Biomedical subjects

J S Sholl

Publications and source records attributed to J S Sholl.

18 recordsLinked to original sources

PubMed1998

Midtrimester amniocentesis. Influence of operator caseload on sampling efficiency.

OBJECTIVE: To evaluate the impact of operator caseload on the sampling efficiency for early and standard, midtrimester amniocentesis. STUDY DESIGN: Prospective ascertainment of genetic amniocenteses performed during 36 months, grouped into early (13-14 weeks' gestation) and standard procedures (15-20 weeks' gestation). Details of each amniocentesis were recorded immediately after sampling, and pregnancy outcomes were retrieved via questionnaires completed by the delivering physician. Sampling efficiency was evaluated separately in the early and standard cohorts in relation to operator caseload. RESULTS: In total, 193 and 707 patients underwent early and standard amniocentesis, respectively. Forty of 46 physician-operators performed < 50 total procedures during the study interval (group A). When compared to operators performing > or = 50 cases (group B, n = 6), a higher rate of single-pass success was noted among group B physicians for both early and standard procedures (A vs. B, early: 40/45 vs. 145/148, P = .018; standard: 243/295 vs. 384/412, P < .0001). Logistic regression confirmed an independent effect of physician caseload on sampling efficiency and a significant interaction between physician caseload and simultaneous ultrasound guidance in predicting single-attempt success. CONCLUSION: Operator caseload directly influenced sampling efficiency for both early and standard, midtrimester amniocentesis.

Adult↗

PubMed1998

Perinatal outcome associated with outpatient management of triplet pregnancy.

OBJECTIVE: Our goal was to compare the lengths of hospitalization and the perinatal outcomes of triplet pregnancies managed with either outpatient or inpatient third-trimester bed rest. STUDY DESIGN: Thirty-two triplet pregnancies in which outpatient bed rest was prescribed (April 1993 to April 1996) were compared with a historic cohort of 34 triplets (January 1985 to March 1993) in which routine hospitalization was undertaken in the third trimester. Length of hospitalization and maternal and neonatal outcome parameters were compared between groups. RESULTS: Maternal inpatient hospital days were significantly reduced for the group managed as outpatients, but combined maternal and neonatal hospitalization was similar between groups. The mean gestational age at delivery was 1 week greater in the hospitalized cohort (33.5+/-2.8 vs 32.5+/-2.8, respectively; p=0.16), and average birth weight was correspondingly greater in hospitalized cases (1942 gm vs 1718 gm, p < 0.005). Neonatal lengths of stay were similar between groups, reflecting earlier postnatal discharge in the outpatient era of this study. Preeclampsia occurred with greater frequency in the outpatient group (31.3% vs 8.8%, p=0.02), and the neonatal complication of intraventricular hemorrhage occurred more commonly in this cohort as well (10/96 vs 1/102, p=0.004). All other maternal and neonatal complications were similar between groups. CONCLUSION: Reduction in the length of hospitalization attributable to outpatient management was limited to the maternal length of stay. It is possible that the observed maternal and neonatal complications in the outpatient group may have been related to less rigorous bed rest. We would suggest that the differences noted in preeclampsia, birth weight, and intraventricular hemorrhage support prospective evaluation of bed rest in triplet pregnancy.

Adult↗

PubMed1997

Multifetal reduction increases the risk of preterm delivery and fetal growth restriction in twins: a case-control study.

OBJECTIVE: To compare pregnancy outcome in twin gestations resulting from multifetal reduction to "primary" twin pregnancies derived from either spontaneous conception or infertility therapy. DESIGN: Case-control study. SETTING: University-affiliated tertiary center. PATIENT(S): Multifetal pregnancies (quadruplets or more) reduced to twins (group A) compared with twin gestations conceived either spontaneously (group B) or through infertility therapy (group C). INTERVENTION(S): Multifetal reduction for group A; perinatal care for groups A, B, and C. MAIN OUTCOME MEASURE(S): Comparison of perinatal complications between groups including antepartum bleeding, premature membrane rupture, and preterm labor. Neonatal outcomes compared including gestational age at delivery, birth weight, incidence of fetal growth restriction, and twin discordancy. RESULT(S): A higher incidence of idiopathic preterm labor was noted in group A cases (14/18) compared with either of the control groups (B: 26/54, or C: 24/54). As a consequence, group A had the lowest gestational age at delivery (32.6 +/- 3.9 weeks) compared with groups B (33.6 +/- 4.4 weeks) and C (36.0 +/- 3.4 weeks). Corresponding birth weights of both first- and second-born twins were significantly lower in group A compared with group C, whereas the birth weight comparison between groups A and B showed a nonsignificant difference. The proportion of pregnancies in which one or both twins weighted less than the 10th percentile was greatest in group A pregnancies (A: 5/18 versus C: 5/54). Discordant birth weight among twin pairs was proportionately greater for group A cases at both the 20% and 30% discordance levels. CONCLUSION(S): Twin gestations resulting from multifetal reduction are at increased risk for preterm birth, fetal growth restriction, and discordancy when compared with fertility therapy-derived, nonreduced twins.

