Biomedical subjects
Publications and source records attributed to Luis Sanchez-Ramos.
A 31-year-old woman with a history of laparoscopic Roux-en-Y gastric bypass surgery presented at 25 6/7 weeks' gestation with complaints of abdominal pain. Maternal death followed midgut volvulus, perforation, and septic shock.
The rate of labor induction continues to rise significantly in the United States because of a growing use of labor induction for postterm pregnancies and elective induction of labor. Although different types and doses of prostaglandins used for cervical ripening often initiate uterine activity, the principal role of these agents is to soften the unripe cervix independent of uterine activity. Several systematic reviews with meta-analyses have shown that prostaglandins are superior to placebo and oxytocin alone in ripening of the cervix. Numerous studies and meta-analyses have assessed misoprostol's efficacy and safety as a labor induction agent. The most appropriate dose and route of administration has not yet been confirmed.
OBJECTIVE: To perform an updated systematic review with meta-analysis to further elucidate the efficacy of progestational agents for the prevention of preterm births in patients at elevated risk. DATA SOURCES: Computerized databases, references in published studies, and textbook chapters in all languages were used to identify randomized controlled trials (RCTs) evaluating the use of progestational agents for the prevention of preterm births in women at elevated risk. METHODS OF STUDY SELECTION: We identified RCTs that compared progestational agents with placebo for patients at risk for preterm birth and evaluated at least one of the following: delivery before 37 weeks of gestation, birth weight less than 2,500 g, threatened preterm labor, respiratory distress syndrome, and perinatal mortality. The primary outcomes assessed were preterm delivery and perinatal mortality. TABULATION, INTEGRATION, AND RESULTS: Ten studies met inclusion criteria for this review. For each study with binary outcomes, an odds ratio (OR) with 95% confidence intervals (CIs) was calculated for selected outcomes. Homogeneity was tested across the studies. Compared with women allocated to receive placebo, those who received progestational agents had lower rates of preterm delivery (26.2% versus 35.9%; OR 0.45, 95% CI 0.25-0.80). Similar results were noted when comparing patients who were specifically treated with 17alpha-hydroxyprogesterone caproate (29.3% versus 40.9%; OR 0.45, 95% CI 0.22-0.93). Additionally, subjects allocated to receive 17alpha-hydroxyprogesterone caproate had lower rates of birth weights less than 2,500 g (OR 0.50, 95% CI 0.36-0.71). No differences in rates of hospital admissions for threatened preterm labor or perinatal mortality were noted for subjects receiving progestational agents in general or for those receiving only 17alpha-hydroxyprogesterone caproate specifically. CONCLUSION: The use of progestational agents and 17alpha-hydroxyprogesterone caproate reduced the incidence of preterm birth and low birth weight newborns.
OBJECTIVE: To compare the effectiveness of 50 microg compared with 100 microg of repetitive misoprostol dosages administered sublingually for labor induction. METHODS: Two hundred twelve women who presented with an indication for cervical ripening and labor induction were randomly assigned to 50 microg or 100 microg of misoprostol tablets administered sublingually with double masking of treatment group dose allocation. The primary outcome was the interval from start of induction to vaginal delivery. RESULTS: Among the 203 evaluable participants, 102 were randomly assigned to the 50-microg group and 101 to the 100-microg group. The proportion of patients who delivered vaginally in less than 12 hours and less than 24 hours was significantly higher in the 100-microg group: 28% and 63% in the 100-microg group compared with 15% and 36% in the 50-microg group, respectively (P = .01 and P = .001). The incidence of tachysystole was significantly higher in the 100-microg group (P = .02). The incidence of hyperstimulation syndrome was higher in the 100-microg group, but not statistically significant (P = .46). With respect to the proportion of patients delivered after a single dose, mode of delivery, and perinatal outcome, no significant differences between treatment groups were observed. Regarding the need for oxytocin augmentation, 61% required augmentation in the 100-microg group compared with 81% in the 50-microg group (P = .002). CONCLUSION: One hundred micrograms of sublingual misoprostol is more effective than 50 microg of sublingual misoprostol, but is associated with a higher incidence of tachysystole and uterine hyperstimulation syndrome. LEVEL OF EVIDENCE: I.
