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Biomedical subjects

J A Bofill

Publications and source records attributed to J A Bofill.

At least 19 recordsLinked to original sources
PubMed2001

Maternal morbidity and mortality associated with intrauterine fetal demise: five-year experience in a tertiary referral hospital.

BACKGROUND: Risk factors for and management of intrauterine fetal demise (IUFD) have been investigated, but the maternal morbidity has not been evaluated. METHODS: Over a 60-month interval, all cases of IUFD after 20 weeks' gestation were reviewed for maternal trauma and maternal postpartum complications. RESULTS: In this retrospective analysis, 498 singleton and 24 twin pregnancies with an IUFD were identified. A cervical or perineal laceration requiring surgical repair complicated 9.4% of pregnancies. One uterine dehiscence and one uterine rupture occurred. Endometritis, the most common postpartum complication, occurred in 63 of 522 patients (12%). One maternal death occurred. Total mean hospital stay was 4.9 +/- 5.7 days. CONCLUSION: Maternal morbidity and rarely mortality can follow IUFD, but this morbidity is similar to that observed without IUFD.

Adult↗
PubMed2000

Instrumental delivery of the fetal head at the time of elective repeat cesarean: a randomized pilot study.

We sought to ascertain whether the routine use of instruments, forceps or vacuum, at the time of elective repeat cesarean delivery, permits a delivery that is as safe for mother and infant and as easy for mother and physician as traditional manual delivery of the fetal head. In this prospective study 44 women undergoing elective repeat cesarean were randomized to deliver by Vacuum (V), Forceps (F), or by Manual (M) means. Groups were compared with regard to demographic variables and maternal and neonatal outcomes. Deliveries were timed from entry into the uterus until full delivery of the infant. Maternal pain scores were assessed using a 10-cm visual analog scale. There were no differences in demographic variables except that the M group had fewer women with up to two cesareans. A large percentage of women in each group were delivered with the randomized instrument. Use of the V did not demonstrate fewer extensions of the uterine incision or lesser amounts of blood loss as measured by serial hemoglobin determinations. There was a trend for the F group to require a longer period of time for delivery (p = 0.061). Women in the V group reported significantly lower pain scores (p = 0.015). There were no serious neonatal injuries. The routine use of instruments at the time of elective repeat cesarean delivery appears safe and effective.

Adult↗
PubMed1999

Sequential use of instruments at operative vaginal delivery: is it safe?

OBJECTIVE: Our purpose was to examine maternal and neonatal outcomes in a cohort of women who underwent delivery with the sequential use of instruments. STUDY DESIGN: This retrospective case-control study included deliveries from May 1996 through March 1998. Charts of women who underwent delivery with the sequential use of instruments (vacuum first, then forceps, or vice versa) were identified. Two control groups (1 forceps group, 1 vacuum group) were randomly selected and matched for each case. Maternal and neonatal outcomes were abstracted and compared. RESULTS: There were 34 patients in each group. There were no significant demographic differences. The vacuum group had lower rates of episiotomy (P =.01) and deep perineal lacerations (P =.014), whereas these outcomes were similar in the sequential and forceps groups. All other maternal outcomes were equivalent. There were no differences in any neonatal parameter except for superficial scalp trauma, which was more common in the vacuum group (P =.002). CONCLUSION: We conclude that the prudent use of sequential instruments at operative vaginal delivery did not engender higher rates of maternal or neonatal morbidity.

Adult↗
PubMed1999

Familial inheritance of mandibular arch malformations affecting three individuals in one family.

Mandibular aplasia is defined as incomplete development of the mandibular process of the first brachial arch. Its prevalence is less than 1:70,000. It is usually associated with low-set ears, transposition of the viscera, congenital heart defects, and rib abnormalities, and is incompatible with life. In this case report, fetal demise at 26 weeks' gestation in a previous pregnancy revealed the phenotypic features listed. The second pregnancy described here resulted in therapeutic termination of a similar appearing fetus. Because of this recurrence and a positive family history, familial inheritance is postulated.

Abnormalities, Multiple↗
PubMed1999

DNA probe for beta-hemolytic group B Streptococcus. Diagnostic accuracy in threatened preterm labor.

