Biomedical subjects
Publications and source records attributed to Ihab M Usta.
Calcium channel blockers are becoming more popular as first-line tocolytic agents. Serious side effects have rarely been reported and involved mainly intravenous use of nicardipine. We report the first case of acute pulmonary edema following tocolytic oral nifedipine. Possible contributing factors are mentioned.
The objective of this study was to compare incidence of antenatal and intrapartum complications among women who had previously delivered five or more times (grandmultiparas cases, 155) with that of age-matched women with two to three previous deliveries (multiparas controls, 155) from 1998 to 2003. Grandmultiparity was associated with a low socioeconomic status, higher incidence of smoking, and a higher body mass index. Grandmultiparas had approximately 2-fold increased risk of gestational diabetes, hypertensive disorders, malpresentation, and preterm delivery, and a 3-fold increased risk of abruption; none reached statistical significance. No significant differences were found in antepartum hemorrhage, anemia, postdatism, polyhydramnios, or placenta previa. Intrapartum complications (labor induction, nonreassuring fetal heart, primary cesarean delivery, and intrapartum fever) were similar; however, operative vaginal delivery was significantly lower in grandmultiparas cases. Both groups were similar regarding birthweight, macrosomia, intrauterine growth restriction, Apgar scores, and stillbirth rates. Our study shows a trend toward an increased risk of adverse obstetrical outcome in grandmultiparas compared with multiparas independent of maternal age.
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Little is known about the outcome of pregnancy in women with beta-thalassemia intermedia (TI). Over 10 years, maternal and neonatal outcomes of women with TI followed at a single thalassemia center were reviewed. Nine spontaneous pregnancies in five women with TI were studied. Six pregnancies resulted in live newborns; two were complicated by first-trimester abortions and one by an unexplained intrauterine fetal death at 36 weeks' gestation. Two patients had splenectomy before pregnancy: one required cesarean delivery and splenectomy at 31(2/7) weeks' gestation for worsening hemolytic anemia and thrombocytopenia and another had splenectomy 8 weeks postpartum for symptomatic hypersplenism. Two patients had received transfusions before pregnancy, and two required them for the first time during pregnancy and developed antibodies, which contributed to worsening of their anemia and repeated transfusions. The mean number of transfusions received during pregnancy was 8.0 +/- 5.2 units. The mean lowest hemoglobin level in pregnancy was 5.2 +/- 2.0 g/dl. Cesarean delivery was performed in 42.9% of cases. Mean gestational age at delivery was 36.7+/- 3.1 weeks with intrauterine growth restriction (IUGR) complicating 57.1% of cases. In conclusion, IUGR complicates more than half of pregnancies with TI. Transfusions are needed in most cases, even in non-transfusion-dependent patients. Postpartum splenectomy might be necessary in some patients.
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BACKGROUND: Magnesium sulfate continues to be widely used as a tocolytic agent despite a paucity of evidence supporting its use. Many practitioners use prolonged courses of magnesium sulfate, sometimes for months. This study was conducted to determine maternal and neonatal outcome of patients exposed to prolonged tocolytic magnesium sulfate. METHODS: A retrospective review of maternal and neonatal charts (1995-2003) of pregnancies that received tocolytic magnesium sulfate. Cases who received magnesium sulfate >48 h (n=78) were compared to controls who received it < or =48 h (n=77) for maternal side effects and neonatal outcome. RESULTS: Cases were more likely to be nulliparous (55.1% versus 37.7%, p=0.044), multiple gestations (33.3% versus 10.4%, p=0.001), and of lower gestational age (29.0+/-3.9 versus 30.5+/-3.8 weeks, p=0.017) compared to controls. The median magnesium sulfate infused was 154 (78-5,500) versus 54 (8-86) g (p<0.001) and the highest maternal magnesium level was 6.5+/-1.7 versus 5.6+/-1.9 mg/dl (p=0.002) in cases and controls, respectively. Cases were more likely to have > or =1 adverse side effect (30.8% versus 15.6%, p=0.045). The median neonatal magnesium level was significantly higher in cases (3.3 (1.4-7.2) versus 2.6 (1.1-5.2) mg/dl, p=0.016); however, neonatal mortality and other neonatal morbidity rates were similar in both groups. Abnormal bone mineralization was encountered in 3 neonates (cases). CONCLUSIONS: Maternal morbidity rate is higher with prolonged intake of tocolytic magnesium sulfate compared to < or =48-h regimen. Despite similar neonatal morbidity and mortality rates, bone demineralization in the neonates may be encountered.
