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Biomedical subjects

R B Gherman

Publications and source records attributed to R B Gherman.

At least 19 recordsLinked to original sources
PubMed2003

Application of learning theory to obstetric maloccurrence.

The average fellow of the American College of Obstetricians and Gynecologists performs approximately 140 deliveries per year. Based on this estimation and the established prevalence of three commonly litigated maloccurrences, we calculated the number of years of clinical experience required to encounter one case. Permanent brachial plexus palsy complicates only 1 per 4553 deliveries so a clinician would encounter such a case in 33 years of practice. For every 6667 deliveries, there is a case of cerebral palsy attributable to intrapartum hypoxia, so a practioner would see only one case every 48 years. Since the rate of asphyxia with uterine rupture is 1 per 2819 vaginal births after Cesarean section and the average provider performs seven vaginal births after Cesarean deliveries per year, a clinician would have a case in 403 years of practice. Adverse outcomes expressed as an absolute percentage or as the number of cases per number of deliveries are statistically accurate. Expression of these maloccurrences in terms of the number of years of clinical experience permits the generation of a clinically relevant data point and also allows insight into why their prevalence has not decreased.

Birth Injuries↗
PubMed2001

Oral misoprostol vs. intravaginal prostaglandin E2 for preinduction cervical ripening. A randomized trial.

OBJECTIVE: To compare orally administered misoprostol with intravaginal prostaglandin E2 for cervical ripening and labor induction. STUDY DESIGN: Patients presenting with medical or obstetric indications for labor induction whose Bishop's score was < or = 6 were randomly allocated to receive either 50 micrograms of oral misoprostol or 4 mg of intravaginal prostaglandin E2. If adequate cervical ripening (Bishop score of 9 or cervical dilatation of 3) or active labor did not ensue, repeat doses of each medication were administered every four hours. A maximum of six doses of either oral misoprostol or intravaginal prostaglandin E2 was permitted. Intravenous oxytocin was subsequently administered according to a standardized infusion protocol. RESULTS: Sixty patients were enrolled, with 29 randomized to the oral misoprostol arm and 31 to the prostaglandin E2 group. The data on 58 patients were eligible for analysis. Delivery occurred within 48 hours in 96.4% (27/28) of those administered oral misoprostol as compared to 76.7% (23/30) of those who received intravaginal prostaglandin E2 (P = .03). The mean time intervals from the start of induction to delivery were similar between the two groups (1,496 +/- 120 vs. 1,723 +/- 230 minutes, P = .40). No statistically significant differences existed between the two groups with respect to intrapartum complications, tachysystole, uterine hyperstimulation or adverse neonatal outcomes. CONCLUSION: Oral administration of misoprostol is an effective alternative to intravaginal prostaglandin E2 for preinduction cervical ripening.

Administration, Intravaginal↗
PubMed2001

Serum tryptase analysis in a woman with amniotic fluid embolism. A case report.

BACKGROUND: Recent studies have noted a striking similarity between amniotic fluid embolism (AFE) and anaphylaxis. Serum tryptase levels may therefore serve as a marker of mast cell degranulation in AFE cases. CASE: A 40-year-old woman, gravida 6, para 4, experienced the acute onset of facial erythema, eclampsia-type seizures, severe hypoxia, cardiac arrest and disseminated intravascular coagulation while in early active labor. The patient was declared dead 37 minutes after the onset of resuscitative efforts. At autopsy, fetal squames were found within the pulmonary tree, uterine blood vessels and brain. A peripheral venous blood specimen, obtained approximately one and a half hours postmortem, revealed a tryptase level of 4.7 ng/mL (normal, < 1). CONCLUSION: An elevated serum tryptase level, in conjunction with our patient's clinical history, adds further supporting evidence to the concept of AFE as an anaphylactoid syndrome of pregnancy.

Adult↗
PubMed2000

Outpatient cervical ripening with intravaginal misoprostol.

