Biomedical subjects

J P VanDorsten

Publications and source records attributed to J P VanDorsten.

13 recordsLinked to original sources

PubMed2000

Risks of preeclampsia and adverse neonatal outcomes among women with pregestational diabetes mellitus. National Institute of Child Health and Human Development Network of Maternal-Fetal Medicine Units.

OBJECTIVES: This study was undertaken to determine the frequencies of preeclampsia and adverse neonatal outcomes among women with pregestational diabetes. STUDY DESIGN: This was a prospective observation of pregnancy outcomes among 462 women with pregestational diabetes mellitus (White classes B-F) and singleton pregnancies who were enrolled in a multicenter trial to compare low-dose aspirin with placebo for preeclampsia prevention. The main outcome measures were preeclampsia and neonatal outcomes. RESULTS: Among 462 women with pregestational diabetes, 92 (20%) had preeclampsia. Preeclampsia frequency rose significantly with increasing severity of diabetes according to White classification (class B, 11%; class C, 22%; class D, 21%; class R plus class F, 36%; P <.0001). Preeclampsia was also more common among women who had proteinuria at baseline (28% vs 18%; odds ratio, 1.75; 95% confidence interval, 1.02-3.01). Frequency of preterm delivery at <35 weeks' gestation rose greatly with increasing severity of diabetes (P =.0002). Women with proteinuria at baseline were significantly more likely to be delivered at <35 weeks' gestation (29% vs 13%; odds ratio, 2.6; 95% confidence interval, 1.5-4.6) and to have small-for-gestational-age infants (14% vs 3%; odds ratio, 5. 4; 95% confidence interval, 2.7-17.7), and they were less likely to have large-for-gestational-age infants (14% vs 40%; odds ratio, 0.2; 95% confidence interval, 0.1-0.5). CONCLUSION: Among women with pregestational diabetes mellitus, the frequency of preeclampsia rose with increasing severity of diabetes. Proteinuria early in pregnancy was associated with marked increases in adverse neonatal outcomes independent of preeclampsia development.

Aspirin↗

PubMed2000

The preterm prediction study: cervical lactoferrin concentration, other markers of lower genital tract infection, and preterm birth. National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network.

OBJECTIVE: This study was undertaken to determine the relationship among cervical lactoferrin concentration, other cervical markers potentially related to infection, and spontaneous preterm birth. STUDY DESIGN: Cervical lactoferrin concentrations obtained at 22 to 24 weeks' gestation among 121 women who had a spontaneous preterm birth <35 weeks' gestation were compared with cervical lactoferrin concentrations among 121 women matched for race, parity, and center who were delivered at >/=37 weeks' gestation. Results were compared against levels of cervical interleukin 6, fetal fibronectin, and sialidase, against cervical length according to ultrasonography, and according to the bacterial vaginosis Gram stain score. RESULTS: Cervical lactoferrin concentrations ranged from not measurable (19% of the concentrations were below the threshold for this assay) to a titer of >/=1:64. There was no significant difference in the overall distributions of lactoferrin concentrations between the case patients and control subjects (P =.18). Only when the highest titers of lactoferrin were considered were there more women in the spontaneous preterm birth group (6/121 vs 0/121; P =.03). According to Spearman correlation analyses the cervical lactoferrin concentrations were strongly related to interleukin 6 concentration (r =.51; P =.0001), sialidase activity (r =.38; P =.0001), and bacterial vaginosis (r =.38; P =.0001), were weakly related to fetal fibronectin (r =. 16; P =.01), and were not related to cervical length. With the 90th percentile (a dilution of 1:32) used as a cutoff to establish a dichotomous variable, lactoferrin concentration had the following odds ratios and 95% confidence intervals for associations with other potential markers of infection: bacterial vaginosis odds ratio, 4.8 (95% confidence interval, 2.2-10.3); interleukin 6 concentration odds ratio, 2.8 (95% confidence interval, 1.2-6.5); sialidase activity odds ratio, 5. 5 (95% confidence interval, 2.2-13.7); fetal fibronectin concentration odds ratio, 0.6 (95% confidence interval, 0.2-2.0); chlamydiosis odds ratio, 2.3 (95% confidence interval, 0.8-6.9); and short cervix odds ratio, 0.5 (95% confidence interval, 0.2-1.4). CONCLUSIONS: Lactoferrin found in the cervix correlated well with other markers of lower genital tract infection. High lactoferrin levels were associated with spontaneous preterm birth but had a very low predictive sensitivity.

