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Biomedical subjects

D A Luthy

Publications and source records attributed to D A Luthy.

At least 37 records · Page 2Linked to original sources
PubMed1995

Preinduction prostaglandin E2 gel prior to induction of labor in women with a previous cesarean section.

The objective of the study was to evaluate the efficacy and safety of preinduction cervical ripening with 0.5 mg of intracervical prostaglandin E2 (PGE2) gel in women with a previous cesarean section. A retrospective cohort study design was used to compare 117 women with one previous cesarean section (VBACS) with 354 nulliparas. Both groups received preinduction cervical ripening treatment with intracervical PGE2 gel. Student's t and chi 2 tests were used to evaluate group differences. Mantel-Haenszel summary risk ratios and 95% confidence intervals were examined in order to assess the relative risk of cesarian section delivery after adjusting for potential confounders. The mean numbers of PGE2 gel applications were 2.4 and 2.5 for VBACS and controls, respectively (p < 0.05). Thirty-nine percent of VBACS entered labor spontaneously as compared with 33% of nulliparas. Mean duration of ruptured membranes (8.2 vs. 12.1 h) and length of labor (20.1 vs. 28.5 h) were reduced among VBACS as compared with controls (p < 0.05). Overall, VBACS had a higher cesarean section rate as compared with controls (49.6 vs. 31.9%; adjusted relative risk = 1.6, 95% confidence interval 1.2-2.1). There were no differences in the occurrence of maternal and fetal morbidity. Overall, the efficacy and safety of 0.5 mg PGE2 gel administered for preinduction cervical ripening in VBACS is comparable to that observed in nulliparas.

Adult↗
PubMed1995

A longitudinal study of maternal serum human chorionic gonadotropin levels during pregnancy.

OBJECTIVE: To determine if pregnant women with normal singletons will continue to have elevated serum human chorionic gonadotropin (hCG), given that they had an elevated serum hCG in the second trimester. METHODS: Nineteen women with second-trimester hCG levels > or = 2.0 multiples of the median, and 20 women with second-trimester hCG levels < 2.0 multiples of the median were the subjects of this investigation. All study participants had serum hCG levels repeated during the third trimester of pregnancy. We used a chi-square test and Student's t test for comparing categorical variables, and the means of continuous variables, respectively. RESULTS: Using the criterion of > or = 2.0 multiples of the median of the comparison group to define hCG elevation, women with elevated second-trimester hCG levels were women with normal second-trimester hCG levels (risk ratio = 3.9; 95% confidence interval 1.6-9.8; p < 0.001). Adjustment for potential confounders did not materially alter the association. CONCLUSION: Women with elevated hCG in the second trimester continued to have elevations in the third trimester. The persistence of elevated hCG levels in pregnancies uncomplicated by fetal anomalies should be evaluated as a clinical marker of adverse pregnancy outcomes.

Chorionic Gonadotropin↗
PubMed1994

Meningomyelocele: management in utero and post natum.

We report a four year follow-up of 39 of 47 infants born after pre-labour Caesarean section and 68 of 79 born vaginally. Loss of motor function due to late complications was more frequent in the Caesarean section group (Fisher's Exact; P = 0.004). However, the means of the differences between the X-ray levels (measured as the last intact vertebral arch seen on standard anteroposterior roentgenograms of the spinal column) subtracted from the motor levels still favour Caesarean section (mean = 3.24; SD = 2.7) over vaginal delivery (mean = 1.2; SD = 2.7) (Student's t-test; P = 0.0003). The frequencies of other complications, death and neonatal meningitis, were not significantly different. Another 38 infants born by Caesarean section after labour were more paralysed (mean of X-ray and motor difference = 1.8, SD = 2.2) following rupture of amniotic membranes than those with intact amniotic membranes with or without labour (mean = 3.4; SD = 2.2) (Student's t-test; P = 0.0067). The differences between X-ray and motor levels for patients born by Caesarean section with intact amniotic membranes and without labour (mean = 3.6; SD = 2.4) were not significantly different from those with labour and intact amniotic membranes (mean = 2.89; SD = 1.5). The number of new cases of meningomyelocele presenting to our clinic has decreased from an average of 30 per year between 1970 and 1987 to 14 between 1988 and 1992.