Adult↗

PubMed1995

Midtrimester Rh sensitization associated with circulating anticardiolipin antibodies and elevated maternal serum alpha-fetoprotein. A case report.

The incidence of antepartum Rh isoimmunization has been limited by third-trimester Rh immune globulin (RhIg) administration. Prophylactic failures are uncommon but can occur if sensitization takes place prior to the 28th week of gestation. We report a case of midtrimester Rh sensitization in an anticardiolipin antibody-positive primipara coincident with the discovery of an elevated maternal serum alpha-fetoprotein value, oligohydramnios and fetal growth retardation. This case suggests that fetal-maternal hemorrhage and subsequent sensitization may be facilitated by anticardiolipin antibody-induced placental damage. Prophylactic midtrimester RhIg administration might avoid sensitization in similar cases.

Adult↗

PubMed1993

Comparative trial of prednisone plus aspirin versus aspirin alone in the treatment of anticardiolipin antibody-positive obstetric patients.

OBJECTIVE: We compared the use of aspirin alone with combined therapy (prednisone plus aspirin) in antiphospholipid antibody-positive obstetric patients with prior adverse pregnancy outcome. STUDY DESIGN: Thirty-nine patients meeting specific laboratory and clinical inclusion criteria were randomized to receive either combined therapy (prednisone plus low-dose aspirin, n = 17) or aspirin alone (n = 22). The daily aspirin dose was 81 mg; prednisone was begun at 20 mg/day and increased or decreased on the basis of observed changes in serial antibody levels. Perinatal outcomes were compared between groups. Evaluation of treatment-related maternal complications and serial antibody titers was also accomplished. RESULTS: Thirty-four randomized subjects were evaluable (prednisone plus low-dose aspirin, n = 12 vs aspirin only, n = 22); no perinatal losses were observed in the study cohort. Preterm delivery was experienced by significantly more patients receiving prednisone plus low-dose aspirin than aspirin only (8/12 vs 3/22, respectively; p = 0.003), and prednisone exposure appeared to be an independent risk factor for preterm birth. CONCLUSIONS: The use of prednisone therapy in conjunction with low-dose aspirin does not appear to improve outcome and may provoke obstetric complications in antiphospholipid antibody-positive patients.

Adult↗

PubMed1993

Antenatal steroid therapy before 33 weeks' gestation.

OBJECTIVE: The purpose of this study was to determine those factors influencing contemporary antenatal steroid use in pregnancies delivered prior to 33 weeks of gestation. METHOD: We analyzed the clinical circumstances of 86 consecutive patients who delivered prior to 33 weeks of gestation and compared to 20 women who received dexamethasone prior to delivery with the remaining 66 untreated cases. RESULT: Known risk factors for preterm delivery (e.g. prior preterm birth, n = 17; prior admission and tocolysis during the index pregnancy, n = 15) did not discriminate between treated and untreated subsets. Premature membrane rupture (3/20 vs. 34/66; P < 0.01) and documented preterm labor (1/20 vs. 23/66 P < 0.01) were more common in the untreated cohort and a shorter mean interval from admission to delivery was also observed (2.8 vs 11.2 days). However, a full course of steroids would have been possible in 22/66 untreated women, since delivery was delayed for at least 36 h in these patients. CONCLUSION: These observations reflect the fact that many preterm births cannot be anticipated, even among hospitalized patients. We would therefore suggest that universal steroid treatment be considered for all women with documented preterm labor prior to 33 weeks of gestation. Initiation of steroid therapy at the referral center, (prior to maternal transport) should also be considered. Since both premature membrane rupture and early gestational age (24-28 weeks') confounded many of these cases, steroid use in patients with these circumstances should be reevaluated.

