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Biomedical subjects

R H Paul

Publications and source records attributed to R H Paul.

At least 19 recordsLinked to original sources
PubMed1992

Asphyxial complications in the term newborn with severe umbilical acidemia.

OBJECTIVE: Our purpose was to determine the relationship of umbilical acid-base status and Apgar score to neonatal asphyxial sequelae in infants with severe acidemia (pH < 7.00). STUDY DESIGN: The obstetric and neonatal course of 129 term, nonanomalous singleton infants with umbilical pH < 7.00 was reviewed. RESULTS: There were three stillbirths (failed resuscitation). Seventy-two of 126 (57%) were admitted to the neonatal intensive care unit. Thirty-eight percent had pulmonary dysfunction, 26% renal dysfunction, 31% cardiac dysfunction, and 31% hypoxic ischemic encephalopathy (seizures and hypotonia, n = 29; seizures only, n = 3; hypotonia only, n = 10). There were five neonatal deaths. In 109 cases umbilical arterial values were available, and among these infants there was a significant increase in the incidence of seizures with declining pH from 9% (5/57), with a pH of 6.90 to 6.99, to 80% (8/10), with a pH of 6.61 to 6.70. Respiratory acidemia (PCO2 > 65, base deficit < 10) was identified in 28 of 109 (26%), all but six occurring in the pH range above 6.90. Compared with infants with comparable umbilical artery pH, infants with respiratory acidemia did not differ significantly with respect to asphyxial end-organ injury in general (8/35 vs 6/22), but there was a trend toward a lower incidence of hypoxic ischemic encephalopathy (6/35 vs 1/22, p = 0.06). All infants with definite abnormal outcome (five neonatal deaths and 10 severe neurologic deficit) had seizures, hypotonia, and at least one other organ system dysfunction. Twenty-four of 29 infants (83%) who developed seizures had a 5-minute Apgar score < 7, but only 12 of 29 (41%) had a 5-minute Apgar score of < or = 3. Two infants with Apgar scores of 6 and 7 at 5 minutes and no evidence of nonasphyxial comorbidity subsequently manifested profound neurologic deficit. CONCLUSIONS: Infants with severe umbilical acidemia can be separated with regard to risk of hypoxic ischemic encephalopathy and abnormal neurologic outcome by consideration of the severity and composition of the acidemia and evidence of other end-organ dysfunction. Even in this pH range the Apgar score is not highly predictive of asphyxial complications.

Acids↗
PubMed1992

Prophylactic amnioinfusion improves outcome of pregnancy complicated by thick meconium and oligohydramnios.

OBJECTIVE: The null hypothesis is that the use of intrapartum amnioinfusion in labors complicated by the presence of thick meconium and oligohydramnios will not decrease the incidence of fetal distress, cesarean delivery, meconium aspiration, or meconium aspiration syndrome. STUDY DESIGN: One hundred seventy term and postterm patients with thick meconium and oligohydramnios were randomly chosen to receive amnioinfusion or standard obstetric care without amnioinfusion. The frequency of fetal distress, cesarean section, meconium aspiration, and meconium aspiration syndrome were subject to chi 2 analysis, Student's t test, or Fisher's exact test. RESULTS: The rate of fetal distress was significantly reduced in the amnioinfusion group compared with controls (three of 85 vs 19 of 85, relative risk 0.15, 95% confidence interval 0.06 to 0.42). The rate of cesarean section for fetal distress was significantly reduced in the amnioinfusion group (two of 85 vs 17 of 85, relative risk 0.118, confidence interval 0.03 to 0.49). The rates of meconium aspiration (four of 85 vs 33 of 85, relative risk 0.12, confidence interval 0.0449 to 0.327) and meconium aspiration syndrome (0 of 85 vs five of 85, relative risk 0.09, confidence interval 0.009 to 0.872) were significantly reduced by amnioinfusion. CONCLUSIONS: Amnioinfusion improves the outcome in pregnancies complicated by thick meconium and oligohydramnios.

Amnion↗
PubMed1992

Amnioinfusion does not affect the length of labor.