Cesarean Section↗
PubMed1994

The outcome of fetal myelomeningocele brought to term.

14 years experience with 354 infants born with myelomeningocele are reviewed in view of prelabor and pre-rupture of amniotic membranes vs vaginal delivery or delivery by cesarian section after labor and rupture of amniotic membrane. The apparent lack of effect of severity of impairment determined by prenatal diagnosis on parental decision to carry their baby to term, the negative effect on motor function of kyphos or congenital kyphoscoliosis, the equivocal effect of breech presentation with or without rupture of amniotic membranes and the beneficial effect of prelabor and prerupture of membranes delivery of selected infants is discussed. The need for further multiple center, collaborative study to identify the contribution of a number of factors influencing the outcome of fetuses diagnosed as having myelomeningocele is emphasized.

Breech Presentation↗
PubMed1993

Fetal hyperechogenic bowel and Down's syndrome.

Hyperechogenic bowel was identified among 55 of 6781 (0.81%) fetuses prior to second-trimester genetic amniocentesis. Trisomy 21 was found in eight of the 55 (14.5%) fetuses identified with hyperechogenic bowel compared to 60 of 6726 (0.89%) fetuses with normal bowel echogenicity (p < 0.001). Hyperechogenic bowel carried a 16-fold greater risk for Down's syndrome than normal bowel echogenicity (relative risk 16.8, 95% confidence intervals 8.2-32.5). Chromosome abnormalities other than trisomy 21 were found in four additional fetuses with hyperechogenic bowel (two triploid and one each with 47,XXX; 45,X/47,XXX mosaicisim). Combining these four cases with the eight fetuses having trisomy 21, 21.8% (12 of 55) of fetuses with hyperechogenic bowel proved to have a chromosome abnormality. We conclude that hyperechogenic bowel is associated with chromosome abnormalities, particularly Down's syndrome, when detected during the second trimester.

Journal Article↗
PubMed1993

Stuck twin syndrome: outcome in thirty-seven consecutive cases.

OBJECTIVE: Our purpose was to further evaluate the role of serial amniocentesis in pregnancies complicated by the "stuck twin" syndrome. STUDY DESIGN: A cohort of 37 consecutive cases of stuck twin syndrome was followed up from 1986 through 1992. Evaluations included gestational age at diagnosis and at delivery, mean number of amniocenteses, volume of amniotic fluid withdrawn, placentation, perinatal complications, fetal survival, and neonatal follow-up. RESULTS: Five pregnancies were terminated, five had no intervention, and 27 underwent serial amniocenteses. The mean number of amniocenteses was 3.4 (range 1 to 6), and mean total amniotic fluid volume withdrawn was 5.8 L (range 0.75 to 4.0). In the serial amniocentesis group mean gestational age was 23.1 weeks (range 16 to 30) at diagnosis and 31.5 weeks (range 20 to 38) at delivery. Eighty-two percent had monochorionic placentas, and 36% had marginal or velamentous cord insertions. Infant survival was 39 of 54 (74%) in the serial amniocentesis group compared with four of 10 (40%) in the nonintervention group (relative risk 0.46, 95% confidence interval 0.24 to 0.90). CONCLUSION: Serial amniocentesis was associated with a 54% reduction in fetal and neonatal death in cases of stuck twin syndrome.

Adolescent↗
PubMed1993

Cook obstetrics and gynecology catheter multicenter chorionic villus sampling trial: comparison of birth defects with expected rates.

OBJECTIVE: The null hypothesis was that offspring of women undergoing first-trimester chorionic villus sampling do not experience a rate of birth defects exceeding background rates. STUDY DESIGN: Follow-up information regarding major malformations was prospectively sought on offspring of 4105 women undergoing first-trimester chorionic villus sampling from nine centers participating in a collaborative study with the Cook obstetrics and gynecology catheter. These data were compared with data from the Collaborative Perinatal Project and other registries. RESULTS: A total of 84 offspring with major malformations was identified (2.36%). Compared with background rates, there was no increase in the incidence of total malformations or specific malformations (including limb reduction defects) in the subjects. One institution experienced all three limb reduction defects in this series; the probability of this occurring by chance alone is < 1%. CONCLUSION: Chorionic villus sampling was not found to result in an increase in major birth defects or in specific categories of birth defects in this series.