Cohort Studies↗

PubMed1991

Enhanced sensitization after cordocentesis in a rhesus-isoimmunized pregnancy.

It has been suggested that the optical density at 450 nm may be an unreliable predictor of the severity of fetal anemia in the midtrimester of pregnancy; therefore fetal blood sampling, rather than amniotic fluid evaluation, should be performed in all isoimmunized pregnancies with elevated maternal antibody titers in the midtrimester. Potential complications of such an approach are discussed and an alternative plan of management is offered.

Adult↗

PubMed1990

An evaluation of the chorionic villus sampling learning curve.

Prior studies have identified a correlation between the rate of fetal loss (subsequent to chorionic villus sampling) and the operator's level of experience. However, centers performing only modest numbers of procedures during the initial phase of their programs have reported loss rates similar to those of the more active diagnostic units. Our personal experience would suggest that a "learning curve" for chorionic villus sampling does exist but that fetal loss may be an insensitive end point with which to evaluate the impact of cumulative performance. In an attempt to quantify the learning curve that we have appreciated subjectively, a detailed analysis of our initial experience with chorionic villus sampling was undertaken. Between May 1988 and August 1989, a total of 185 procedures were accomplished consecutively by one operator and form the basis for this analysis. Transcervical (n = 82) and transabdominal (n = 103) techniques were used for posterior and anterior-fundal placental locations, respectively. Three pregnancy losses occurred and insufficient material for analysis was retrieved in five patients. We observed a significant reduction in the required number of placental aspirations during the study interval (p less than 0.001). When analyzed separately, consecutive performances of the transabdominal technique demonstrated a significant reduction in the mean number of placental passes (p less than 0.00001) along with more efficient sampling (increased sample weight/aspiration attempt; p less than 0.01). Although the fetal loss rate is a critical measure of safety and may directly be related to operator experience, other measures of expertise (e.g., single-pass success rate) may be more appropriate indicators of competence and may be useful to centers wishing to initiate their own chorionic villus sampling programs.

Abortion, Spontaneous↗

PubMed1990

Fetal posterior urethral valve syndrome: a prospective application of antenatal prognostic criteria.

A case of posterior urethral valve syndrome is presented. Four weeks after a normal 24-week ultrasound examination, diminished amniotic fluid, megacystis, and renal hyperechogenicity were observed. A repeat ultrasound examination at 30 weeks' gestation identified oligohydramnios and increased renal echogenicity. These findings prompted the performance of a percutaneous cystocentesis to assess fetal renal function indirectly. The specimen was evaluated for osmolality and sodium and chloride concentrations. The urine electrolyte concentrations (sodium 115 mEq/L; chloride 93 mEq/L) and the osmolality (230 mOsm/L) were elevated, suggesting impaired renal function and a poor prognosis. Despite these findings, aggressive management was used, including administration of antenatal corticosteroids and elective preterm delivery. A percutaneous cystocentesis was required during the infant's initial resuscitation, followed by a difficult urethral catheterization. Ultimately, a vesicostomy performed on day 4 of life was associated with prompt return of renal function (serum creatinine 0.7 mg/dL at the time of discharge). At 6 months of age, normal renal function has been documented and the vesicostomy has been closed. This case demonstrates the potential limitations of available prognostic criteria in evaluating fetal urinary obstruction and residual renal function. In selected cases (when the onset of obstruction is documented in the third trimester), refinement of these prognostic criteria may be indicated. Similar cases may be best managed by preterm delivery and prompt postnatal decompression.

Adult↗

PubMed1990

Initiating a chorionic villus sampling program. Relying on placental location as the primary determinant of the sampling route.