Bacterial Infections↗

PubMed2000

The Preterm Prediction Study: sequential cervical length and fetal fibronectin testing for the prediction of spontaneous preterm birth. National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network.

OBJECTIVES: This study was undertaken to further elucidate the pathogenesis of preterm birth by means of traditional risk factors and new markers for preterm birth derived from the Preterm Prediction Study. STUDY DESIGN: A total of 3076 women (2929 with singleton gestations and 147 with twin pregnancies) were categorized according to the presence of risk factors including black race, low body mass index, the presence of bacterial vaginosis, and previous preterm birth. At 24 and 28 weeks' gestation cervical length was measured and categorized as short (</=25 mm) or normal (>25 mm). Vaginal and cervical fetal fibronectin concentrations were measured at 24, 26, 28, and 30 weeks' gestation and results were categorized as positive (>/=50 ng/mL) or negative (<50 ng/mL). RESULTS: At 24 to 26 weeks' gestation women with each of the risk factors were more likely to have positive fibronectin test results or to have a short cervix. Among women with negative fetal fibronectin results at 24 to 26 weeks' gestation those with a short cervix were more likely to have positive fetal fibronectin results at 28 to 30 weeks' gestation, and among those with normal cervical length those women who had positive fetal fibronectin results were more likely to have a short cervix at later evaluation. Most women who had positive fetal fibronectin results at 24 to 26 weeks' gestation had negative results at 28 to 30 weeks' gestation, whereas most but not all women who had a short cervix at 24 to 26 weeks' gestation still had a short cervix at 28 to 30 weeks' gestation. In each period women with both a positive fetal fibronectin result and a short cervix were at substantially increased risk of spontaneous preterm birth; women with either marker alone had intermediate and approximately equal risks of spontaneous preterm birth, and women without either marker had a low risk of spontaneous preterm birth. CONCLUSION: Regardless of other risk factors, a short cervix predicts a subsequent positive fetal fibronectin result, and a positive fetal fibronectin result predicts subsequent cervical shortening. These data do not support a single sequence of events leading to spontaneous preterm birth.

Biomarkers↗

PubMed1999

Indicated versus spontaneous preterm delivery: An evaluation of neonatal morbidity among infants weighing </=1000 grams at birth.

OBJECTIVE: The aim of the study was to determine whether infants weighing </=1000 g after birth who are born to women who undergo indicated preterm delivery have different neonatal outcomes than do those born as a result of either spontaneous preterm labor or preterm premature rupture of membranes. STUDY DESIGN: In a 1-year observational study (1992-1993) the National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network collected outcome data for 799 infants whose birth weights were </=1000 g. Only singleton infants with gestational age >20 weeks who were not produced as the result of an induced abortion were included. Our analysis was further limited to infants without major congenital anomalies who survived >2 days, were deemed potentially viable by the obstetrician, and would have undergone a cesarean delivery for fetal indications (N = 411). The primary reason for delivery was categorized as indicated delivery, spontaneous preterm labor, or spontaneous preterm premature rupture of membranes. Selected neonatal outcomes were evaluated among infants born to women in each of these groups. Logistic regression analyses were used to control for the effects of other potentially confounding variables. RESULTS: A total of 156 of the 411 infants were born to women who underwent an indicated preterm delivery, whereas 160 were born after spontaneous preterm labor and 95 were delivered after preterm premature rupture of membranes. Univariate analyses revealed significantly lower incidences of grade III or IV intraventricular hemorrhage, grade III or IV retinopathy of prematurity, and seizure activity among infants born in an indicated preterm delivery than among those born after spontaneous preterm labor or preterm premature rupture of membranes. However, infants of women who underwent indicated preterm delivery had a more advanced mean gestational age at birth than did those born after spontaneous preterm labor or preterm premature rupture of membranes (28 +/- 2 weeks, 26 +/- 2 weeks, and 26 +/- 1 weeks, respectively, P <.001). Multiple logistic regression analysis was therefore used to control for the disparity in gestational age. Multivariate analyses did not confirm the apparent improvement in neonatal outcome in the indicated delivery group. CONCLUSION: In this population of infants weighing </=1000 g, selected neonatal outcomes did not differ according to birth by indicated preterm delivery, spontaneous preterm labor, or preterm premature rupture of membranes.