OBJECTIVE: To determine if outpatient cervical ripening using misoprostol can initiate labor within 48 hours of medication administration and to determine if time from medication administration to time of delivery is decreased using outpatient cervical ripening. METHODS: Uncomplicated singleton, vertex pregnancies at 41 weeks' gestation or later with Bishop score of 4 or less were eligible for enrollment. Other inclusion criteria included intact membranes, less than eight uterine contractions per hour, a reactive nonstress test, and amniotic fluid index (AFI) over 5 cm. After randomization, 25 micro(cg) of misoprostol or placebo was placed within the posterior vaginal fornix. Patients were continuously monitored for 4 hours, then discharged if not in active labor. Patients returned in 24 hours for a repeat administration of the respective medication. Patients not delivered within 48 hours were admitted for inpatient induction of labor. Statistical analysis was performed with the Fisher, Student t, chi(2), and Mann-Whitney U tests, with P <.05 considered statistically significant. RESULTS: Among the 60 patients enrolled, 27 (45%) received misoprostol and 33 (55%) received placebo. The majority (24 of 27, 88.9%) of study group patients entered active labor within 48 hours after dosing, compared with 16.7% (five of 33) of placebo group patients (P <.001). The time from initial dose to delivery was significantly shorter in the misoprostol group (36.9 +/- 3.8 compared with 61.3 +/- 3.8 hours, P <.001). CONCLUSION: Intravaginal misoprostol is effective for outpatient cervical ripening. No adverse effects were encountered, although further study is required to determine the safety of this treatment regimen.

Administration, Intravaginal↗
PubMed2000

Analysis of McRoberts' maneuver by x-ray pelvimetry.

OBJECTIVE: To document radiographically the changes in pelvic dimensions created by McRoberts' maneuver. METHODS: Women at least 37 weeks' pregnant who presented to labor and delivery were eligible for study entry. Anterior-posterior and lateral x-rays were taken with women in the dorsal lithotomy position and after application of McRoberts' maneuver, in which the maternal legs were hyperflexed 45 degrees onto the maternal abdomen. A two-tailed paired t test was used to assess the changes in the pelvic diameters, with P < .05 considered statistically significant. RESULTS: Thirty-six subjects were enrolled in the study and 34 x-rays were suitable for analysis. McRoberts' maneuver was associated with an increase in the mean angle of inclination between the symphysis pubis and the sacral promontory (51.53 +/- 2.03 versus 38.07 +/- 1.96 degrees, P < .001). There was a 24% decrease in the angle created by drawing a line bisecting the symphysis pubis relative to the horizontal (P < .001). With McRoberts' maneuver the angle created by a line bisecting the longitudinal axis of the fifth lumbar vertebra and the longitudinal axis of the upper sacrum also increased (133.75 +/- 2.25 to 140.14 +/- 2.12 degrees, P = .04). CONCLUSION: Ours are the first systematic observations of pelvic changes associated with McRoberts' maneuver, confirming the traditional thinking that the maneuver causes a significant cephalad rotation of the symphysis pubis and subsequent flattening of the sacrum.

Adult↗
PubMed2000

Obstetric implications of activated protein C resistance and factor V Leiden mutation.

An increasing number of reports have focused on activated protein C resistance (APCR) as it has been shown not only to be the most common genetic factor predisposing patients to thromboembolic disease but the most common identifiable cause overall. More than 90 percent of the cases of APCR are caused by the factor V Leiden mutation, in which a guanine to adenine substitution in the factor V gene at nucleotide position 1691 results in a glutamine to arginine switch at position 506. Recent studies have also pointed to evidence of an association between APCR/factor V Leiden mutation and hypertensive disorders of pregnancy, first and second trimester miscarriage, placental infarction, and placental abruption.

Activated Protein C Resistance↗
PubMed2000

Successful pregnancy outcome following first trimester pelvic inflammatory disease.

Pelvic inflammatory disease rarely complicates pregnancy. Although few in number, most of the previously reported cases have resulted in spontaneous abortion or intrauterine fetal demise. At 5 weeks gestation, a 20 year old gravida 2 para 1 underwent uterine curettage and diagnostic laparoscopy for a suspected ectopic gestation. Seventeen days later, she presented with severe bilateral lower abdominal pain, cervical motion tenderness, uterine tenderness, and bilateral adnexal tenderness. After 84 hours of intravenous cefazolin, gentamycin, and clindamycin, the patient had resolution of all symptoms. She then completed 14 days of outpatient antibiotic therapy with oral cephalexin. At 39 weeks gestation, she delivered a 3611 g male fetus via spontaneous vaginal delivery. Successful pregnancy outcome can occur after first trimester pelvic inflammatory disease.

Adult↗
PubMed2000

Uterine rupture associated with vaginal birth after cesarean section: a complication of intravaginal misoprostol?

Intravaginal misoprostol has become increasingly employed for labor induction among patients with an unfavorable Bishop's score. Almost all of the reported studies have specifically excluded patients with prior uterine surgery. There has been, therefore, very little information concerning its usage among patients attempting vaginal birth after cesarean section. We report a patient with two prior low transverse uterine incisions who experienced uterine rupture after having received a single 25-microg intravaginal dose of misoprostol.