OBJECTIVE: To systematically review and summarize the medical literature regarding the effects of tocolysis with indomethacin on neonatal outcome. DATA SOURCES: We supplemented a search of entries in electronic databases with references cited in original studies and review articles to identify studies pertaining to indomethacin tocolysis and neonatal outcome. METHODS OF STUDY SELECTION: We evaluated, abstracted data, and performed quantitative analyses in studies assessing the neonatal outcomes of patients undergoing tocolysis with indomethacin. Observational studies and randomized trials were included in this systematic review. TABULATION, INTEGRATION, AND RESULTS: Forty-six studies were identified, 28 of which met criteria for systematic review and meta-analysis. These 28 studies included 6,008 infants. Of these infants, 1,621 were exposed to indomethacin for tocolysis antenatally; 4,387 infants not exposed to indomethacin served as the comparison group. An estimate of pooled odds ratios with 95% confidence intervals was calculated for dichotomous outcomes using random- and fixed-effects models. Observational studies and randomized trials were analyzed separately. Pooled estimates from observational studies and randomized trials revealed no significant differences in the rates of intraventricular hemorrhage, patent ductus arteriosus, necrotizing enterocolitis, or neonatal mortality between infants exposed to indomethacin antenatally and those not exposed. Meta-analysis of randomized trials revealed increased risk of bronchopulmonary dysplasia. However, the meta-analysis included only 3 randomized clinical trials, one of which showed increased risk. An association of bronchopulmonary dysplasia and indomethacin use was not noted in our analysis of observational studies. CONCLUSION: Although our pooled results did not identify significantly increased risks of adverse effects, the limited statistical power of published randomized trials does not allow us to exclude the possibility that indomethacin tocolysis increases the risk of adverse neonatal outcomes.
OBJECTIVE: To compare, by conducting a randomized trial, Filshie clip and Pomeroy techniques for postpartum and intrapartum cesarean sterilizations in a United States teaching hospital with respect to surgeon preference and perioperative outcomes. METHOD: Thirty-two obstetric patients consented for sterilization were randomized to Pomeroy technique or Filshie clip placement. Following the surgical procedure, surgeons and operating room technicians completed a survey regarding their experience with the procedures and preference. Patient demographic data, time for procedure and follow-up visits were obtained by chart review. RESULTS: For most postpartum sterilizations, the mean duration of the procedure was almost 7 min faster for the Filshie clip technique (p = 0.08); perioperative outcomes were equivalent (p = 0.05). Application of the Filshie clip was rated easier than Pomeroy suture application and, overall, the Filshie clip sterilization procedure was rated less difficult (p = 0.03). Seventy percent of surgeons preferred the Filshie clip technique and would choose it if only one postpartum sterilization method was available. CONCLUSION: For obstetric sterilization, surgeons preferred the Filshie clip over the Pomeroy technique. In addition, operating time was shorter for the Filshie clip. This pilot study suggests that use of the Filshie clip technique has the potential to establish a new standard of care for postpartum and intrapartum cesarean sterilization.