OBJECTIVE: Our objective was to determine whether amnioinfusion prolongs or shortens the length of labor in patients who have an accepted indication for amnioinfusion. STUDY DESIGN: We performed a retrospective post hoc analysis of the length of labor of 437 patients who were enrolled in three prospective, randomized, controlled studies of amnioinfusion. RESULTS: The length of labor was not significantly different for patients who received amnioinfusion compared with those who did not receive amnioinfusion (control group). Among the subgroup with vaginal delivery, the duration of labor after amnioinfusion did not differ from the duration of labor among the controls. The length of labor (mean +/- SD, in hours) for the amnioinfusion group was 9.3 +/- 6.3 versus 10.6 +/- 6.9 for the control groups (p not significant). Among the subgroup that required cesarean delivery, the duration of labor after amnioinfusion did not differ from the duration of labor among the controls. The length of labor (mean +/- SD, in hours) in patients requiring cesarean delivery in the amnioinfusion group was 11.1 +/- 6.3 versus 13.0 +/- 7.5 for the control group (p not significant). CONCLUSION: Amnioinfusion does not prolong or shorten the length of labor among patients who have an accepted indication for the treatment.

Adult↗
PubMed1992

Significance of intrapartum amniotic fluid volume in the presence of nuchal cords.

Among 70 women delivering infants with nuchal cords, there was a significantly higher incidence of meconium passage and severe variable fetal heart rate decelerations/fetal bradycardia in those who had intrapartum oligohydramnios, as defined by an amniotic fluid index less than or equal to 5.0 cm. Oligohydramnios in the presence of nuchal cord entanglement might represent an increased risk of ominous intrapartum fetal heart rate patterns.

Amniotic Fluid↗
PubMed1992

Nonstress test assessment of twins.

Twin pregnancies have higher perinatal morbidity and mortality rates than singleton pregnancies. Researchers have demonstrated that one major benefit of prenatal care in the twin gestation is reduced fetal death rate. This study to determine the relationship of nonstress tests (NSTs) to pregnancy outcome in twin gestations comprised 665 women who delivered at Los Angeles County-University of Southern California Women's Hospital from January 1985 to January 1989. These patients, all of whom had prenatal care (PNC), were subdivided into two groups: (1) PNC and NSTs and (2) PNC and no NSTs. The groups did not differ statistically with regard to gravidity, parity and abortions. NSTs were selectively done on twin gestations complicated by discordancy or other fetal/maternal complications. Ten pregnancies were complicated by fetal demise of one or both twins in patients who received prenatal care without NSTs. Among the NST group there was one fetal demise. Although the NST group had fewer fetal deaths, the reduction was not statistically significant (P = .062). Infant birth weight was identified as a confounder because the NST group had a statistically higher mean birth weight. Definitive proof of the ability of NSTs to reduce the fetal death rate in twin gestations complicated by discordancy or other pregnancy complications awaits a large, prospective, randomized trial.

Female↗
PubMed1992

Identifying the obstetric patient at high risk of multiple-unit blood transfusions.

We sought to characterize the obstetric patient who required more than the 1 or 2 units of blood products typically available by autologous donation. Medical records from 1988 were reviewed retrospectively. During this period, 16,462 deliveries were performed. Twenty-seven patients (0.16%) received more than 2 units of blood products during their pregnancies. The most common diagnoses associated with a transfusion were placenta previa (10), uterine atony (8) and abruption (5). Platelets, fresh frozen plasma and cryoprecipitate were administered to 7, 12 and 4 patients, respectively. An antepartum condition associated with hemorrhage was identified in only 11 of the 27 patients (41%) who received greater than or equal to 3 units of blood products. The remainder of the cases were not diagnosed during the antepartum period, when autologous donation is an option.

Adult↗
PubMed1992

Selective labor induction in postterm patients. Observations and outcomes.