Adult↗

PubMed1999

Obstetrical determinants of neonatal neurological morbidity in < or = 1000-gram infants.

The purpose of this study is to identify obstetrical factors associated with adverse neurological outcome in < or =1000-g infants. In a 1-year (1992-1993) observational study, the NICHD MFMU Network collected obstetrical risk factors for 486 infants who weighed < or =1000 g at birth and who survived > 2 days. Infants' records were abstracted for seizures, intraventricular hemorrhage, and an abnormal neurological evaluation. Seventy-nine (16%) infants had a Grade III or IV intraventricular hemorrhage, 46 (9%) developed seizures and 57 (14%) had an abnormal neurological evaluation. Both lower birth weight and earlier gestational age correlated (P <0.01) with an increasing incidence of all three outcomes. Several other factors appeared to be associated with neurological morbidity, however, after controlling for potential confounders in the multivariate analyses, most of these factors were no longer significant. African-American race, odds ratio (OR) 0.6 (0.3-1.0), and severe preeclampsia, OR 0.2 (0.1-0.7), were protective against intraventricular hemorrhage. Maternal treatment with corticosteroids did not impact neurological outcome in this study population. We conclude that, in a population of < or =1000-g infants, lower birth weight and earlier gestational age were the only consistently significant predictors of all three adverse neurological outcomes.

Alabama↗

PubMed1998

Fetal anomaly detection by second-trimester ultrasonography in a tertiary center.

OBJECTIVE: Our purpose was to determine the relative accuracy of indicated versus screening second-trimester ultrasonography for detection of fetal anomalies and to assess the cost effectiveness of anomaly screening. STUDY DESIGN: The study population consisted of 2031 pregnant women with singleton gestations who prospectively underwent ultrasonographic scanning between 15 and 22 weeks and received complete obstetric care at the Medical University of South Carolina between July 1, 1993, and June 30, 1996. Patients were divided into two groups: (1) indicated and (2) screening. The cost of screening ultrasonography was compared with the cost of newborn care for selected anomalous fetuses. RESULTS: Forty-seven fetuses (2.3%) were diagnosed by ultrasonography as having a major anomaly: 8.6% in the indicated group and 0.68% in the screening group (p=0.001). The sensitivity for detecting the anomalous fetus was 75.0% overall: 89.7% in the indicated group and 47.6% in the screening group (p=0.001). Of the 47 patients diagnosed with fetal anomalies, 11 (23.4%) chose pregnancy termination; of the 35 (74.5%) live-born anomalous infants, 29 (82.9%) were discharged alive. Projected newborn cost savings offset the cost of routine midtrimester screening. CONCLUSIONS: Detection of anomalous fetuses was significantly better in the indicated compared with the screening group. Nevertheless, routine ultrasonographic screening appeared cost-effective in our population.

Congenital Abnormalities↗

PubMed1997

Glucometer analysis of one-hour glucose challenge samples.

