Biomedical subjects

S P Wong

Publications and source records attributed to S P Wong.

At least 19 recordsLinked to original sources

PubMed2005

Rapid construction of a patient-specific torso model from 3D ultrasound for non-invasive imaging of cardiac electrophysiology.

One of the main limitations in using inverse methods for non-invasively imaging cardiac electrical activity in a clinical setting is the difficulty in readily obtaining high-quality data sets to reconstruct accurately a patient-specific geometric model of the heart and torso. This issue was addressed by investigation into the feasibility of using a pseudo-3D ultrasound system and a hand-held laser scanner to reconstruct such a model. This information was collected in under 20 min prior to a catheter ablation or pacemaker study in the electrophysiology laboratory. Using the models created from these data, different activation field maps were computed using several different inverse methods. These were independently validated by comparison of the earliest site of activation with the physical location of the pacing electrodes, as determined from orthogonal fluoroscopy images. With an estimated average geometric error of approximately 8 mm, it was also possible to reconstruct the site of initial activation to within 17.3 mm and obtain a quantitatively realistic activation sequence. The study demonstrates that it is possible rapidly to construct a geometric model that can then be used non-invasively to reconstruct an activation field map of the heart.

Cardiac Pacing, Artificial↗

PubMed2000

Initial experience with the freestyle stentless aortic bioprosthesis.

AIMS: We report our initial experience with the Freestyle aortic bioprosthesis. METHODS: This prosthesis was implanted in 40 patients between February 1993 and December 1998. Operative indications were aortic stenosis in 32 patients (80%), aortic regurgitation in seven patients (18%) and a combined lesion in one (3%). The mean patient age was 71.4+/-9.7 (SD) years, with 29 (72%) females. Pre-operative New York Heart Association (NYHA) class was III or IV in 28 (70%). Left ventricular systolic function was impaired in four (10%). Six (15%) patients had undergone previous cardiac surgery. Concomitant procedures were carried out in 21 patients (53%). RESULTS: Early mortality was zero. Early morbidity included three re-operations for bleeding, one cerebrovascular event, one haemorrhagic complication and one case of valve dysfunction. At follow up (range 4.6 to 75.6 months, mean 29.5+/-25.5) there has been one (3%) late death which was non valve related, one (3%) episode of study-valve endocarditis, and three (8%) thromboembolic episodes. NYHA Class was I or II in all but one survivor. Echocardiographic follow-up has shown no further instances of valve dysfunction with satisfactory haemodynamic parameters at 24-months post-operation, and a significant and sustained regression of left ventricular mass. CONCLUSIONS: The initial experience with the Freestyle valve is that it results in good clinical and haemodynamic performance, suggesting it as an ideal bioprosthesis for this patient group.

Adult↗

PubMed2000

Early experience with the mosaic bioprosthesis: a new generation porcine valve.

BACKGROUND: The Mosaic bioprosthesis is a new generation stented porcine valve. METHODS: Between May 1995 and April 1998, this valve was implanted in the aortic position in 98 patients (70 men; mean age, 69.2 years [34.2 to 83.6 years]). Preoperatively 35 patients were in New York Heart Association functional class 3 or 4. Fifty-nine patients underwent concomitant procedures. The mean duration at follow-up in January 1999 was 23.7 +/- 10.2 months (0.3 to 39.4 months) and totaled 193 patient-years. All but one survivor was in New York Heart Association class 1 or 2. RESULTS: Early complications included 1 death, 3 reoperations for bleeding, greater than mild regurgitation (paravalvar) in 1 patient and thromboembolism in 4 patients. Late complications included four deaths, study-valve endocarditis in 3 patients, more than mild regurgitation or hemolysis in 2, and thromboembolism in 2 patients. Late follow-up echocardiography in all survivors showed a mean transaortic gradient of 13.6 +/- 6.7 mm Hg, and an aortic valve area of 1.80 +/- 0.61 cm2. Valve replacement was followed by a significant and sustained decrease in left ventricular mass for all valve sizes. There has been no primary structural valve failure. CONCLUSIONS: The early experience with the Mosaic valve in the aortic position has been promising.

Adult↗

PubMed2000

Ventricular septal aneurysm: a complication of myocardial infarction.