Six hundred twenty-nine postterm patients with reliable dates were evaluated for expectant management. Patients with medical or obstetric complications, a Bishop score greater than 6 or abnormal antepartum testing were ineligible for such management. The incidences of macrosomia, fetal distress necessitating cesarean section and low five-minute Apgar scores were similar in patients with labor induction as compared to those managed expectantly. The cesarean section rate was significantly lower in patients who underwent induction for a Bishop score greater than 6 as compared to those followed expectantly (15% vs. 28%). The lowest cesarean section rate was seen in patients with Bishop scores greater than 8 (5%) versus 15% in patients with Bishop scores of 6-8.

Cesarean Section↗
PubMed1992

Amniotic fluid index and prolonged antepartum fetal heart rate decelerations.

Both prolonged fetal heart rate (FHR) decelerations and decreased amounts of amniotic fluid (AF) have been associated with adverse fetal outcome. To determine whether adverse outcome could be predicted by a quantitative assessment of AF in patients with prolonged FHR decelerations, we identified 97 consecutive pregnancies found during antepartum testing to have prolonged FHR decelerations. A four-quadrant AF index was measured concurrently in 92 of these 97 patients. Women with an AF index less than 2 cm had operative intervention for fetal distress in seven of 11 cases (64%), compared with 17 of 81 (21%) who had an index of 2 cm or more (P = .005). We conclude that in patients with a prolonged FHR deceleration during antepartum testing, the need for operative intervention for fetal distress is increased when oligohydramnios is present.

Amniotic Fluid↗
PubMed1992

Post-term pregnancy: fetal death rate with antepartum surveillance.

Management of the post-term pregnancy depends on the certainty of dating, likelihood of successful induction, and risks of expectant management. To estimate the risk of fetal death in an expectantly managed post-term population, we reviewed 8038 consecutive post-term gestations followed expectantly with a twice-weekly nonstress test and amniotic fluid index. There were nine antepartum fetal deaths and no intrapartum fetal deaths, a fetal mortality rate of 1.12 per 1000. Timing of delivery of the post-term gestation balances this risk of loss of a viable fetus with the risks of uncertain dating and failure of induction of labor.

Female↗
PubMed1991

Prophylactic amnioinfusion as a treatment for oligohydramnios in laboring patients: a prospective, randomized trial.

Prophylactic amnioinfusion was studied in a randomized sample of 305 patients with oligohydramnios in labor. One hundred seventy-five patients underwent amnioinfusion with the remainder serving as controls. Amniotic fluid was titrated to an amniotic fluid index greater than 10.0 cm in the treatment group. Patients receiving amnioinfusion had significantly less operative intervention for fetal distress (p = 0.0001) and fewer cesarean sections (p = 0.0001). Umbilical artery pH at the time of delivery also was increased (p = 0.0001). Rates of amnionitis and endometritis were not significantly different between infused patients and controls, although the length of hospital stay was significantly decreased (p = 0.002) in the treatment group. Our data support earlier reports in the literature that amnioinfusion is a useful technique for decreasing intrapartum morbidity for both mother and fetus.

Adult↗
PubMed1991

The intrauterine probe electrode.

An intrauterine probe electrode was inserted into 100 laboring women and 366 bipolar electrode combinations were tested. A noise-cancelling technique was used with the final 28 subjects to remove competing maternal cardiac signals. Twenty-four (86%) had fetal heart rate tracings with sufficient technical quality to allow determination of the baseline fetal heart rate.

Electrocardiography↗
PubMed1991

Intrauterine manometry: reapplication of an old concept.

Electronic fetal heart rate and uterine activity monitoring during labor requires expensive equipment and a source of electricity. However, it is not available to most of the women in the world. Intrauterine manometry provides a method which can be employed in underdeveloped settings to assess uterine contractions and to time auscultation. The vertical column of fluid in a standard intrauterine pressure catheter (IUPC) correlated well (R = 0.93) with the intrauterine pressure measurements obtained by a standard IUPC/pressure transducer system. Intrauterine manometry provides an alternative measure of uterine tone which may be employed in underdeveloped areas.

Catheters, Indwelling↗
PubMed1990

Prevalence and etiology of respiratory distress in infants of diabetic mothers: predictive value of fetal lung maturation tests.