OBJECTIVE: To compare routine labor induction with expectant management for patients who reach or exceed 41 weeks' gestation. DATA SOURCES: Computerized databases, references in published studies, and textbook chapters in all languages were used to identify randomized controlled trials (RCTs) evaluating induction and expectant management of labor for postterm pregnancies. METHODS OF STUDY SELECTION: We identified RCTs that compared induction and expectant management for uncomplicated, singleton, live pregnancies of at least 41 weeks' gestation and evaluated at least one of the following: perinatal mortality, mode of delivery, meconium-stained fluid, meconium aspiration syndrome, meconium below the cords, fetal heart rate (FHR) abnormalities during labor, cesarean deliveries for FHR abnormalities, abnormal Apgar scores, and neonatal intensive care unit (NICU) admissions. The primary outcomes assessed were cesarean delivery rate and perinatal mortality. TABULATION, INTEGRATION, AND RESULTS: Sixteen studies met inclusion criteria for this review. For each study with binary outcomes, an odds ratio (OR) with 95% confidence intervals (CIs) was calculated for selected outcomes. Estimates of ORs for dichotomous outcomes were calculated using fixed and random-effects models. Homogeneity was tested across the studies. Compared with women allocated to expectant management, those who underwent labor induction had lower cesarean delivery rates (20.1% versus 22.0%) (OR 0.88; 95% CI 0.78, 0.99). Although subjects whose labor was induced experienced a lower perinatal mortality rate (0.09% versus 0.33%) (OR 0.41; 95% CI 0.14, 1.18), this difference was not statistically significant. Similarly, no significant differences were noted for NICU admission rates, meconium aspiration, meconium below the cords, or abnormal Apgar scores. CONCLUSION: A policy of labor induction at 41 weeks' gestation for otherwise uncomplicated singleton pregnancies reduces cesarean delivery rates without compromising perinatal outcomes.
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The results obtained from current systematic overview do not support the routine administration of maintenance tocolytic treatment after parenteral tocolytic therapy has halted acute preterm labor. Eliminating or reducing such routine maintenance therapy, therefore, could substantially decrease costs and side effects associated with managing preterm labor without compromising perinatal outcomes. It remains to be elucidated whether it will become possible to accurately identify some groups of pregnancies for which maintenance tocolysis would be beneficial.
We are continually reminded that the preterm birth rate has failed to improve; in fact, it has increased over the last 20 years. Much of this increase is related to the tremendous strides made by neonatologists and the resulting increased willingness of obstetricians to deliver preterm babies from hostile intrauterine environments. However, there is still much to learn concerning the pathogenesis, accurate early detection, treatment, and prevention of spontaneous preterm labor. This article concentrates on the clinical diagnosis and acute management of this enigmatic clinical problem.
OBJECTIVE: The study was undertaken to identify the clinical characteristics associated with an abnormal clomiphene citrate challenge (CC) test. STUDY DESIGN: The medical records of 123 women seen in a referral-based infertility practice who had a CC test as part of their infertility workup were reviewed. Eighty-five patients had a normal CC test and 38 patients had an abnormal test. Demographic, clinical, and laboratory characteristics were reviewed and analyzed. RESULTS: Women with abnormal CC tests were significantly older, had a lower mean body mass index, family history of early menopause, and shorter cycle intervals. Patients with an abnormal CC test had a pregnancy rate significantly lower than other women in this case series. CONCLUSION: Increased age, lower body mass index, shorter cycle intervals, lower cycle day 21 progesterone levels, and decreased pregnancy rates are associated with an abnormal CC test. Women with an abnormal CC test also tended to have a familial history of early menopause.
Evidence from the obstetric literature suggests that the frequency of labor induction is increasing. According to the National Center for Health Statistics, the rate of labor induction has more than doubled during the past 10 years: from 9% in 1989 to 19.9% in 2000. As labor induction has become more widely used in recent years, the number of medications used for preinduction cervical ripening has expanded greatly. In this article, we review the evidence-based literature assessing the safety and efficacy of the most common cervical ripening and labor induction agents.