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OBJECTIVE: To assess the impact of the Women's Health Initiative (WHI) study on gynecologists' attitudes regarding hormone therapy (HT). METHODS: Questionnaires were mailed to a random sample of Lebanese gynecologists (n=178). The questionnaires solicited practice patterns of HT for postmenopausal women and information provided while counseling before and after the WHI study. Descriptive statistical methods were used to evaluate the responses. RESULTS: Questionnaires were returned by 140 physicians (78.7%), 93.6% of whom were aware of the WHI study. More than 90% of respondents routinely offered HT prior to the study. Of the 85.6% who used a combination of oral estrogen and progesterone (E/P), 40.0% used conjugated equine estrogen (CEE) and medroxyprogesterone acetate (MPA). Around 67% of gynecologists reported a change in their therapeutic approach after the study. The main changes were: not offering CEE+MPA (27.3%), prescribing CEE+MPA to a select group of patients (37.5%), using other forms of HT (56.8%), or abandoning any form of HT (6.8%). Other practice modifications included a shift to the use of tibolone (18.2%) or alternative therapies (29.5%). Whereas 76.2% of physicians counseled their patients about a decreased risk of cardiovascular events with HT prior to WHI study, only 34.1% continued to do so after the study (p<0.001). The percentage of gynecologists that inform their patients of an increased risk of breast cancer on HT rose from 45.2 to 73.2% (p=0.018). Almost 51% of gynecologists allow their patients to participate in decision making regarding the type of HT, 42.4% would choose for their patients after counseling, while 6.8% of physicians do not counsel their patients in order not to confuse them. CONCLUSION: In a representative sample of Lebanese gynecologists, there was a significant change in physicians' attitudes towards HT following the publication of the WHI study.
BACKGROUND: Fowler syndrome is characterized by hydranencephaly, brain stem and basal ganglion calcifications, a glomeruloid vasculopathy of the brain vessels, and a fetal akinesia deformation sequence with muscular hypoplasia. The natural progression of the ultrasonographic features of Fowler syndrome has never been described. METHODS: Case report and review of the literature. RESULTS: A primiparous woman with a negative ultrasound at 11 weeks of pregnancy was noted at 15 weeks to have fetal nuchal thickening, generalized skin edema, prominent lateral ventricles, akinesia with arthrogryposis, and pterygia. At 18 weeks, a cystic hygroma with facial edema, hypertelorism, and hydrocephaly were noted; the limb deformity was still evident. Within 1 week, the cystic hygroma regressed partially, but the hydrocephaly deteriorated. CONCLUSION: The multiple ultrasonographic features of Fowler syndrome may not occur simultaneously and their severity may vary with gestational age.
OBJECTIVE: The purpose of this study was to identify risk factors and complications of placenta previa-accreta (PA). STUDY DESIGN: Patients with placenta previa (n = 347) delivered over 20 years were reviewed, divided into PA (cases, n = 22) and no accreta (controls, n = 325), and compared. RESULTS: Cases were older with a higher incidence of smoking and previous cesarean delivery (CS). Grandmultiparity, recurrent abortions, anterior/central placentae, and low socioeconomic status were similar. PA incidence increased with the number of previous CS: 1.9%, 15.6%, 23.5%, 29.4%, 33.3%, and 50.0% after 0, 1, 2, 3, 4, and 5 previous CS, respectively. Hypertensive disorders (odds ratio [OR] 13.9, 95%CI 2.1-91.2], P = .006), smoking (OR 3.4, 95%CI 1.1-10.2, P = .031) and previous CS (OR 7.9, 95%CI 1.7-37.4, P = .009) were selected by the stepwise logistic regression analysis as predictors of PA. Cases had a longer hospital stay, a higher estimated blood loss, and need for transfusion. Cesarean hysterectomy and hypogastric artery ligation were only performed in PA cases. The 2 groups had a similar delivery gestational age and neonatal outcome. CONCLUSION: Hypertensive disorders, smoking, and previous cesarean are risk factors for accreta in placenta previa patients. Placenta previa-accreta is associated with higher maternal morbidity, but similar neonatal outcome compared with patients with an isolated placenta previa.
