a slow rate of gain during the latter part of pregnancy may be particularly important. To improve our understanding of the mechanisms of these relationships, future studies should examine pattern of gain; they should stratify analyses on the different subtypes of preterm delivery and provide more detailed descriptions of methods for assessing gestational duration.

Delivery, Obstetric↗
PubMed2007

Short cervix: is a follow-up measurement useful?

OBJECTIVE: To study if a repeat cervical length (CL) measurement in the patient already diagnosed with a short cervix has any additional value in the prediction of preterm delivery. STUDY DESIGN: This was a retrospective study of singleton pregnancies with cervical lengths 1-25 mm at a gestational age of 16-28 weeks seen in our institution between 2002 and 2005. Patients who were managed expectantly and had a follow-up CL measurement within 3 weeks were included. Delivery data were obtained from the patients' computerized medical records. RESULTS: Sixty-eight patients met the inclusion criteria. 37% of the patients had a shorter CL on the second measurement. These patients delivered at an earlier gestational age (36+4 vs. 38+2 weeks, P=0.031) and were more likely to deliver at <37 weeks (60% vs. 26%, P=0.009). The change in the CL correlated with earlier gestational age at delivery and delivery at <37 weeks. CONCLUSION: In patients diagnosed with a short cervix, follow-up CL measurement is a strong predictor of preterm delivery. Greater change in the CL correlates with an earlier gestational age at delivery. In the patient diagnosed with a short cervix, a repeat measurement of CL gives additional predictive value.

Adult↗
PubMed1986

Assessment of an on-line computerized perinatal data collection and information system.

An on-line maternity data collection system has been designed to provide the information required for perinatal audit and to allow many of the letters and forms required for effective communication in pregnancy to be produced automatically. The system meets the requirements of the Korner Committee on Health Services Information and has been approved by the Computer Policy Committee. Pregnancy is followed prospectively from the first antenatal clinic visit until the file is closed 28 days after delivery. Data are entered by midwives and secretaries onto a network of microcomputers placed at convenient points in the maternity unit. The system has been fully operational with no significant problems since the beginning of 1984 and has led to improved communication between hospital and the community. Analysis of 253 consecutive case notes showed a high level of accuracy of the data recorded on computer. Reports and clinical audit are readily available both from the system locally, from standard programmes on the regional mainframe computer and via a mainframe computer at London University.

Computer Systems↗
PubMed1994

A linear theory of transdermal transport phenomena.

A theory of charge, fluid-mass, and solute (including macromolecular) transport through porous media is applied to describe transport phenomena across the external layer of mammalian skin. Linear relationships are derived between transport fluxes and applied fields. These relationships introduce six effective transdermal transport coefficients. Formulas for each of these coefficients are provided. The practical relevance of these parameters is emphasized in the specific context of transdermal drug delivery. By employing typical physiological values for the various geometrical and physicochemical parameters that appear in the formulas for the transdermal transport coefficients, predictions are made for transport rates of charge, fluid mass, and solute species across a uniform-thickness skin sample contained within a diffusion-cell apparatus. These results are used to explore transdermal phenomena involving forced convection, current flow, electroosmosis, iontophoresis, and molecular diffusion (including convective dispersion). Comparisons with existing transdermal drug delivery data are made. On the basis of these comparisons, the theory suggests that transdermal transport in the presence of an electrical field may occur through corneocytes of the stratum corneum. The theory confirms the importance of a shunt route for small ion transport, as well as an intercellular route of transport for passive diffusion of noncharged substances. These latter conclusions, also based on comparisons with experimental data, are consistent with previous statements in the literature. A new form of solute transport enhancement, termed transdermal convective dispersion, is included in the theory, and methods for its measurement are described. Generalizations and future applications of the theory are discussed.

Administration, Cutaneous↗
PubMed2000

Maternal risk factors for abnormal vascular coiling of the umbilical cord.