We report the case of a ventricular septal aneurysm in a patient with a previous inferior myocardial infarction. Two-dimensional echocardiography demonstrated a cystic cavity in the muscular septum with a small communication into the left ventricle. No evidence of left-to-right shunt was detected with Doppler echocardiography or during left ventriculography.

Aged↗

PubMed1999

Prognostic significance of cerebrospinal fluid cyclic adenosine monophosphate in neonatal asphyxia.

OBJECTIVE: In piglets prolonged asphyxia resulted in decreased cerebrospinal fluid (CSF) 3;,5;-cyclic adenosine monophosphate (cAMP) during recovery; this was associated with reduced pial arteriolar responses to stimuli that use cAMP as a second messenger. We hypothesized that asphyxia in human neonates results in decreased CSF cAMP and that low CSF cAMP is associated with abnormal outcome. DESIGN: We studied 27 infants with evidence of hypoxic-ischemic insult; 19 were term (group 1) and 8 were preterm (group 2). The normal values of CSF cAMP were determined from 75 infants with no asphyxia; 44 were term (group 3) and 31 were preterm (group 4). CSF cAMP was measured by using radioimmunoassay procedures. RESULTS: CSF cAMP levels in infants with asphyxia (groups 1 and 2) were 12 +/- 9. 5 and 7.9 +/- 7.1 pmol/mL, respectively, significantly lower than those of groups 3 and 4 (control infants), that is, 21.1 +/- 8.7 and 27.1 +/- 9.2 pmol/mL, respectively (P <.0001). Among infants with asphyxia, 3 died and 10 had abnormal neurologic outcome. Univariate analysis showed that abnormal outcomes were significantly related to CSF cAMP levels, phenobarbital use, and multi-organ failure. However, only CSF cAMP was retained in the model by stepwise logistic regression. CSF cAMP of 10.0 pmol/mL discriminated between those with normal and those with abnormal neurologic outcome. Low CSF cAMP concentration was associated with abnormal long-term outcome, estimated odds ratio of 12.4 (95% CI, 2.1-109.3; P <.006), and sensitivity, specificity, and positive and negative predictive values of 85%, 69%, 73%, and 80%, respectively. CONCLUSION: CSF cAMP concentrations were decreased in infants with asphyxia. Low CSF cAMP levels were associated with poor neurologic outcome.

Apgar Score↗

PubMed1999

Cardiac surgery in octogenarians--The Green Lane Hospital Experience 1995-1998.

BACKGROUND: An increasing number of patients aged 80 years and over are being considered and accepted for cardiac surgery. AIM: To review the experience of surgery in this elderly group of patients at our institution. METHODS: Hospital records of octogenarians undergoing surgery between January 1995 and September 1998 were reviewed and follow-up was obtained by general practitioner (GP) and patient questionnaires. RESULTS: Thirty-seven patients underwent cardiac surgery. The mean age was 82.8+/-1.4 years (range 80.8 to 86.2 years). Twenty-three (62%) were male. All were independent pre-operatively with severe symptoms and minor co-existing morbidity. All operations were urgent except two (emergency). Twenty patients (54%) had isolated coronary surgery, six (16%) aortic valve replacement alone, and 11 (30%) combined surgery. There were four (11%) early deaths and five (14%) peri-operative neurological events. The mean duration of post-operative intensive care stay was 2.4+/-3.9 days (range 0.05 to 16, median 1.0) and post-operative hospital stay 14.0+/-13.9 days (range 0 to 79, median 11). At the time of follow-up (mean duration 20.0+/-11.2 months) two further patients had died (non-cardiac). Twenty-six of the 31 survivors were living at home (23 independently), one with relatives, and four in residential care. Their cardiac symptoms were well controlled. The GPs of all hospital survivors, and all surviving patients themselves, felt that cardiac surgery had been beneficial. CONCLUSIONS: Cardiac surgery in the very elderly has been reserved for those with severe disease or symptoms and little co-morbidity. Early mortality is higher than for the general population undergoing cardiac surgery, but post-operative resource use is acceptable and the intermediate-term outcome for survivors is good.

Aged↗

PubMed1999

Unassisted conception with a normal pregnancy outcome in a woman with active Mycobacterium tuberculosis infection of the endometrium. A case report.