In initiating a chorionic villus sampling (CVS) protocol, we relied upon placental locations as the determinant in the choice of technique. An anterior or fundal location prompted a transabdominal (TA) CVS, while the transcervical (TC) approach was reserved for posterior placentas. A coaxial needle system was used for TA CVS (18-gauge, 15-cm guide needle and 20-gauge, 20-cm sampling needle), while TC CVS was accomplished with a 5.8-French, 27-cm polyethylene catheter. Between July 1988 and February 1989 our initial 118 procedures were performed for 115 consecutive pregnancies using this protocol. Testing indications and antenatal characteristics of the TA (n = 56) and TC (n = 63) groups were similar. One procedure failure occurred in the TC group, and a single aspiration was sufficient in 59% of the cases (TA, 30/55; TC, 39/63). In TC procedures an increased aggregate sample weight was observed as compared to TA cases (25.8 g vs. 16.9 g, respectively; P less than .001). This difference was not attributable to an increased number of placental aspirations in TC cases. One abnormal karyotype was observed (45X), and four pregnancy losses occurred (TC, 3; TA, 1). Using placental location to determine the choice of CVS technique appears to be feasible and may be associated with a lower failure rate during a facility's initial experience (when compared to reliance upon one technique alone). Trials comparing the safety of these two methods should consider placental location an independent variable before randomization.

Abdomen↗

PubMed1989

Prediction of hematocrit decline after intravascular fetal transfusion.

Fetal blood sampling and intravascular transfusion via cordocentesis allow more precise fetal evaluation and treatment in isoimmunized pregnancies. However, the timing of repeat transfusion has remained empiric. In this report we review our experience with fetal transfusions in isoimmunized pregnancies to evaluate the ability to predict fetal hematocrit decline and thereby determine the optimum timing for repeat transfusions. Between March 1986 and March 1988, 60 intravascular fetal transfusions were performed in 20 patients. Fetal transfusions were excluded from analysis if blood samples were unable to be obtained before and after transfusion, as well as at the beginning of the next transfusion or birth. Fifty-three procedures were analyzed. Two equations were used to predict the fetal hematocrit at the subsequent transfusion. The difference between observed and predicted hematocrits at the beginning of a subsequent transfusion or birth was -0.9% +/- 5.8% with equation 2, which was the more accurate formula in the majority of fetuses. Prediction of fetal hematocrit decline may be used to determine the optimum timing of repeat transfusion.

Blood Transfusion, Intrauterine↗

PubMed1987

Abruptio placentae: clinical management in nonacute cases.

One hundred thirty cases of clinically diagnosed abruptio placentae encompassing the wide range of acuity were grouped by gestational age at delivery into previable, preterm, and term divisions for comparison of demographic data, presenting symptoms, delay to delivery, mode of delivery, and delivery indications. Attention was focused on the preterm group of patients to assess the implications of presenting symptoms, the usefulness of ultrasonography, and the safety and efficacy of tocolysis. Cigarette smoking and a previous poor obstetric history were found to be more frequent in the preterm compared to the term abruptio placentae. Ultrasonic visualization of a clot was successful in 25% of the preterm patients but otherwise appeared to have little or no impact on course or management. Tocolysis for the preterm patients appeared to be beneficial in prolonging gestation and did not increase the likelihood of cesarean delivery, hemorrhage, or fetal distress. The cumulative rates of delivery following admission were compared with and without tocolysis, with and without sonographic visualization of a clot, and overall as a function of gestational age at initial hospitalization. Perinatal mortality was 17%. Inpatient management with frequent fetal heart rate monitoring, tocolysis if indicated, and timely use of cesarean delivery are advocated to promote prolongation of the pregnancy and minimized perinatal mortality.

Abruptio Placentae↗

PubMed1987

Pseudosarcoma botyroides in pregnancy: report of a case with ultrastructural observations.

A case of pseudosarcoma botryoides of the vagina diagnosed in advanced pregnancy is described. The cellular characteristics (atypical cells and abnormal mitoses) suggested malignancy, but ultrastructural studies demonstrated the fibroblastic nature of the cells, thus confirming the diagnosis of pseudosarcoma. Local excision and subsequent cesarean section was the method of treatment. Three years later, another pregnancy was terminated by repeat cesarean section and uncontrollable hemorrhage requiring emergency hysterectomy. The histologic study of the bleeding area revealed very edematous areas and lacunaelike endothelium-lined vessels. No cellular abnormalities were observed.

Adult↗

PubMed1985

Myotonic muscular dystrophy associated with ritodrine tocolysis.