Administration, Intravaginal↗
PubMed2000

Low-dose methotrexate treatment for interstitial pregnancy. A case report.

BACKGROUND: Only a small number of case reports have described medical treatment of interstitial ectopic pregnancies. Almost all of the reported patients were treated with repeated high doses (1 mg/kg) of methotrexate. CASE: At 6 weeks of gestation, a 31-year-old woman, gravida 5, para 4, was diagnosed with a 0.96 x 1.36-cm right cornual pregnancy. As the patient desired future fertility, she received 100 mg of intramuscular methotrexate (50 mg/m2). She was then followed on an outpatient basis, with serum human chorionic gonadotropin values appropriately declining. Serial ultrasound also showed decreasing size of the gestational sac. Twenty-one days after the methotrexate dose, the patient experienced rupture of the right posterior cornu, necessitating exploratory laparotomy. CONCLUSION: Extreme caution should be used when treating interstitial gestations with single-dose methotrexate. All patients should be extensively counseled regarding the significantly increased risk of failure, possibility of rupture and need for emergency surgery.

Abortifacient Agents, Nonsteroidal↗
PubMed2000

Bladder rupture associated with uterine rupture. A report of two cases occurring during vaginal birth after cesarean.

BACKGROUND: Uterine rupture occurs in < 1% of patients undergoing a trial of labor after cesarean section. Associated injury to adjacent organs within the maternal pelvis has likewise been very rarely reported. CASE: Two cases of posterior bladder wall rupture occurred in association with rupture of low transverse uterine incisions. CONCLUSION: Bladder rupture may be associated with uterine rupture during attempted vaginal birth after cesarean. The potential for bladder injury should be included in the patient's antepartum counseling.

Adult↗
PubMed2000

Peripartum cardiomyopathy presenting as lower extremity arterial thromboembolism. A case report.

BACKGROUND: Although venous thromboembolism has been associated with peripartum cardiomyopathy, there have been no prior reports of lower extremity arterial thromboembolism complicating cardiac failure. CASE: A 38-year-old woman, gradiva 5, para 5, presented on postpartum day 9 with left pedal parasthesia. Lower extremity angiography found acute thrombotic emboli in the left popliteal artery, right tibial artery and right peroneal artery. When respiratory decompensation ensued, a transthoracic echocardiogram revealed global hypokinesis and a left ventricular ejection fraction of 30%. The patient had an uneventful recovery after treatment with digoxin, furosemide and intravenous heparin. CONCLUSION: Lower extremity arterial thromboembolism may be the initial manifestation of peripartum cardiomyopathy.

Adult↗
PubMed1999

Favorable response of Eisenmenger syndrome to inhaled nitric oxide during pregnancy.

OBJECTIVE: Our goal was to evaluate the effectiveness of therapy with a specific pulmonary vasodilator, nitric oxide, in a woman with Eisenmenger syndrome during pregnancy. STUDY DESIGN: Eisenmenger syndrome consists of a congenital communication between the systemic and pulmonary circulation with secondary pulmonary hypertension causing reversal of flow through the shunt. Maternal morbidity is approximately 50% with the greatest risk of death being in the peripartum period. Pharmacologic therapy to relieve worsening pulmonary hypertension is confounded by the undesired effects of vasodilators on the systemic circulation. Therapy with a specific pulmonary vasodilator, nitric oxide, was attempted. RESULTS: A 27-year-old woman with Eisenmenger syndrome at 36 weeks' gestation was treated with inhaled nitric oxide during the second stage of labor and the postpartum period when she experienced progressive refractory hypoxemia. Administration of nitric oxide was followed by improved oxygenation and lowering of pulmonary artery pressures. A brief episode of methemoglobinemia responded to lowering of the nitric oxide concentration and administration of intravenous methylene blue. Nitric oxide was discontinued after 48 hours. The patient died 2 days later despite continued vasodilator therapy including intra-pulmonary artery prostacyclin. CONCLUSION: Inhaled nitric oxide can be used to correct the hypoxemia of Eisenmenger syndrome. Nitric oxide inhalation is easily performed, and pulmonary vasodilatory effects commence within minutes after administration.

Administration, Inhalation↗
PubMed1999

Brachial plexus palsy: an in utero injury?

Acquired brachial plexus injury historically has been linked with excessive lateral traction applied to the fetal head, usually in association with shoulder dystocia. Recent reports in the obstetric literature, however, have suggested that in utero forces may underlie a significant portion of these injuries. Brachial plexus palsies may therefore precede the delivery itself and may occur independent of the actions of the accoucheur. Thus we propose that the long-held notions of a traction-mediated pathophysiologic mechanism for all brachial plexus injuries warrant critical reappraisal.