BACKGROUND: Tuberculosis of the endometrium is usually associated with infertility. Once a patient is diagnosed with endometrial tuberculosis, she is almost certain to experience infertility; in vitro fertilization and embryo transfer offer the only realistic treatment for tuberculous infertility. We describe one case of unassisted conception with a normal pregnancy outcome in a patient with Mycobacterium tuberculosis infection of the endometrium. CASE: A 34-year-old woman who suffered from 10 years of infertility was investigated in the authors' unit. She gave no significant past medical or surgical history, and initial examinations and investigations were normal. Her husband was 34 years old, and his semen analysis was normal. The patient underwent diagnostic laparoscopy, chromohydrotubation and endometrial biopsy, which showed patency of both fallopian tubes and normal pelvic organs, with no evidence of endometriosis or previous pelvic inflammatory disease. Histologic examination of the biopsied endometrium showed no granulomas; however, culture of the endometrium yielded Mycobacterium tuberculosis. When the patient was called back for antituberculosis chemotherapy, we found that she had become pregnant within one month of the endometrial biopsy. Antituberculosis chemotherapy was commenced at 14 weeks' gestation with rifampicin, isoniazid, pyrazinamide and pyridoxine. The pregnancy remained uneventful, and the patient delivered a normal female infant, 3,380 g at term. Pathologic examination of the placenta was performed, but there were no granulomas or features of chronic inflammation. CONCLUSION: Despite the successful fertility outcome in our patient, we do not think that this case was a challenge to previous concepts of endometrial tuberculosis. In vitro fertilization and embryo transfer are usually the most suitable options for these patients.

Adult↗

PubMed1998

Cervical assessment by magnetic resonance imaging--its relationship to gestational age and interval to delivery.

The aim of this cross-sectional study was to assess the uterine cervix in late pregnancy, using MRI, and to study its relationship to the gestational age and the time interval to delivery. 91 women with a singleton cephalic presenting fetus had MRI of the pelvis between 35 and 41 weeks. All had had one prior lower segment Caesarean section and no history of prior vaginal delivery. The cervical length, internal and external os diameter, cervical signal intensity and the angulation of the cervix with the cephalocaudal axis were measured on sagittal T2 weighted images and correlated with the gestational age and the interval from the MRI examination to delivery. It was found that the signal intensity of the cervical stroma increased with the gestational age. A higher signal intensity in the cervical stroma was associated with a shorter time interval to delivery. Deliveries after 40 weeks tended to occur more commonly in those with lower signal intensity in the cervical stroma and also in those with a smaller external os diameter. It is concluded that cervical softening as assessed on MRI correlated with gestational age and the time interval to delivery.

Cervix Uteri↗

PubMed1997

Characteristics of depressive symptoms in elderly urban and rural African Americans.

BACKGROUND: Despite considerable progress in the epidemiology of late life depression, little data have been documented in the scientific literature on depressive symptoms among elderly African Americans. The present investigation identifies characteristic symptoms of depression in African American community-resident elders. METHOD: Ninety-six African American men and women aged 60 years and older, with equal representation from urban and rural counties in west Tennessee, composed the sample. The sample was stratified in each of the two counties into three age categories; 60-69, 70-79, and 80 and older. Data from the Center for Epidemiological Studies-Depression scale were compared with the association of medical illness, medication use, social network, level of physical function in activities of daily living, and demographic characteristics. RESULTS: Residents screening positive for the presence of depressive symptoms showed an increased report of hypertension (p < .036), arteriosclerosis (p < .035), and circulatory problems (p < .008). There was an increased report of symptoms of depression among those who had six or more different chronic illnesses (p < .001) and among those who reported using four or more different prescription medications in the past month for chronic illnesses (p < .015). Regression analyses of data indicated that medical illness (p < .001) and social network (p < .041) were the most important predictors of depressive symptoms among residents. CONCLUSIONS: Considering the projected increase of African Americans reaching age 60, and because depressive illness is an important public heath concern, early identification of salient risk factors for depression is critical in instituting early intervention programs for the ethnic minority elderly population.

Black or African American↗

PubMed1996

Gonadoblastoma in patient with Turner's syndrome.

A 15-year-old phenotypic female referred for the investigation of primary ammenorrhea, was found to have a 45,XO karyotype and an ovarian cyst. She demonstrated some of the features of Turner's syndrome, as well as virilization. On laparotomy, she was found to have bilateral gonadoblastomas. She was treated with total abdominal hysterectomy and bilateral salpingo-oophorectomy. Subsequently, repeated chromosomal analysis detected the presence of Y chromosomes, which was confirmed by the use of polymerase chain reaction (PCR). The difficulties encountered in searching for the Y chromosome in patients with gonadoblastoma are discussed. Prophylactic gonadectomy is suggested in those cases associated with atypical features.