A patient thought to be normal was admitted with premature labor at 29+ weeks' gestation. Treatment with the beta-mimetic ritodrine hydrochloride appeared to provoke symptoms of myotonic muscular dystrophy. Neurological history and examination confirmed the presence of previously unsuspected myotonic dystrophy in the patient, her father, and paternal grandfather. Discontinuation of the drug led to improvement in myotonia symptoms but worsening premature labor. Magnesium sulfate did not provoke the same symptoms but was unsuccessful in controlling premature contractions. Long-term management with bed rest, phenytoin, and isoxsuprine hydrochloride resulted in term delivery. Subsequently, maternal symptoms of myotonia disappeared. Congenital myotonia was suspected in the fetus because of the ultrasonic demonstration of polyhydramnios and reduced fetal movements. This was confirmed at delivery. The mechanism by which ritodrine unmasked the myotonia is unclear but may be related to changes in the cell membrane (chloride conductance, the sodium-potassium pump, or membrane polarization).

Adult↗

PubMed1984

Cesarean section. Assessment of the convenience factor.

To assess the potential input of physician convenience on the performance of cesarean sections (C-sections), analysis of C-sections by time of day and day of the week was undertaken at four Chicago-area hospitals. The primary C-section rate at the University of Chicago Chicago Lying-In Hospital, with a relatively high-risk patient population and a full-time salaried resident and faculty staff, was lower than at three other hospitals staffed predominantly by private practitioners. Indications for primary C-sections were classified as "acute," "semiacute" or "nonacute." Acute and semiacute C-sections were performed without demonstrated time biases in regard to the time of day or the day of the week at all four hospitals. Nonacute C-sections (70% cephalopelvic disproportion) were not performed as frequently at night (12-8 A.M.) as at other times at three of the four hospitals, but there were no differences in the individual characteristics of the outcomes of such deliveries between day and night. There was also no Friday afternoon or Monday morning frequency increase. The data failed to reveal significant variations in the performance of acute C-sections but did show day-night variability in C-sections done for non-acute indications.

Appointments and Schedules↗

PubMed1983

Postdates pregnancy. Assessment of fetal risk and obstetric management.

Two hundred forty-eight well-dated pregnancies that exceeded their expected dates of confinement were followed with serial maternal urinary or plasma estriol determinations and weekly fetal heart rate tests. Most pregnancies (176) delivered after spontaneous labor, while 72 had labor induced for abnormal test results or electively. Perinatal mortality (8.1/1,000) was comparable to that of our term (37-40-week) population; the two deaths occurred in the 43rd week. Intrapartum fetal distress, meconium staining, postmaturity syndrome and primary cesarean section rates all increased with gestational age beyond the 40th week. Induced labors, irrespective of indication, were significantly longer than spontaneous ones and were associated with higher rates of fetal distress and primary cesarean section. In the study group, fetal distress often arose during labor and was not anticipated by the antenatal testing.

Female↗

PubMed1982

Intrauterine growth retardation risk detection for fetuses of unknown gestational age.

A method of plotting growth rate of the biparietal diameter against the concurrent size of the biparietal diameter was used to assess risk of intrauterine growth retardation. The technique does not require knowledge of gestational age of the fetus. Therefore, it is uniquely useful for patients with unknown or uncertain menstrual dates who present relatively late in pregnancy when a reliable estimate of gestational age cannot be sonographically obtained. One hundred twenty-one patients were studied. Ninety-seven percent of the fetuses who demonstrated a normal rate of growth were either appropriate or large for gestational age by weight. Thirty-five percent of the fetuses who had a subnormal rate of growth of the biparietal diameter were intrauterine growth retarded by weight. The data presented support the use of this technique for assessing the risk for intrauterine growth retardation, when an accurate estimate of gestational age account be made.

Age Determination by Skeleton↗

PubMedDate not supplied

In utero diagnosis of pericardial tumor with successful surgical repair.

A large intrapericardial tumor with pericardial effusion was diagnosed by ultrasound examination in a 32-week gestation fetus. Serial in utero examinations excluded fetal hydrops and normal labor ensued at 38 1/2 weeks. After delivery by Caesarian section, pericardiocentesis and subsequent successful surgery were performed. The tumor was found to be a cavernous hemangioma arising within the pericardium and adherent to the right atrial wall.

Adult↗