Catheterization↗
PubMed1993

Humerus and femur length shortening in the detection of Down's syndrome.

OBJECTIVE: Our purpose was to determine the utility of screening for humerus and femur length shortening in prenatal detection of Down's syndrome (trisomy 21). STUDY DESIGN: On the basis of the biparietal diameter, predicted humerus and femur lengths were derived from a sample control group of 350 karyotypically normal fetuses. The regression formulas were prospectively applied to 45 consecutive fetuses with Down's syndrome and 942 fetuses with normal karyotypes. Ratios of measured humerus length/predicted humerus length and measured femur length/predicted femur length were calculated for each fetus. RESULTS: Eleven of 45 (24.4%) fetuses with Down's syndrome had short humerus (measured humerus length/predicted humerus length ratio of < or = 0.89), and 11 (24.4%) had short femur (measured femur length/predicted femur length ratio of < or = 0.91. In comparison, among 942 karyotypically normal fetuses only 43 (4.5%) showed short humerus and 44 (4.7%) showed short femur (p < 0.05). Fetuses with both short humerus and short femur carried an 11-fold greater risk of Down's syndrome (risk ratio = 11.1; 95% confidence interval = 5.0 to 25.0). CONCLUSION: Prenatal ultrasonographic detection of short humerus to short femur, or both significantly increase the risk of Down's syndrome; this information may be useful in screening programs.

Bone Lengthening↗
PubMed1993

An association between elevated levels of human chorionic gonadotropin in the midtrimester and adverse pregnancy outcome.

OBJECTIVE: Unexplained elevations in maternal serum alpha-fetoprotein in the midtrimester are associated with adverse pregnancy outcome. Recently it has also been suggested that elevations of maternal serum human chorionic gonadotropin in the second trimester may be associated with adverse pregnancy outcome. STUDY DESIGN: We conducted a cohort study of 460 women at Swedish Medical Center, Seattle, Washington, between Jan. 1, 1990, and Aug. 15, 1991, inclusive. Entry criteria for the cohort included (1) triple screen analysis (maternal serum alpha-fetoprotein, human chorionic gonadotropin, unconjugated estriol) between 15 and 18 weeks' gestation, (2) a risk for Down syndrome of more than one in 195 on the basis of triple screen analysis, (3) study group human chorionic gonadotropin > or = 2 multiples of the median and referent group < or = 2 multiples of the median, alpha-fetoprotein < or = 2 multiples of the median, unconjugated estriol > or = 0.5 multiples of the median, and (4) chromosomally normal single gestation without anomalies. Cumulative incidence risk ratios were estimated for each pregnancy outcome as a measure of the relative association with elevated human chorionic gonadotropin (> or = 2.0 multiples of the median) and adverse pregnancy outcome: low birth weight, < or = 2500 gm; preterm delivery, < 37 weeks' gestation; and small for gestational age, < or = 10th percentile. The Mantel extension test was used to evaluate any apparent linear trend in risk between level of human chorionic gonadotropin and adverse pregnancy outcome. RESULTS: Elevated human chorionic gonadotropin levels were associated with an increased risk for low birth weight (relative risk = 4.0), preterm delivery (relative risk = 2.8), and small for gestational age (relative risk = 1.8). The risk for each adverse outcome increased with increasing levels of human chorionic gonadotropin. CONCLUSIONS: Elevations of human chorionic gonadotropin in the midtrimester appear to be associated with adverse pregnancy outcome. The magnitude of the risk correlates with the level of human chorionic gonadotropin. This risk appears to be independent of the risk for adverse pregnancy outcome associated with unexplained elevations of maternal serum alpha-fetoprotein.

Chorionic Gonadotropin↗
PubMed1993

Echogenic fetal bowel during the second trimester: clinical importance.