Adolescent↗

PubMed1996

The influence of glucose tolerance tests on subsequent carbohydrate metabolism in pregnancy.

BACKGROUND: This present study was designed to prospectively confirm a previous observational finding that a 75g glucose load exerts an influence on the results of a subsequent 50g glucose tolerance test performed after an interval of one week. METHODS: Pregnant Chinese patients were given both 50g 3-hour and 75g 2-hour oral glucose tolerance test (OGTT) in random order, 7 days apart, between 28 and 32 weeks of gestation. Patients were divided according to whether they received 50g test first (group 1) or 75g test first (group 2). Student's t-test for independent samples and for paired samples were used for between group comparisons and within patient comparisons respectively using SPSS for Windows software. RESULTS: Significant decrease in fasting glucose levels (p<0.0001) between paired 50g and 75g OGTT was found when 75g test was performed first. The mean difference in 2-hour values was also 35% lower. Similar results were also found when individual timed glucose levels were compared between groups. CONCLUSIONS: Differences in the blood glucose levels between OGTTs were confirmed to be related to which glucose load was given first. The 75g test exerts a significant effect on the fasting glucose and the response to a 50g glucose load up to one week later. These effects are consistent with improvement in glucose utilization. The differences observed will not significantly alter current clinical practice but may necessitate modification in the diagnostic crieria of mild abnormal glucose tolerance in pregnancy. We postulate that in some cases of mild glucose intolerance, the response to diet may not be due to caloric reduction but rather stimulation of a previously inadequate insulin response since a proportion of our local pregnant women consistently have calorice intakes significantly below the 1800 kcal per day.

Administration, Oral↗

PubMed1994

How many subjects to screen? A practical procedure for estimating multivariate normal probabilities for correlated variables.

This article suggests a practical procedure for estimating the number of Ss that need to be screened to obtain a sample of fixed size that meets multiple correlated criteria. The procedure is based on the fact that least squares regression provides a good quadratic fit for Monte Carlo estimates of multivariate probabilities when they are plotted as a function of mean pairwise correlations (r) for the criterion variables. The equations given here can be used to predict selected 3- to 5-variable joint probabilities with reasonable accuracy as long as pairwise correlations for the selection criteria range from .10 to .90.

Humans↗

PubMed1994

A prospective study of the treatment of cervical intraepithelial neoplasia by loop electrosurgical excision procedure (LEEP) in Hong Kong population.

From May to December 1990, 72 patients suffering from cervical intraepithelial neoplasia confirmed with guided biopsy were treated with loop electrosurgical excision procedure (LEEP) as outpatients under local anaesthesia. Overall success rate of a single treatment at 6 weeks follow-up was 88.9%. All the specimens obtained from the procedure were of good quality for histological examination. The overall significant complication rate of the procedure was 4.2% during treatment and 8.4% after treatment. The results suggested that LEEP is an effective and safe outpatient treatment for CIN lesions. It is easy to use and readily acceptable to patients. It also has the advantage of providing histological confirmation and more economical than the use of laser.

Adult↗

PubMed1993

Significance of serial C-reactive protein responses in neonatal infection and other disorders.