The objective of this paper is to identify maternal risk factors for abnormal vascular coiling of the umbilical cord. The umbilical cords of 657 neonates were examined and the coiling index determined by dividing the total number of complete vascular coils by the length of the cord in cm. Obstetrical history, delivery data, and neonatal outcome were also evaluated. The frequency distribution of umbilical coiling index was normal (10 th and 90th percentile and mean +/- SD = 0.17, 0.37, and 0.26 +/- 0.09 coils/cm, respectively). Maternal risk factors for abnormal vascular coiling were extremes of age for hyper-coiling, obesity, gestational diabetes mellitus, and preeclampsia for non-coiling. Hyper-coiled and non-coiled cords were significantly associated with adverse perinatal outcome (p < 0.001) and cesarean delivery (p < 0.0001). Neonates whose mothers are old or young, obese, diabetic, or have preeclampsia are likely to have hyper-coiled or non-coiled umbilical blood vessels.

Adult↗
PubMed2004

Seasonal variation in preeclampsia based on timing of conception.

OBJECTIVE: Studies have suggested that the incidence of preeclampsia may be partially dependent on the month or season of delivery. We sought to evaluate whether preeclampsia occurs seasonally in our population and whether the timing of conception or delivery is more strongly associated with risk. METHODS: Between January 1995 and August 2003, we identified 142 primiparous women with singleton pregnancies who met the American College of Obstetricians and Gynecologists' definition for preeclampsia and compared them with 7,762 primiparous control deliveries. We analyzed rates of preeclampsia by individual month and 3-month seasonal blocks based on conception and delivery. Data were analyzed with the chi2 test, and logistic regression and odds ratios were calculated where appropriate. RESULTS: Preeclampsia occurred in 1.8% of singleton primiparous gestations (142/7,904). Cases were younger than controls (26.5 +/- 5.6 versus 28.0 +/- 0 6.0 years, P < .003), of similar race (97% white versus 96% white, P = .69), and equally likely to have a female child (45% versus 48%, P = .41). We found no significant association of month (logistic regression P = .20) of delivery with the risk of preeclampsia. There was a significant association of month (P = .003) of conception with risk of preeclampsia. Conception during the summer months had the highest risk (incidence 2.3%; odds ratio 1.7; 95% confidence limits 1.06, 2.75) compared with spring (incidence 1.4%). Fall (1.7%) and winter (1.6%) conceptions were associated with intermediate rates of preeclampsia. CONCLUSION: We identified a seasonal variation in preeclampsia that appears to be more strongly related to timing of conception than to the timing of delivery. The highest incidence of preeclampsia was associated with conception in the summer months. LEVEL OF EVIDENCE: II-2.

Female↗
PubMed2000

The cost-effectiveness of elective Cesarean delivery for HIV-infected women with detectable HIV RNA during pregnancy.

OBJECTIVES: To determine the net health consequences, costs, and cost-effectiveness of alternative delivery strategies for HIV-infected pregnant women with detectable HIV RNA in the USA. DESIGN: Cost-effectiveness analysis using a probabilistic decision model. METHODS: The model compared two strategies: elective Cesarean section and vaginal delivery. Data for HIV transmission rate, maternal death rate, health-related quality of life and costs were obtained from the literature, national databases, and a tertiary hospital's cost accounting system. Model outcomes included total lifetime costs, quality-adjusted life expectancy, maternal death rate, HIV transmission rate, and incremental cost-effectiveness ratios. RESULTS: Elective Cesarean section resulted in a vertical HIV transmission rate of 34.9 per 1000 births compared with 62.3 per 1000 births for vaginal delivery. Elective Cesarean section was more effective (38.7 quality adjusted life years per mother and child pair) and less costly ($10600 per delivery) than trial of labor (38.2 combined quality adjusted life years at a cost of $14500 per delivery). However, elective Cesarean section increased maternal mortality by 2.4 deaths per 100000 deliveries. The results were consistent over a wide range of the variables, but were sensitive to the risk of HIV transmission with vaginal delivery and the relative risk of HIV transmission with elective Cesarean section. CONCLUSIONS: In pregnant HIV-infected women with detectable HIV RNA, elective Cesarean section would reduce total costs and increase overall quality-adjusted life expectancy for the mother-child pair, albeit at a slight loss of quality adjusted life expectancy to the mother.

Adult↗