We present 2 unusual cases of prolapsed pedunculated submucous myomas. In 1 patient, the prolapsed part measured 12 cm, with a 64-cm intrauterine part. The second patient had prolapsed pedunculated submucous myoma, which subsequently retracted into the uterus. Gynecologists should be aware of unusual presentations of pedunculated submucous myoma to plan surgery.
We present a 35-year-old previously healthy primigravida who presented at 26(4/7) weeks of gestation with pancytopenia and hepatosplenomegaly. She received 10 transfusions and delivered at 34(4/7) weeks of gestation by cesarean section. Two months later following splenectomy, she was diagnosed with malaria. Physicians should have a high index of suspicion for malaria in the context of splenomegaly and pancytopenia in pregnancy even in the absence of fever.
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OBJECTIVE: To compare small-for-gestational-age (SGA) twins to appropriate-for-gestational-age (AGA) twins regarding preterm delivery (PTD). STUDY DESIGN: Retrospective review of maternal and neonatal records of live, nonanomalous twins > or = 25 weeks' gestation delivered in 1984-2000 in a tertiary care center. Pregnancies (N = 679) were divided into AGA/ AGA (n = 347), SGA-AGA (n = 191) and SGA/SGA (n = 141) groups using singleton growth curves. The PTD rate was compared and logistic regression analysis was done to study factors that influenced PTD at < or = 34 weeks. p < 0.05 was considered significant. RESULTS: The PTD rate at < or = 34 weeks was AGA/AGA (38.6%), SGA-AGA (14.7%) and SGA/SGA (1.4%) (p < 0.001). On multiple logistic regression analysis, discordance significantly increased PTD (OR = 5.05, 2.47-10.31, p = 0.001), while smallness for gestational age significantly decreased PTD (OR = 0.095, 0.05-0.17, p < 0.001). The PTD rate increased directly with the increase in the relative overall weight of the twins. CONCLUSION: The PTD rate is higher in AGA twins as compared to SGA twins. The PTD rate is directly related to the overall weight of the twins.
OBJECTIVE: This study was undertaken to evaluate the risks and pregnancy outcome in women with prosthetic heart valves on different anticoagulent regimens. STUDY DESIGN: A retrospective chart review of 82 pregnancies in 33 women with mechanical valve prostheses at a tertiary referral center from 1987 to 2002. The main outcome measures were major maternal complications and perinatal outcome. RESULTS: The valve replaced was mitral (60.6%), aortic (18.2%), and both (21.2%). Fifty-four pregnancies (65.9%) resulted in live births, 9 (11.0%) had stillbirths (all on warfarin), and 12 (14.6%) had spontaneous and 7 (8.5%) therapeutic abortions (all on warfarin). The rate of spontaneous abortion was highest in women on warfarin throughout pregnancy (P < .01). The live birth rate was higher in women on heparin compared with those on warfarin (P < .01), and in those on heparin/warfarin compared with warfarin alone (P < .01). There were no maternal deaths; however, 3 patients had mitral valve thrombosis (2 on heparin and 1 on warfarin) necessitating surgery in 1 patient and medical thrombolysis in 2 patients. Hemorrhagic complications occurred in 5 patients, 4 of whom required transfusion. CONCLUSION: No single anticoagulant regimen confers complete protection from thromboembolic phenomena in pregnancy. Despite a high maternal morbidity rate, the perinatal outcome is acceptable when pregnancy progresses beyond the first trimester.
BACKGROUND: Medical therapy for thrombosed valve in pregnancy has become an acceptable alternative to surgery, especially in hemodynamically compromised patients. Placental changes after thrombolytic therapy have rarely been reported. CASES: Sonograms were done within 24 hours after administration of thrombolytic agents at 15 and 26 weeks of gestation, respectively, in 2 women whose pregnancies were complicated with thrombosis of prosthetic mitral valves. Both patients developed massive subchorionic hematomas, which persisted in 1 patient who underwent cesarean delivery at 34 weeks of gestation for cardiac indications (Apgar scores 9 and 10 at 1 minute and 5 minutes, respectively). The hematomas resolved in the other patient, who delivered at term. CONCLUSION: Massive subchorionic hematomas may be observed in patients after thrombolytic therapy. Other reports are needed to establish whether such placental findings are common lesions after such therapy and to determine their impact on pregnancy outcome.
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