Clinical outcomes of 95 second-trimester fetuses prospectively considered to have echogenic bowel at ultrasound were compared with a control group of 110 consecutive second-trimester fetuses. Among the 95 fetuses in the study group, 64 (67%) had moderately echogenic (grade 2) or markedly echogenic (grade 3) bowel relative to the liver. Among the 110 fetuses in the control group, only two (1.8%) had moderately echogenic (grade 2) bowel; the rest (98.2%) had isoechoic (grade 0) or midly echogenic (grade 1) bowel relative to the liver. Adverse outcomes occurred in 45 of the 95 fetuses (47%) with echogenic bowel compared with eight of the 110 fetuses (7.27%) in the control group (P < .01; relative risk, 6.5; 95% confidence interval, 3.2, 13.1). Adverse outcomes included chromosomal abnormalities, intrauterine growth retardation, fetal demise, or other fetal anomalies. Within the study group, adverse outcomes occurred in 40 of the 64 fetuses (62%) with grade 2 or 3 bowel echogenicity, compared with five of the 31 fetuses (16%) with grade 1 echogenicity. Echogenic bowel is associated with an increased risk of adverse fetal outcome and this risk is confined primarily to grades 2 and 3 echogenicity.

Chromosome Aberrations↗
PubMed1993

Prenatal sonographic findings of trisomy 18: review of 47 cases.

Prenatal sonographic findings were reviewed in 47 consecutive fetuses with trisomy 18. One or more abnormalities, excluding choroid plexus cysts, were found in 39 fetuses (83%), including 21 of 29 (72%) fetuses examined between 14 and 24 weeks and all 18 (100%) fetuses examined after 24 weeks. Abnormalities most frequently detected before 24 weeks included cystic hygromas, nuchal thickening, and meningomyelocele. Intrauterine growth retardation, cardiac defects, and an enlarged cisterna magna were detected more frequently after 24 weeks than before 24 weeks (P < 0.05). Intrauterine growth retardation was the single most common abnormality, detected in 51% of all fetuses and 89% of fetuses examined after 24 weeks. Choroid plexus cysts were identified in 25% (12 of 47) of fetuses, including 11 of 29 (38%) fetuses seen before 24 weeks. Additional abnormalities were identified in 10 of 12 (83%) fetuses with choroid plexus cysts; one of the two remaining fetuses showed clenched hands and a cardiac anomaly at autopsy, and the other showed unusually large, multiple choroid plexus cysts. Awareness of the type of anomalies and the usual menstrual age of diagnosis in fetuses with trisomy 18 should improve patient counseling and prenatal detection of fetuses considered at risk for this disorder.

Abnormalities, Multiple↗
PubMed1993

A prospective evaluation of a second-trimester screening test for fetal Down syndrome using maternal serum alpha-fetoprotein, hCG, and unconjugated estriol.

OBJECTIVE: To test the efficacy of a screening protocol using a combination of maternal age plus three biochemical markers--maternal serum alpha-fetoprotein (MSAFP), hCG, and unconjugated estriol (E3)--for the antenatal detection of fetal Down syndrome. METHODS: We conducted a prospective cohort study of 7718 women who underwent the triple-marker analysis between weeks 15-18 of pregnancy. A second-trimester risk for Down syndrome of 1:195 or greater was considered positive. Sensitivity, specificity, positive predictive value, and their 95% confidence intervals (CIs) were calculated. We evaluated test performance for various maternal age groups and screen-positive cutoffs, as well as the relative screening efficacies of maternal age and MSAFP, MSAFP plus hCG, and MSAFP, hCG, and unconjugated E3. RESULTS: Four hundred sixty-one of the 7718 women screened (6%) were identified as positive; 319 women chose amniocentesis, for an overall amniocentesis rate of 4.1%. Twenty of 22 pregnancies affected with Down syndrome were correctly identified, as were 7255 of 7696 unaffected pregnancies, yielding a sensitivity and specificity of 91% (95% CI 79-100%) and 94% (95% CI 93.8-94.8%), respectively. The use of maternal age plus all three analytes improved test performance compared with maternal age plus MSAFP and hCG, but either had a significantly improved detection rate compared with that for maternal age and MSAFP alone. CONCLUSION: The triple-marker screen appears to be an effective method of detecting Down syndrome pregnancies while maintaining an acceptable amniocentesis rate.

Adult↗
PubMed1992

Elevated maternal serum alpha-fetoprotein levels and midtrimester placental abnormalities in relation to subsequent adverse pregnancy outcomes.