OBJECTIVE: To determine the diagnostic accuracy of a DNA probe for beta-hemolytic group B Streptococcus (GBS) in women with threatened preterm labor. STUDY DESIGN: Two identical vaginal/perianal samples were collected from 75 pregnant women who were being evaluated for threatened preterm labor. One sample was managed in the traditional manner, with direct plating onto blood agar followed by plating after 8 and 24 hours of LIM broth enhancement. The "gold standard" was 24 hours of LIM broth enhancement followed by blood agar plating. The second sample was placed in LIM broth, and DNA probe testing was performed after incubation for 8 and 24 hours. RESULTS: The prevalence of GBS colonization by the gold standard culture was 32%. After 8 hours of incubation in LIM broth, the DNA probe had poor sensitivity (79%); however, after 24 hours of incubation in LIM broth the DNA probe sensitivity rose to 96%. The DNA probe demonstrated only one false negative result after 24 hours of LIM broth enhancement. All DNA probe results were known 25 hours after sample collection. CONCLUSION: This DNA probe gave results nearly identical to those of standard cultures and allowed a substantial saving of time.

Adult↗
PubMed1999

Pregnancy complicated by traumatic diaphragmatic rupture. A case report.

BACKGROUND: Diaphragmatic rupture may be easily overlooked at the time of multiple trauma. Occult diaphragmatic rupture may first manifest during pregnancy as severe dyspnea. CASE: A parous woman who had sustained multiple traumatic injuries prior to pregnancy presented in midtrimester with abdominal pain and dyspnea. Chest roentgenography and computed tomography revealed bowel in the left hemithorax, compatible with a left-sided diaphragmatic rupture. Surgical correction was indicated secondary to the symptomatic nature of the presentation. CONCLUSION: Diaphragmatic rupture may be occult and may first present during a subsequent pregnancy. Surgical therapy is the cornerstone of management when a diaphragmatic defect is symptomatic. The route of delivery may be individualized for patients with diaphragmatic repairs in whom there has been sufficient time for healing.

Adolescent↗
PubMed1998

Obstetric sonography. Who to scan, when to scan, and by whom.

Most patients in the United States have an indication for and receive sonography during pregnancy. The issue of routine sonography for low-risk women continues to be contentious even though the randomized trials have not been able to demonstrate a clear benefit. Clinics that routinely offer sonography for all pregnancies usually schedule such a procedure at 16 to 20 weeks of gestation. Although great progress is being made in the first-trimester diagnoses of congenital anomalies, most targeted studies are performed at 18 to 20 weeks of gestation. Although many private obstetricians perform in-office sonography, the highest rates of detection of congenital anomalies are seen in tertiary care settings such as a university medical center. In difficult or otherwise high-risk cases, a consulting perinatologist is commonly the physician most likely to integrate the ultrasound findings with a rational management plan for the remainder of the pregnancy and for delivery.

Clinical Competence↗
PubMed1998

Ascertainment of 68,XX double aneuploidy by midtrimester biochemical screening: a case report.

A fetus with 68,XX karyotype was ascertained by an elevated midtrimester MSHCG. By antenatal ultrasound, the only unusual finding was in relation to the placenta. Preterm delivery was mandated by the development of severe preeclampsia. Postmortem examination of the stillborn fetus demonstrated no abnormal physical findings other than bilateral syndactyly of fingers and toes.

Adolescent↗
PubMed1998

Fatal maternal beta-hemolytic group B streptococcal meningitis: a case report.

Meningitis secondary to beta-hemolytic group B streptococcus is rare and represents less than 1% of cases of adult meningitis. We report the first known case of maternal mortality attributed to beta-hemolytic group B streptococcal meningitis. A 23-year-old African-American woman with a benign prenatal course delivered a viable male infant at term. Labor was complicated by thick meconium for which a saline amnioinfusion was utilized. On postpartum Day 1, the patient complained of right hip pain and a headache. Within 12 hr the patient was comatose with fixed and dilated pupils. Life support measures were discontinued secondary to absence of electrocortical activity. Postmortem examination revealed endomyometritis and fulminant meningitis with gram-positive cocci. Placental histologic sections demonstrated acute chorioamnionitis and bateriological cultures noted beta-hemolytic group B streptococcus. The virulence of beta-hemolytic group B streptococcus in the neonate is well recognized. This case demonstrates that beta-hemolytic group B streptococcus is also a potentially fatal maternal pathogen.

Adult↗
PubMed1998

Prophylactic angiotensin II infusion during spinal anesthesia for elective cesarean delivery.

