Biomedical subjects

William A Grobman

Publications and source records attributed to William A Grobman.

26 records · Page 2Linked to original sources

PubMed2005

When has an induction failed?

OBJECTIVE: To evaluate the length of the latent phase that, during labor inductions in nulliparous women, is associated with significantly decreased chance of vaginal delivery and increased risk of maternal and neonatal morbidity. METHODS: All inductions of labor during a 6-month period were identified. Only those women who were nulliparous with a pregnancy of 36 weeks or more of gestation underwent further data analysis. Demographic data, intrapartum course, and maternal and neonatal outcomes were abstracted from the medical record. The latent phase was defined as beginning after oxytocin had been initiated and amniotomy performed and continuing until either 4 cm cervical dilation and 80% effacement or 5 cm cervical dilation regardless of effacement. RESULTS: A total of 397 nulliparous women, 32% of whom underwent cervical ripening, presented during the study period. Only 8 women (2%) never achieved active phase labor before cesarean, and the overall cesarean rate was 26.0%. A longer latent phase was associated with a greater rate of cesarean delivery, although only after 18 hours did a majority of induced labors result in cesarean. Chorioamnionitis and postpartum hemorrhage were more frequent with latent phases of labor greater than 18 hours (16% and 26%, respectively), although these diagnoses did not translate into greater risk of transfusion, hysterectomy, or prolonged hospitalization. Neonatal outcomes, including meconium passage, fetal acidemia, neonatal intensive care unit admission, or other morbidity did not increase in conjunction with longer latent phases. CONCLUSION: A latent phase of as long as 18 hours during induction of labor in nulliparous women allows the majority of these women to achieve a vaginal delivery without being subject to a significantly increased risk of significant maternal or neonatal morbidity. LEVEL OF EVIDENCE: II-2.

Adult↗

PubMed2004

The thrombogenic effect of an inflammatory cytokine on trophoblasts from women with preeclampsia.

OBJECTIVE: This study was undertaken to investigate whether the increased thrombogenic potential of cytotrophoblastic cells of women with preeclampsia can be accounted for by increased rates of apoptosis. STUDY DESIGN: Cytotrophoblasts were isolated from the placenta of (a) nulliparous women without hypertensive disease who were delivered at term and (b) nulliparous women with preeclampsia. The cytotrophoblasts were identified by morphology, and cytokeratin and gonadotropin-releasing hormone positivity. The inflammatory cytokine tumor necrosis factor-alpha (TNF-alpha) was added to cytotrophoblasts in vitro and incubated for 24 hours. Tissue factor antigen, activity, and amount of apoptosis were evaluated both before and after TNF-alpha stimulation. RESULTS: TNF-alpha simulation significantly increased tissue factor activity both in the cytotrophoblasts of women with (0.08 +/- 0.04 pmol/min/10 6 cells to 0.53 +/- 0.19 pmol/min/10 6 cells) and without (0.07 +/- 0.04 pmol/min/10 6 cells to 0.30 +/- 0.16 pmol/min/10 6 cells) preeclampsia. TNF-alpha stimulation of the cytotrophoblasts also significantly increased tissue factor antigen in the cytotrophoblasts of both groups of women (3.6 +/- 0.9 fmol/10 6 cells to 34.0 +/- 7.5 fmol/10 6 cells, and 7.5 +/- 1.4 fmol/10 6 cells to 25.4 +/- 2.2 fmol/10 6 cells, respectively). For both tissue factor antigen and activity, the magnitude of increase after stimulation was significantly greater in the preeclamptic cytotrophoblasts. In contrast, both normal and preeclamptic cytotrophoblasts showed similar increases in their apoptotic indices (approximately 2-fold) after induction by TNF-alpha. CONCLUSION: The greater response of tissue factor activity and antigen to TNF-alpha by preeclamptic cytotrophoblasts cannot be accounted for by the increase in apoptosis. These data suggest that preeclamptic cytotrophoblasts are inherently more thrombogenic and more sensitive to TNF-alpha stimulation.

Adult↗

PubMed2004

Elective cesarean delivery to prevent perinatal transmission of hepatitis C virus: a cost-effectiveness analysis.

OBJECTIVE: This study was undertaken to determine whether elective cesarean delivery to avert perinatal hepatitis C virus (HCV) transmission is cost-effective. STUDY DESIGN: Using decision analysis, we compared 2 approaches: (1) offering elective cesarean delivery to avert perinatal HCV transmission, (2) performing a cesarean delivery only for obstetric indications. Lifetime cost and quality-adjusted-life-years (QALYs) for HCV-infected neonates were evaluated with Markov analysis. We assumed elective cesarean delivery reduces perinatal HCV transmission, and we varied both the risk reduction caused by elective cesarean delivery and the background risk of perinatal HCV infection. RESULTS: When elective cesarean section prevents all perinatal HCV transmission, 18 elective cesarean deliveries are necessary to avert 1 neonatal infection with a cost-effectiveness ratio of 34,812 dollars/QALY. At a background perinatal transmission rate of 7.7% elective cesarean deliveries is cost-effective only if it reduces the risk of perinatal transmission by more than 77%. CONCLUSION: Elective cesarean delivery is cost-effective only if it substantially reduces the risk of perinatal HCV transmission.

Cesarean Section↗

PubMed2004

Neurodevelopmental outcome of very low birth weight infants after multiple courses of antenatal corticosteroids.