OBJECTIVE: Our purpose was to explore a cost-saving measure for diabetes screening by using glucometer testing on venous whole blood obtained after a 1-hour glucose challenge test. Glucometer results falling above an upper threshold would predict abnormal plasma values and mandate a glucose tolerance test; results below the lower threshold would predict normal plasma values and avoid further testing. Results between the thresholds would require traditional plasma analysis. STUDY DESIGN: We performed a prospective cohort study on 222 consecutive pregnant women. A standard 50 gm glucose screen was performed with venous blood drawn at 1 hour. We immediately removed a drop of whole blood from the venous sample and analyzed it on a portable glucometer, Accu-Chek III. The remaining sample was submitted immediately for routine plasma analysis. All values were obtained on the same glucometer, which was calibrated daily in our clinic laboratory. Regression analysis was performed on 129 samples to select the two thresholds. The selected thresholds were then applied prospectively to the next 93 consecutive samples for validation. RESULTS: Excellent correlation (r = 0.9045) exists between the glucometer and laboratory values. Glucometer threshold values of 110 mg/dl and 155 mg/dl were selected because they predicted plasma values < 135 mg/dl or > 135 mg/dl with 95% certainty, respectively. Prospectively, the thresholds were completely accurate in classifying the values. CONCLUSION: Venous whole blood assayed by glucometer can reliably predict an elevated or normal automated plasma glucose value. By applying thresholds, three fourths of all patients can immediately receive reassuring information, whereas the patients with poorest glucose tolerance are immediately identified and diagnostic testing is scheduled. Additionally, our model reduces the number of automated laboratory studies by 80% and reduces the cost of diabetic screening.

Blood Glucose↗

PubMed1995

Route of delivery for the breech presentation: a conundrum.

OBJECTIVE: Our purpose was to determine the feasibility of resolving the controversy regarding route of delivery for breech presentation in a randomized, prospective fashion. STUDY DESIGN: The National Institute of Child Health and Human Development-sponsored Maternal-Fetal Medicine Units Network, which is composed of 11 perinatal centers, was surveyed to determine the feasibility of a randomized clinical trial of cesarean section versus trial of labor for breech presentation. A review of the literature was performed to determine the experience of other investigators with designing and conducting an adequate prospective, randomized trial. RESULTS: Principal investigators and faculty from seven of 11 centers within the Maternal-Fetal Medicine Units Network agreed to participate adn felt that they could adequately recruit patients for a trial in very-low-birth-weight infants. This would provide approximately 200 very-low-birth-weight fetuses in a breech presentation per year. Sample size calculations indicated that 1700 infants would be required. Investigators also had strong reservations about performing a trial of vaginal breech delivery for other gestational ages. A review of the literature indicates that other authors have encountered difficulty in attempting randomized clinical trials of this nature. CONCLUSIONS: The Maternal-Fetal Medicine Units Network with its pool of 60,000 deliveries per year agreed that a randomized, controlled delivery route of labor in the 24- to 28-week breech presentation was not feasible in a reasonable period of time. A randomized clinical trial of larger fetuses in a breech presentation was also considered extremely difficult. These findings are similar to those of other authors who have attempted or proposed randomized clinical trials to determine the safety of planned vaginal delivery of the breech presentation at various gestational ages.

Breech Presentation↗

PubMed1993

Predicting success of external cephalic version.

OBJECTIVE: Many authors have identified prognostic factors for external cephalic version success, but there has not been an attempt to integrate these factors into a simple, quantitative scoring system for predicting version success. Nor have any prognostic factors been prospectively tested. STUDY DESIGN: We examined the clinical characteristics of 108 consecutive breech versions performed between 1984 and 1986. These characteristics were evaluated by stepwise linear regression and discriminate analysis to identify those factors associated with success. Five factors explained the majority of the variability in outcome (parity, placental location, dilation, station, and estimated fetal weight). A model was developed to incorporate the trends identified among these five variables to create a scoring system similar to that of Bishop. This scoring system was then applied to 286 women undergoing external cephalic version since October 1986. RESULTS: There was a positive relationship between a rising version score and the likelihood of successful breech version. No versions were successful with a score < or = 2, and all breech versions were successful with a score of 9 or 10. The results of the version score may have significantly altered physician recommendations in more than one third of cases. CONCLUSION: We believe that this simple, quantifiable scoring system is a refinement in our ability to predict the likelihood of external cephalic version success.

Body Weight↗

PubMed1993

Breech presentation.