Brachial Plexus↗
PubMed1999

Desmoid tumor of the larynx complicating pregnancy: a case report.

Desmoid tumors are locally invasive fibrous neoplasms that arise from musculoaponeurotic structures. We report the first case of a desmoid tumor of the larynx complicating pregnancy. At 21 weeks' gestation fiberoptic and indirect otolaryngologic examination of the patient's larynx revealed a submucosal tumor involving the left true vocal cord, ventricle of the larynx, and false vocal cord. Histopathologic examination revealed areas of extensive fibrosis intermixed with degenerated vocal cord skeletal muscle. Despite a subtotal excisional biopsy, growth of the desmoid tumor continued during pregnancy. Endoscopic evaluation 9 weeks post partum revealed complete regression of the tumor.

Adult↗
PubMed1999

Incidence, clinical characteristics, and timing of objectively diagnosed venous thromboembolism during pregnancy.

OBJECTIVE: To estimate the incidence, timing, and associated clinical characteristics of objectively diagnosed pregnancy-associated venous thromboembolism. METHODS: We retrospectively reviewed venous thromboembolism cases (deep venous thrombosis and pulmonary embolism) that occurred between 1978 and 1996. Study inclusion criteria required the objective diagnosis with either Doppler ultrasound, venography, impedance plethysmography, pulmonary angiography, ventilation-perfusion scanning, or computed tomography or magnetic resonance imaging. RESULTS: Among 268,525 deliveries there were 165 (0.06%) episodes of venous thromboembolism (one per 1627 births). There were 127 cases of deep venous thrombosis and 38 cases of pulmonary embolism. Only 14% (23 of 165 patients) had a history of venous thromboembolism. Most cases of deep venous thrombosis were in the left leg (104 of 127, 81.9%), with nearly three quarters of them (94 of 127, 74.8%) occurring during the antepartum period. Among cases of antepartum deep venous thrombosis, half were detected before 15 weeks' gestation (47 of 95, 49.5%), and only 28 cases occurred after 20 weeks (P < .001). Most of the pulmonary embolisms occurred in the postpartum period (23 of 38, 60.5%) and were strongly associated with cesarean delivery (19 of 36,470 compared with four of 232,032, P < .001). CONCLUSION: The incidence of venous thromboembolism during pregnancy is lower than has been previously described. Most cases occurred in the antepartum period, with the risk of deep venous thrombosis appearing to begin even before the second trimester.

Adolescent↗
PubMed1999

Streptococcus viridans intra-amniotic infection associated with antecedent cunnilingus.

Introduction of bacteria into the amniotic cavity has been associated with oral sex through an ascending infectious route. Previous reports have implicated both Capnocytophaga and Fusobacterium nucleatum via this process. We report a case of Streptococcus viridans intra-amniotic infection occurring at 25 weeks' gestation. Patient questioning revealed a close temporal relationship between the onset of symptoms and previous episodes of cunnilingus. The diagnosis of subclinical bacterial colonization of the amniotic fluid should be considered in patients presenting with preterm labour and no apparent aetiology. A history of recent cunnilingus may be associated with the presence of Streptococcus viridans in the amniotic fluid.

Adult↗
PubMed1999

Postpartum hemolytic-uremic syndrome associated with lupus anticoagulant. A case report.

BACKGROUND: Hemolytic uremic syndrome is a rare thrombotic microangiopathy characterized by acute renal failure, thrombocytopenia and hemolysis. The underlying abnormality is currently thought to involve enothelial injury within the microcirculation. CASE: A 30-year-old woman, gravida 2, para 1, underwent emergency cesarean delivery at 36 +/- 2 weeks' estimated gestational age for repetitive late decelerations and presumed severe preeclampsia. Postoperatively, the blood pressure remained persistently elevated despite multigent hypertensive therapy. By postpartum day 4 the patient continued to display acute oliguric renal failure, persistent severe thrombocytopenia and worsening hemolysis. Percutaneous renal biopsy was consistent with the clinical diagnosis of hemolytic uremic syndrome. Lupus anticoagulant was present, corroborated by markedly abnormal tissue thromboplastin inhibition and platelet neutralization procedures. With supportive therapy and daily plasmapheresis, the patient was discharged 22 days after delivery, with full recovery of renal function and resolution of the hemolytic process. CONCLUSION: Hemolytic uremic syndrome can be associated with lupus anticoagulant. This autoantibody may promote localized platelet aggregation, causing endothelial damage.

Adult↗