The purpose of this study was to investigate the prevalence of respiratory distress syndrome attributable to surfactant deficiency in infants of diabetic mothers tested for fetal lung maturation. Three tests were assessed: (1) lecithin/sphingomyelin ratio, (2) phosphatidylglycerol concentration, and (3) optical density at 650 nm. From January 1987 through June 1989, 526 diabetic gestations were delivered within 5 days of fetal lung maturation testing. Surfactant-deficient respiratory distress syndrome was present in five infants (0.95%); all were less than 34 weeks' gestational age. Other causes of respiratory distress were transient tachypnea of the newborn (n = 5), hypertrophic cardiomyopathy (n = 4), pneumonia (n = 2), polycythemia (n = 1), and meconium aspiration syndrome (n = 1). The use of standard maturity values of lecithin/sphingomyelin ratio greater than or equal to 2.0, phosphatidylglycerol greater than 2% to 5%, and optical density at 650 nm greater than or equal to 0.150 were evaluated. Each test had a 100% sensitivity in identifying surfactant-deficient respiratory distress syndrome and a 100% negative predictive value in identifying the absence of disease. All three tests had a low positive predictive value: 15% for lecithin/sphingomyelin ratio, 9% for phosphatidylglycerol, and 3% for optical density at 650 nm. We concluded that most cases of respiratory distress in the infants of diabetic mothers were unrelated to surfactant deficiency. The standard maturity values used in fetal lung maturation tests were valid in the diabetic gestation. The optical density at 650 nm was useful as a first-line test to predict the absence of surfactant-deficient respiratory distress syndrome.

Cardiomegaly↗
PubMed1990

The correlation of arterial lesions with umbilical artery Doppler velocimetry in the placentas of small-for-dates pregnancies.

The placentas of 14 growth-retarded fetuses with abnormal umbilical artery velocimetry and 15 appropriately grown fetuses with normal waveforms were collected immediately after delivery and analyzed in a blinded fashion. A large percentage of the arterial vessels in the placentas from the former group showed abnormal changes in the vessel wall. The percentage of abnormal arterial vessels in all placentas correlated significantly with the resistance index. This study provides an anatomical basis for the elevated resistance to blood flow in placentas from growth-retarded fetuses.

Adult↗
PubMed1979

Fetal heart rate variability: an approach to automated assessment.

Three hundred seventy-five hours of fetal heart rate (FHR) data derived from the direct fetal electrocardiogram (ECG) were studied. This data had been stored on magnetic tape from 83 intrapartum patients. By means of a computerized technique, the FHR variability was assessed quantitatively. The degree of variability was then related to: (1) state of labor, (2) fetal scalp pH values, and (3) the 1-minute Apgar score. FHR variability was computed from differences between consecutive R-R intervals measured from the R wave of each fetal ECG. A trend of increasing variability was seen with advancing labor, defined by either time prior to delivery or cervical dilatation, but values were not statistically significant. Significantly less FHR variability was encountered when fetal scalp pH values below 7.20 were compared to higher values. FHR variability assessed during the 20 minutes immediately preceding delivery was significantly lower in infants with 1-minute Apgar scores less than 7. Machine assessment of FHR variability thus could be correlated with fetal condition as determined by scalp pH and neonatal outcome determined by Apgar score.

Apgar Score↗
PubMed1979

Obstetric factors influencing outcome in infants weighing from 1,001 to 1,500 grams.

The neonatal mortality rate has dramatically improved in recent years. Occurrence of these losses is concentrated in low-birth-weight infants. At Los Angeles County-University of Southern California Medical Center, the infants weighing less than 1,500 grams contribute two thirds of neonatal deaths, although they may represent only 1.5 per cent of total births. Such observations have led to the evaluation of obstetric factors as they relate to the outcome in the low-birth-weight infants weighing from 1,001 to 1,500 grams. Retrospective evaluation of 201 low-birth-weight-infants' charts demonstrated a tendency by the obstetrician to clinically underestimate fetal weight. In cases where fetal estimated weight and measured birth weight correlated, the mortality rate was 20 per cent; in cases of underestimation, the mortality rate rose to 50 per cent. Other obstetric factors evaluated were the use of FHR monitoring, the method of delivery, and the significance of the Apgar score.

Apgar Score↗