OBJECTIVE: This study was performed to determine prospectively whether, in the presence of proved or presumed bacterial infection, the sensitivity of serum C-reactive protein (CRP) response could be enhanced by serial rather than single determinations. We also sought to assess CRP responses to clinically identified noninfectious disorders. DESIGN: The CRP responses of 491 infants on 691 occasions of suspected infection were assessed. CRP levels were measured initially and twice again at 12-hour intervals (rate immunonephelometry). Assessments also included a blood culture, complete blood cell count, and chest radiograph and culture of spinal fluid when appropriate. CRP responses were correlated with four designated clinical groups: (1) positive blood or cerebrospinal fluid cultures (n = 190); (2) negative blood culture-definite infection (necrotizing enterocolitis stages 2 and 3, pneumonia, subcutaneous abscess) (n = 52); (3) negative blood culture-possible infection (antenatal risk factors, meconium aspiration, positive urine group B streptococcus antigen, necrotizing enterocolitis stage 1, febrile infants) (n = 287); and (4) negative blood culture-no infection (respiratory distress syndrome, transient tachypnea of the newborn, patent ductus arteriosus, tissue trauma) (n = 160). Diagnoses were made before CRP results were known. RESULTS: In all, 187 (27%) of the blood cultures were positive. A single organism was recovered from 174 of these; two organisms from 13. Among the single-organism cultures, 50 (29%) were Gram-negative, 120 (69%) were Gram-positive, and 4 (2%) were budding yeasts. CRP levels were elevated in various groups as follows: in the positive blood culture group (by organism), Gram-negative rods, 92% (46/50); group B streptococcus, 92% (12/13); Staphylococcus aureus, 89% (8/9); group D streptococcus, 71% (10/14); Streptococcus viridans, 60% (6/10); Staphylococcus epidermidis, 55% (40/73). In the negative blood culture-definite infection group, CRP levels were abnormal in 88%; in the negative culture-possible infection group, CRP was elevated in 33%; and in the negative blood culture-no infection group, CRP was elevated in 9%. Serial determinations of CRP resulted in enhanced sensitivity in the positive blood culture group, the negative blood culture-definite infection group, and the negative blood culture-possible infection group. Initial determinations by themselves were inadequately sensitive. Serial determinations did not enhance sensitivity of the negative blood culture-no infection group. High specificity (91%) is suggested by the low incidence of abnormal CRP levels among infants who were not infected. CONCLUSIONS: These data suggest that it would be appropriate to conduct a cautious, controlled trial to assess the safety of discontinuing antibiotic therapy if three serial CRP measurements are normal and if there are no other clinical factors suggestive of infection. The data also indicate the necessity for serial determinations of CRP for optimal sensitivity.

Bacterial Infections↗

PubMed1992

The effect of cesarean section on intraventricular hemorrhage in the preterm infant.

OBJECTIVE: The null hypothesis is that active labor is a more important factor with regard to both timing and progression of periventricular-intraventricular hemorrhage than is route of delivery. Infants delivered by cesarean section after entering the active phase of labor will behave in a manner similar to that of previously studied infants delivered vaginally as to when periventricular-intraventricular hemorrhage occurs and frequency of progression. STUDY DESIGN: The 106 infants of 85 women delivered by cesarean section were the subjects of this study. Forty-six infants were in the no-labor group, 33 in the latent-phase labor group, and 27 in the active-phase labor group. Head ultrasonographic examinations were performed at delivery, at 1, 6, 12, and 24 hours, and then daily for the first 7 days of life. Continuous variables were compared by one-way analysis of variance among those infants with no hemorrhage or with periventricular-intraventricular hemorrhage. Categoric variables were compared by chi 2 analysis and Fisher's exact test when appropriate. A p value of less than 0.05 was considered significant. RESULTS: There was no difference in the frequency of early hemorrhage (less than or equal to 1 hour of age), late hemorrhage (greater than 1 hour of age), or overall periventricular-intraventricular hemorrhage in the infants not in labor, in latent-phase labor, or in active-phase labor at the time of cesarean section. However, the frequency of grade 3 or 4 hemorrhage and the progression of hemorrhage were significantly higher in the infants whose mothers had an active phase of labor compared with infants whose mothers had no labor or did not progress beyond the latent phase. Infants who had early periventricular-intraventricular hemorrhage (less than or equal to 1 hour of age) also had a higher frequency of progression of hemorrhage. CONCLUSIONS: Cesarean section before the active phase of labor does not change the overall frequency of hemorrhage but results in a lower frequency of progression to grade 3 or 4 hemorrhage. We do not feel that these data support performing more cesarean sections for preterm delivery as a method of preventing progression of periventricular-intraventricular hemorrhage in the preterm infant.

Birth Weight↗

PubMed1992

Asymptomatic syndrome of polycythemic hyperviscosity: effect of partial plasma exchange transfusion.