BACKGROUND: Angiotensin II may prove useful in treating regional anesthesia-induced hypotension in obstetric patients, because it causes less uterine vasoconstriction than do other vasoconstrictor drugs (such as phenylephrine). This study compared (1) maternal blood pressure and heart rate and (2) fetal status at delivery in parturients given either prophylactic angiotensin II or ephedrine infusion during spinal anesthesia for elective cesarean delivery. METHODS: Fifty-four women were randomized to receive either angiotensin II or ephedrine infusion intravenously during spinal anesthesia for elective cesarean section delivery. Simultaneous with subarachnoid injection, infusion of angiotensin II (2.5 microg/ml) or ephedrine (5 mg/ml) was initiated at 10 ng x kg(-1) x min(-1) and 50 microg x kg(-1) x min(-1), respectively. The rate of each infusion was adjusted to maintain maternal systolic blood pressure at 90-100% of baseline. RESULTS: Cumulative vasopressor doses (mean+/-SD) through 10, 20, and 30 min were 150+/-100, 310+/-180, and 500+/-320 ng/kg in the angiotensin group and 480+/-210, 660+/-390, and 790+/-640 microg/kg in the ephedrine group. Maternal heart rate was significantly higher (P < 0.001) during vasopressor infusion in the ephedrine group than in the angiotensin group. Umbilical arterial and venous blood pH and base excess were all significantly higher (P < 0.05) in the angiotensin group than in the ephedrine group. CONCLUSIONS: Angiotensin II infusion maintained maternal systolic blood pressure during spinal anesthesia without increasing maternal heart rate or causing fetal acidosis.

Acid-Base Equilibrium↗
PubMed1997

A randomized trial of epidural anesthesia to improve external cephalic version success.

OBJECTIVE: This study was designed to determine whether epidural anesthesia would improve external cephalic version success in a safe and effective manner. STUDY DESIGN: All women > 37 weeks' gestation with breech presentation scheduled for external cephalic version at the medical center from Dec. 1, 1993, to July 31, 1996, were randomized to receive an epidural or no epidural anesthesia. Under ultrasonographic guidance up to three version attempts were performed. RESULTS: Sixty-nine women were randomized to receive epidural (n = 35) versus no epidural (n = 34) anesthesia for external cephalic version. There were no statistically significant differences in maternal age, parity, maternal weight, gestational age, estimated fetal weight, or station of the presenting part. The success rate was better for the epidural group (relative risk 2.12, 95% confidence interval 1.24 to 3.62). Neither anterior placentation or oligohydramnios affected the success rate. CONCLUSION: Epidural anesthesia increases success of external cephalic version without any apparent detrimental effect on the maternal-fetal unit.

Adult↗
PubMed1997

Nulliparous active labor, epidural analgesia, and cesarean delivery for dystocia.

OBJECTIVE: Our purpose was to examine the effect of epidural analgesia on dystocia-related cesarean delivery in actively laboring nulliparous women. STUDY DESIGN: Active labor was confirmed in nulliparous women by uterine contractions, cervical dilatation of 4 cm, effacement of 80%, and fetopelvic engagement. Patients were randomized to one of two groups: epidural analgesia or narcotics. A strict protocol for labor management was in place. Patients recorded the level of pain at randomization and at hourly intervals on a visual analog scale. Elective outlet operative vaginal delivery was permitted. RESULTS: One hundred women were randomized. No difference in the rate of cesarean delivery for dystocia was noted between the groups (epidural 8%, narcotic 6%; p = 0.71). No significant differences were noted in the lengths of the first (p = 0.54) or second (p = 0.55) stages of labor or in any other time variable. Women with epidural analgesia underwent operative vaginal delivery more frequently (p = 0.004). Pain scores were equivalent at randomization, but large differences existed at each hour thereafter. The number of patients randomized did not achieve prestudy estimates. A planned interim analysis of the results demonstrated that we were unlikely to find a statistically significant difference in cesarean delivery rates in a trial of reasonable duration. CONCLUSIONS: With strict criteria for the diagnosis of labor and with use of a rigid protocol for labor management, there was no increase in dystocia-related cesarean delivery with epidural analgesia.

Adult↗
PubMed1997

A randomized trial of two vacuum extraction techniques.

OBJECTIVE: To determine whether two techniques of vacuum extraction delivery-continuous vacuum and intermittent vacuum-have different effects on maternal-fetal outcomes. METHODS: Patients to be delivered by vacuum extraction were randomized to receive continuous or intermittent vacuum. All deliveries were performed using the M-cup. In the continuous group, the level of vacuum was brought to 600 mmHg between contractions and was maintained at that level until delivery of the infant. Active efforts were made to prevent fetal loss-of-station between contractions by maintaining traction. In the intermittent group, the level of vacuum was decreased to 100 mmHg between contractions and no effort was made to prevent fetal loss-of-station. RESULTS: A total of 322 patients were randomized: 164 in the continuous arm and 158 in the intermittent group. The continuous method did not effect delivery faster (continuous 167 +/- 175 seconds versus intermittent 167 +/- 150 seconds; P = .97), nor did it lead to a reduction in method failures (continuous 12, intermittent nine; P = .72). The intermittent method did not appear to offer any benefit to the neonate regarding cephalhematoma formation (continuous 20, intermittent 17; P = .686) or any other measure of neonatal outcome. Maternal lacerations and episiotomy extensions were evenly distributed between the groups. Overall, the efficacy rate of the vacuum cup was 93.5% and the cephalhematoma rate was 11.5%. CONCLUSION: No differences in maternal or fetal outcome could be demonstrated if the level of vacuum was decreased between contractions or if an effort was made to prevent fetal loss-of-station. The clinical results obtained in this trial using the M-cup are similar to the published results with the stainless-steel Malmstrom cup.