This review covers recent literature relevant to breech presentation. Some have advocated routine elective cesarean delivery of the breech fetus of any gestational age to reduce the alleged increase in perinatal morbidity and mortality associated with breech presentation. This indication for cesarean delivery accounts for approximately 15% of all cesarean deliveries and costs society approximately US$ 1.4 billion per year. As a result of concerns with vaginal breech delivery, external cephalic version in the term fetus has become well accepted. A new scoring system has been developed to predict the success of external cephalic version. Repeated external cephalic version has been shown to be successful. Careful ultrasound continues to be important before the procedure. It has been suggested that magnetic resonance pelvimetry may be a practical alternative in evaluating candidates for breech vaginal delivery. There is still no compelling prospective data supporting cesarean delivery for preterm breech presentation. Legal considerations have prevented many from attempting vaginal breech delivery, even in carefully selected patients.

Breech Presentation↗

PubMed1991

An integrated, hospital information system based obstetrical medical record and database.

Described in this paper is the implementation and integration of an obstetrical medical record and database into an existing hospital information system. A unique feature of this system was the integration of existing data captured by the established hospital information systems with the newly implemented obstetrical database to form a complete patient data profile. This complete database integrated data from hospital functions such as demographic data obtained at patient registration, outpatient visits and tests, inpatient admission historical data, tests and procedures, newborn data and miscellaneous data required for birth registration. An important second feature was the utilization of physicians and nurses to enter the obstetrical data. This permitted immediate access to patient data from any hospital information system terminal, immediate retrieval for generating reports, and subsequently, ad hoc queries, statistical analysis and the electronic transfer of birth registration data to the State Vital Statistics Registry.

Academic Medical Centers↗

PubMed1984

External cephalic version with tocolysis. Observations and continuing experience at the Los Angeles County/University of Southern California Medical Center.

We considered 113 consecutive patients for attempted external cephalic version with tocolysis (ECV-T) after 37 weeks' gestation. We randomized the first patients to the control group (no ECV-T attempted, 23 patients) or the study group (ECV-T attempted, 25 patients). Nine patients were excluded, and ECV-T was then considered for 88 patients, with a success rate of 77% for the 104 total attempts. Six patients were lost to follow-up. In the successful ECV-T group, 71 of 75 patients (95%) presented the vertex in labor, while 4 patients (5%) reverted to breech. Uterine exploration at delivery revealed uterine anomalies in three of the patients who reverted. The cesarean rate was 25% in the successful-ECV-T group and 87% in the failed-ECV-T group. In the initial group, four patients (18%) spontaneously converted to cephalic presentations after 37 weeks. None of the failed-ECV-T patients spontaneously converted to cephalic presentations. The cesarean rate for the control and failed-ECV-T patients presenting the breech intrapartum was 88%. Complications included transient fetal bradycardia in 37 patients (36%), evidence of fetomaternal bleeding (positive Kleihauer-Betke test) in 2 patients (2%) and one fetal demise three weeks following successful ECV-T and diagnosed at the onset of labor. We lowered the cesarean section rate for breech presentation in labor with the selective application of ECV-T late in gestation. We consider this technique to be a powerful addition to our armamentarium for managing the term breech presentation.

Adrenergic beta-Agonists↗

PubMed1983

Pyelonephritis in pregnancy: a prospective randomized trial to prevent recurrent disease evaluating suppressive therapy with nitrofurantoin and close surveillance.

It has been advocated that if a patient develops acute pyelonephritis during pregnancy, she should receive suppressive therapy for the remainder of the gestation to prevent a recurrence of the disease. We have prospectively evaluated 200 patients following an acute episode of pyelonephritis during pregnancy. All patients were followed in a special clinic. Half the patients received nitrofurantoin as suppressive therapy. Recurrent pyelonephritis occurred in 7% of the patients receiving suppressive therapy versus 8% of those patients receiving close surveillance in the clinic. The results cast doubt upon the need for suppressive therapy and instead dramatized the beneficial effects of close surveillance with cultures. The data also suggest, at least in a high-risk population, that patients with gram-negative bacilluria of less than 10(5) colonies/ml may have a substantial risk of developing symptomatic recurrences. Prompt treatment of even low levels of gram-negative bacilluria should be considered in patients at risk for recurrent disease.

Bacteriological Techniques↗