OBJECTIVE: Unexplained elevations of maternal serum alpha-fetoprotein levels in the second trimester of pregnancy are associated with adverse pregnancy outcomes, including intrauterine growth retardation, preterm delivery, preeclampsia, and abruptio placentae. In addition, elevations of maternal serum alpha-fetoprotein have been associated with placental lesions detected during second-trimester ultrasonographic evaluations. We examined the relationship between adverse pregnancy outcomes and unexplained elevations of maternal serum alpha-fetoprotein and placental abnormalities in the second trimester of pregnancy. STUDY DESIGN: During the period from January 1989 to March 1991 we conducted a cohort study of 201 women with an elevated maternal serum alpha-fetoprotein (> or = 2.0 multiples of the median) and a second-trimester ultrasonographic evaluation at Swedish Hospital Medical Center and 211 women with normal maternal serum alpha-fetoprotein levels who had also undergone ultrasonographic evaluation at the same institution. All women in this investigation had singleton pregnancies without fetal anomalies. RESULTS: Elevated maternal serum alpha-fetoprotein was associated with the following adverse pregnancy outcomes: low birth weight (adjusted risk ratio 3.7), preterm delivery (adjusted risk ratio 3.6), intrauterine growth retardation (adjusted risk ratio 4.0), preeclampsia (adjusted risk ratio 3.8) and abruptio placentae (adjusted risk ratio 4.8). Placental abnormalities detected during second-trimester ultrasonographic evaluations were also associated with adverse pregnancy outcomes: low birth weight (adjusted risk ratio 2.0), preterm delivery (adjusted risk ratio 2.3), intrauterine growth retardation (adjusted risk ratio 1.4), and abruptio placentae (adjusted risk ratio 9.0). A joint positive history of second-trimester elevations of maternal serum alpha-fetoprotein and placental abnormalities was more strongly associated with the following adverse infant outcomes: low birth weight (adjusted risk ratio 6.9), preterm delivery (adjusted risk ratio 5.6), and intrauterine growth retardation (adjusted risk ratio 5.3). CONCLUSIONS: Unexplained elevated levels of maternal serum alpha-fetoprotein and placental abnormalities detected in the second trimester of pregnancy are associated with particularly poor pregnancy outcome. Careful examination for placental abnormalities should be part of the evaluation of elevated maternal serum alpha-fetoprotein.

Birth Weight↗
PubMed1991

Cesarean section before the onset of labor and subsequent motor function in infants with meningomyelocele diagnosed antenatally.

Background. Meningomyelocele can now be detected before birth. Few data are available on its natural history, however, and optimal management at the time of delivery is controversial, although it has been suggested that labor and vaginal delivery may cause pressure on exposed nerve roots, resulting in additional loss of neural function. Methods. To assess the effect of labor and the type of delivery on the level of motor function in fetuses with uncomplicated meningomyelocele, we identified 200 cases of this disorder, accounting for 95 percent of the cases that occurred in the state of Washington during our 10-year study period. We compared the outcomes of 47 infants delivered by cesarean section before labor began, 35 delivered by cesarean section after a period of labor, and 78 who were delivered vaginally (another 40 were ineligible for the study). In cases of meningomyelocele detected prenatally, cesarean section was performed before the onset of labor if isolated meningomyelocele without severe hydrocephalus was present. The infants delivered in this manner were compared with those who were delivered either vaginally or by cesarean section after labor began. Results. At two years of age, the infants who had been exposed to labor were 2.2 times more likely to have severe paralysis than those delivered by cesarean section without labor (95 percent confidence interval, 1.7 to 2.8). Infants delivered by cesarean section before the beginning of labor had a mean (+/- SD) level of paralysis 3.3 +/- 3.0 segments below the anatomical level of the spinal lesion at two years of age, as compared with 1.1 +/- 2.3 for infants delivered vaginally and 0.9 +/- 4.1 for infants delivered by cesarean section after the beginning of labor (P less than 0.001 for both comparisons). Exposure to labor did not affect the frequency of neonatal complications or later intellectual performance. Conclusions. For the fetus with uncomplicated meningomyelocele, delivery by cesarean section before the onset of labor may result in better subsequent motor function than vaginal delivery or delivery by cesarean section after a period of labor.