Adult↗
PubMed1997

The origin of endothelin-1 in patients with severe preeclampsia.

OBJECTIVE: To determine the site of origin of increased concentrations of plasma endothelin-1 in patients with severe preeclampsia. METHODS: Twelve patients with severe preeclampsia undergoing an indicated abdominal delivery had endothelin-1 levels measured from plasma specimens drawn from right and left uterine and antecubital veins before delivery and after placenta removal with uterine curettage. Twelve uncomplicated control patients undergoing abdominal delivery had endothelin-1 concentrations drawn by an identical protocol. Clinical staff members were blinded to endothelin-1 results and laboratory staff were blinded to patient group assignment and sample source. Endothelin-1 plasma concentrations were determined by radioimmunoassay and data were analyzed by paired t test. RESULTS: No difference in endothelin-1 concentration was noted with respect to placental location, central versus peripheral, or predelivery versus postdelivery sampling procedures. Overall, patients with preeclampsia had higher plasma concentrations of endothelin-1 (mean 11.0 +/- 6.6 pg/mL) compared with normotensive patients (mean 8.4 +/- 6.7 pg/mL, P < .005). CONCLUSION: The decidual-placental interface does not appear to be the source of increased plasma endothelin-1 concentrations found in severe preeclampsia. The origin of this increase remains uncertain.

Adult↗
PubMed1997

Neonatal cephalohematoma from vacuum extraction.

OBJECTIVE: To identify factors involved in the development of fetal cephalohematoma from vacuum extraction. STUDY DESIGN: Patients at > or = 34 weeks' gestation were randomly assigned to delivery by vacuum (n = 322) using the continuous (n = 164) or intermittent (n = 158) technique. Neonatal outcome with cephalohematoma was analyzed subsequently and related to prospectively recorded data. RESULTS: Approximately equal numbers of cephalohematoma were recorded in the two groups (continuous 20, intermittent 17; P = .686). Station at point of application (P = .008), increasing asynclitism (P < .001) and increasing application to delivery time (P = .002) correlated significantly with cephalohematoma. Only the last two factors achieved significance after stepwise multiple logistic regression analysis. Factors that did not achieve statistical significance were gestational age (P = .755), birth weight (P = .982), instrumental rotation (P = .896) and previous vaginal delivery (P = .051). CONCLUSION: In this prospective, randomized, controlled trial of vacuum-assisted delivery, the only predelivery factor found to predispose to neonatal cephalohematoma formation was increasing asynclitism. Although cephalohematoma formation was more likely to develop as the duration of vacuum application increased during delivery, only 28% of neonates exhibited this finding when the time from vacuum application to delivery exceeded five minutes.

Female↗
PubMed1996

Forceps and vacuum delivery: a survey of North American residency programs.

OBJECTIVE: To document resident instruction in operative vaginal delivery by forceps and vacuum. METHODS: A survey was sent to all 291 obstetrics-gynecology training programs in the United States and Canada. RESULTS: The overall response rate was 72% (210 of 291). Most programs (60%) have an operative vaginal delivery rate of 10% or less. Nearly all of the responding programs (199 of 209, 95%) teach operative vaginal delivery via the vacuum route; metallic cups are used in only 14% of centers. Forceps are the primary instrument in most programs (68%), but nearly one-third of responding centers use the vacuum method more often than forceps. Instruction in midpelvic operative vaginal delivery is offered in 64% of the programs, with forceps being more common by nearly a two-to-one ratio. Deep transverse arrest is handled initially by forceps by half of the respondents, whereas 28 and 22% would proceed with cesarean or attempt a vacuum extraction, respectively. CONCLUSION: Instruction in both types of operative vaginal delivery is found in most programs. The forceps are used more commonly, but vacuum is the preferred instrument in about one-third of training programs. Instruction in midpelvic delivery is offered in 64% of programs, but we noted a declining trend.

Canada↗