We determined the cerebral hemodynamic changes in infants with asymptomatic polycythemic hyperviscosity syndrome and whether treatment with partial plasma exchange transfusion (PPET) would affect hemodynamics as well as outcome. From a routine cord blood hematocrit screening, 71 babies were identified as needing to be tested for polycythemic hyperviscosity. In addition to clinical evaluation, each infant had radial artery hematocrit and viscosity determinations, blood gas determinations, cerebral blood flow velocity studies, cranial ultrasonography, and noninvasive intracranial pressure determination. Babies with symptomatic hyperviscosity (n = 17) were treated by PPET, whereas those with asymptomatic hyperviscosity (n = 28) were randomly selected to have PPET (n = 14) or to be observed (n = 14). The remaining babies (n = 26) with normal viscosity served as control subjects. Both hematocrit and viscosity decreased after PPET but remained unchanged in babies with hyperviscosity who were merely observed. Reversal of cerebral blood flow velocity abnormalities was observed after PPET in the infants with symptomatic hyperviscosity, whereas those who had no symptoms had normal results on Doppler studies at the outset, and no significant changes occurred with either PPET or observation. There were two deaths in the group with symptoms. A total of 46 babies returned for follow-up evaluation at a mean age of 30 +/- 7.7 months. Outcome of the control group was no better than that of those who had hyperviscosity, and outcomes did not differ between the babies with symptomatic and those with asymptomatic hyperviscosity, nor between those treated with PPET and those who were only observed. Multivariate analysis revealed that other perinatal risk factors and race rather than polycythemia or PPET, significantly influenced long-term outcome.

Blood Viscosity↗

PubMed1992

Early and late intraventricular hemorrhage: the role of obstetric factors.

OBJECTIVE: To evaluate the influence of active phase labor and other obstetric factors on the development of periventricular-intraventricular hemorrhage in the neonate. METHODS: A total of 230 infants were studied. Antenatal enrollment was carried out when estimated fetal weight was 1750 g or less. Serial head ultrasound scans were performed to screen for periventricular-intraventricular hemorrhage, with the initial scan performed within minutes of birth. Scan findings and obstetric and neonatal variables collected prospectively at scheduled intervals were analyzed to determine the significant factors that predispose to intraventricular hemorrhage. RESULTS: In 47 infants (20%), intraventricular hemorrhage was detected within 1 hour of birth (early) and in another 49 (21%) at a later age (late). The overall incidence of hemorrhage was similar between vaginal and cesarean deliveries (41 and 44%, respectively). Early hemorrhage was more frequent in vaginal (28%) than cesarean deliveries (11%), whereas late hemorrhage was more frequent in cesarean deliveries. When the role of delivery mode and labor was analyzed by stepwise logistic regression, the odds ratios for development of early intraventricular hemorrhage increased in the following order: cesarean delivery with no labor, cesarean delivery with latent phase labor, vaginal delivery with forceps use, cesarean delivery with active phase labor, and vaginal delivery without forceps use. For late hemorrhage, the odds ratios increased in the following order: vaginal delivery with forceps, vaginal delivery without forceps, cesarean delivery with no labor, cesarean delivery with latent phase labor, and cesarean delivery with active phase labor. CONCLUSIONS: Active phase labor may predispose to early periventricular-intraventricular hemorrhage, but its influence may be attenuated by use of forceps or by abdominal delivery. The protective effect of forceps remains for late periventricular-intraventricular hemorrhage, but abdominal delivery does not seem to protect against late hemorrhage.

Cerebral Hemorrhage↗

PubMed1988

The relationship between labor and route of delivery in the preterm infant.

The purpose of this prospective study was to evaluate the effects of the active phase of labor and route of delivery on the frequency of germinal layer/intraventricular hemorrhage in 89 infants with ultrasound-estimated fetal weights less than or equal to 1750 gm. Twenty-eight infants (31.5%) had germinal layer/intraventricular hemorrhage within 1 hour after birth and an additional 15 infants (17%) had germinal layer/intraventricular hemorrhage beyond 1 hour after birth. Infants with germinal layer/intraventricular hemorrhage had a significantly lower gestational age (p less than 0.003) and birth weight (p less than 0.007). Germinal layer/intraventricular hemorrhage within 1 hour after delivery was increased in the infants of women who experienced the active phase of labor regardless of the route of delivery. However, the incidence of germinal layer/intraventricular hemorrhage beyond 1 hour after delivery and the overall incidence were similar in the vaginal delivery and cesarean delivery groups. In addition, there was an increased incidence of progression to grades III and IV hemorrhage regardless of route of delivery in the infants whose mothers experienced the active phase of labor.

Apgar Score↗