Cesarean Section↗
PubMed1991

Transcervical chorionic villus sampling and midtrimester oligohydramnios.

To study the possible association between transcervical chorionic villus sampling and midtrimester oligohydramnios, we conducted a prospective cohort study of all women who were seen for genetic counseling in the first trimester during a 2-year period. Women who chose chorionic villus sampling were compared with women who chose traditional amniocentesis for incidence of midtrimester oligohydramnios. Of 442 women exposed to chorionic villus sampling with a normal fetal karyotype, severe oligohydramnios developed in 12 (2.7%) at 16 to 23 weeks' gestation. None of the 391 women with normal fetal karyotypes who were counseled at the same time in pregnancy but who chose amniocentesis had oligohydramnios at the time of amniocentesis (p = 0.01). A nested case-control analysis was performed within the chorionic villus sampling group to evaluate risk factors associated with midtrimester oligohydramnios. Midtrimester oligohydramnios occurring after chorionic villus sampling was associated with postprocedure bleeding and elevated maternal serum alpha-fetoprotein (p less than 0.01). There were no perinatal survivors with midtrimester oligohydramnios.

Adult↗
PubMed1991

Enlarged cisterna magna and the Dandy-Walker malformation: factors associated with chromosome abnormalities.

Thirty-three fetuses with an enlarged cisterna magna (10 mm or more) were evaluated to determine factors that might be associated with an underlying chromosome abnormality. Eighteen fetuses (55%) proved to have a chromosome abnormality, including trisomy 18 or trisomy 18 variant (12), trisomy 13 (three), Turner syndrome (one), or other rearrangements (two). Among various risk factors analyzed, the absence of ventricular dilatation correlated most strongly with a chromosome abnormality. Chromosome abnormalities were found in 17 of 22 fetuses (77%) lacking ventricular dilatation, compared with only one of 11 fetuses (9%) with ventricular dilatation (P less than .001). Other factors statistically associated (P less than .01) with an underlying chromosome abnormality included mild enlargement of the cisterna magna (10-14 mm), concurrent anomalies detected sonographically, and fetal growth retardation. However, stepwise logistic regression showed that only the absence of ventricular dilatation and the presence of concurrent anomalies were significant when multiple factors were evaluated. These observations support the utility of evaluating the cisterna magna as part of a routine anatomical survey.

Cerebral Ventricles↗
PubMed1990

Effects of electronic fetal-heart-rate monitoring, as compared with periodic auscultation, on the neurologic development of premature infants.

In a multicenter, randomized clinical trial, we assessed the early neurologic development of 93 children born prematurely whose heart rates were monitored electronically during delivery and compared it with that of 96 children born prematurely whose heart rates were periodically monitored by auscultation. All the children were singletons with cephalic presentation, and all weighed less than or equal to 1750 g at birth. The mental and psychomotor indexes of the Bayley Scales of Infant Development (standardized mean score +/- SD, 100 +/- 16) and a formal neurologic examination were administered at three follow-up visits (at 4, 8, and 18 months of age, corrected for gestational age). At 18 months, the mean mental-development scores in the groups receiving electronic fetal monitoring and periodic auscultation were 100.5 +/- 2.4 and 104.9 +/- 1.8, respectively (P greater than 0.1). The mean psychomotor-development scores in the two groups at 18 months were 94.0 +/- 2.4 and 98.3 +/- 1.8, respectively (P greater than 0.1). The incidence of cerebral palsy was higher in the electronically monitored group--20 percent as compared with 8 percent in the group that was monitored by auscultation (P less than 0.03). In the electronic-fetal-monitoring group (but not in the periodic-auscultation group), the risk of cerebral palsy increased with the duration of abnormal fetal-heart-rate patterns, as assessed by retrospective review (chi 2 trend = 12.71, P less than 0.001). The median time to delivery after the diagnosis of abnormal fetal-heart-rate patterns was 104 minutes with electronic fetal monitoring, as compared with 60 minutes with periodic auscultation. We conclude that as compared with a structured program of periodic auscultation, electronic fetal monitoring does not result in improved neurologic development in children born prematurely.

Birth Weight↗