OBJECTIVE: To systematically review published randomized controlled trials (RCTs) to compare the safety and efficacy of 25 microg versus 50 microg of intravaginal misoprostol for cervical ripening and labor induction. DATA SOURCES: We supplemented a search of entries in electronic databases with references cited in original studies and review articles to identify RCTs of misoprostol for cervical ripening and labor induction, which compared repeated doses of 25 microg and 50 microg. STUDY SELECTION: We evaluated, abstracted data, and assessed the quality of RCTs to compare the safety and efficacy of 25 microg versus 50 microg of intravaginal misoprostol for cervical ripening and labor induction. TABULATION, INTEGRATION, AND RESULTS: Five RCTs met inclusion criteria for meta-analysis. Odds ratios (OR) with 95% confidence intervals (CI) were calculated for each outcome (random- and fixed-effects models). In addition, we aggregated the results of two separate studies, permitting an indirect comparison of the two doses being analyzed. In the meta-analysis, tachysystole and hyperstimulation syndrome appear to occur less frequently among women who received 25 microg of misoprostol than with 50 microg. However, neonatal outcomes appear to be comparable with the two doses. Regarding efficacy, use of the 50-microg dose was associated with a shorter interval to vaginal delivery, greater proportion of deliveries within 24 hours, and less frequent need for oxytocin augmentation. The indirect comparison of two studies yielded similar results. CONCLUSION: Published data indicate that intravaginal misoprostol at doses of 50 microg for cervical ripening and labor induction is more efficacious but it is unclear whether it is as safe as the 25-microg dose.
OBJECTIVE: To estimate whether a dosage of 50 microg of misoprostol tablets moistened with 3% acetic acid and administered intravaginally is more efficacious for labor induction than a similar dosage regimen using dry tablets. METHODS: A total of 177 women who presented with an indication for cervical ripening and labor induction were randomly assigned to one of two treatment groups: 1) intravaginal misoprostol in dry tablet form, or 2) intravaginal misoprostol moistened with 1 mL of 3% acetic acid solution. The primary outcome assessed was the interval from start of induction to vaginal delivery. To detect at least a 3.5-hour difference in the primary outcome with 80% power, 87 subjects were required in each group. RESULTS: Among 162 patients evaluated, 80 were allocated to the misoprostol dry group and 82 to the misoprostol moistened group. No significant difference was noted for the mean +/- standard deviation interval to vaginal delivery: 1130 +/- 636 minutes for the group who received dry tablets and 1004 +/- 636 minutes for those who received moistened misoprostol tablets (P =.25). Additionally, no statistically significant differences were noted between the groups with respect to need for oxytocin, proportion of patients delivered after a single dose, intrapartum complications (including tachysystole and uterine hyperstimulation), mode of delivery, or perinatal outcomes. CONCLUSION: Tablet moistening with 3% acetic acid solution does not seem to improve the efficacy of intravaginally administered misoprostol for labor induction.
OBJECTIVE: To systematically review and summarize the medical literature regarding the effects of expectant management and labor induction on mode of delivery and perinatal outcomes in patients with suspected fetal macrosomia. DATA SOURCES: We supplemented a search of entries in electronic databases with references cited in original studies and review articles to identify studies assessing management of patients with suspected fetal macrosomia. METHODS OF STUDY SELECTION: We evaluated, abstracted data, and performed quantitative analyses in studies assessing the outcome of patients with suspected fetal macrosomia. Observational studies and randomized trials were included in this systematic review. TABULATION, INTEGRATION, AND RESULTS: Twenty-nine studies were identified, 11 of which met our criteria for systematic review and meta-analysis. These 11 studies included 3751 subjects. Of these, 2700 were managed expectantly, and 1051 underwent labor induction. We calculated an estimate of the odds ratio (OR) with 95% confidence intervals (CIs) for dichotomous outcomes, using random- and fixed-effects models for outcomes. Summary statistics for the nine observational studies showed that, compared with those whose labor was induced, women who experienced spontaneous onset of labor had a lower incidence of cesarean delivery (OR 0.39, 95% CI 0.30, 0.50) and higher rates of spontaneous vaginal delivery (OR 2.07, 95% CI 1.34, 3,19); however, significant differences in these outcomes were not noted when the two randomized trials were assessed. No differences were noted in rates of operative vaginal deliveries, incidence of shoulder dystocia, or abnormal Apgar scores in the analyses of the observational or randomized studies. CONCLUSION: Based on data from observational studies, labor induction for suspected fetal macrosomia results in an increased cesarean delivery rate without improving perinatal outcomes. Although their statistical power is limited, randomized clinical trials have not confirmed these findings.