OBJECTIVE: To determine if two or more courses of antenatal corticosteroids are associated with neurodevelopmental impairment. METHODS: All infants born at Northwestern Memorial Hospital between 1995 and 1998, who met the following criteria, were identified: birth weight < or = 1500 g, gestational age between 24 and 34 weeks, recipient of antenatal corticosteroids, and subsequent neurodevelopmental evaluation in multidisciplinary developmental evaluation clinic. The outcomes of these infants were compared according to degree of corticosteroid exposure. This study had 80% power to detect a difference in the mental development index score of 10% or a relative risk of neurodevelopmental delay of 2.5 in the group receiving at least two courses of corticosteroids. RESULTS: Ninety-three infants were exposed to less than two full courses and 33 infants were exposed to at least two full courses of corticosteroids. The mean duration of follow-up was similar in the two groups (25 months vs 30 months, respectively, P >.05). The two groups had similar neonatal outcomes, and had no differences in any measures of neurodevelopmental outcome on follow-up. CONCLUSION: Repeated courses of antenatal corticosteroids are not associated with increased incidence of abnormalities on subsequent neurodevelopmental outcome measures.

Adrenal Cortex Hormones↗

PubMed2004

Induction of labor after one prior cesarean: predictors of vaginal delivery.

OBJECTIVE: To estimate the characteristics most associated with vaginal birth in patients undergoing induction of labor after 1 prior cesarean delivery. METHODS: All patients who presented for induction of labor from 1996 to 2001 with a history of 1 prior cesarean delivery were identified. Relevant demographic and obstetric data were abstracted from the charts. Univariate analysis was used to identify predictive factors associated with vaginal birth after cesarean. Binary logistic regression was further used to identify which factors were independently associated with the outcome measure. RESULTS: Of the 429 women included in the study, 334 (77.9%) had a successful trial of labor. In the final binary logistic regression equation, prior vaginal delivery (odds ratio [OR] 3.75; 95% confidence interval [CI] 1.96, 7.18) remained independently associated with an increased chance of a vaginal delivery after a trial of labor. Conversely, prior cesarean delivery for dystocia (OR 0.46; 95% CI 0.27, 0.79), induction on or past the estimated date of delivery (OR 0.46; 95% CI 0.27, 0.78), need for cervical ripening (OR 0.35; 95% CI 0.20, 0.61), and maternal gestational or preexisting diabetes (OR 0.16; 95% CI 0.06, 0.40) were all factors associated with a decreased likelihood of achieving a successful trial of labor. CONCLUSION: Several factors are available which may assist in identifying patients with the best chance of vaginal delivery after an induction of labor in the presence of a prior low-transverse cesarean scar. LEVEL OF EVIDENCE: II-2

Adult↗

PubMed2003

Factors associated with success of emergent second-trimester cerclage.

OBJECTIVE: To assess the factors associated with delivery greater than or equal to 28 weeks' gestation after placement of an emergent cerclage in women with singleton gestations. METHODS: All women who underwent emergent cerclage, defined as any cerclage placed between 16 and 24 6/7 weeks' gestation in response to documented cervical change on physical examination, at Northwestern Memorial Hospital from 1980 to 2000 were identified. Univariable and multivariable analyses were used to determine the factors most associated with achieving at least 28 weeks' gestation. RESULTS: One hundred sixteen women were eligible for analysis. Maternal age, race, and operative variables such as suture type and use of antibiotics were not associated with differences in the frequency of delivery at or after 28 weeks. Cerclage placement at or after 22 weeks' gestation increased the likelihood of reaching 28 weeks, whereas several cervical examination findings (dilatation greater than 3 cm, cervical length less than 0.5 cm, and membranes prolapsing beyond the external cervical os) as well as need for placement in a nullipara significantly reduced the likelihood of reaching 28 weeks. In multivariable analysis, nulliparity (odds ratio 0.31, 95% confidence interval 0.1, 0.8) and membranes prolapsing beyond the external cervical os (odds ratio 0.24, 95% confidence interval 0.1, 0.4) continued to be associated with delivery before 28 weeks, whereas cerclage placement at or after 22 weeks (odds ratio 3.2, 95% confidence interval 1.2, 8.6) increased the chance of achieving at least 28 weeks' gestation. CONCLUSION: Nulliparity, the presence of membranes prolapsing beyond the external cervical os, and gestational age less than 22 weeks at cerclage placement are associated with decreased chance of delivery at or after 28 weeks after emergent cerclage; these factors may be used to help counsel patients considering the procedure.

Adult↗

PubMed2003

Management of the second stage of labor in nulliparas with continuous epidural analgesia.

OBJECTIVE: To determine if waiting for a strong urge to push in nulliparas with continuous low-concentration epidural analgesia shortens the pushing duration in the second stage. METHODS: Nulliparas with standardized patient-controlled epidural analgesia (0.0625% bupivacaine with fentanyl 2 microg/mL) were randomly assigned to pushing immediately upon complete cervical dilatation (n = 85) or waiting for a strong urge to push (n = 117). Urge to push and patient satisfaction were quantified on 100-mm visual analogue scales. Duration of pushing and total duration of the second stage were analyzed as survival time data. RESULTS: Women who delayed pushing and those who pushed immediately were similar with respect to maternal characteristics. Women who delayed pushing had a stronger urge to push (P <.01) and a longer second stage (P <.05) than women who pushed immediately. There was no significant difference in the time spent pushing (median 57 versus 62 minutes, respectively) or the median level of patient satisfaction (80 mm for both groups). There were no significant differences in the overall rates of cesarean delivery (6% versus 12%, respectively), cesarean delivery during the second stage (2% in each group), spontaneous vaginal delivery (70% versus 69%, respectively), or neonatal or maternal morbidity. CONCLUSION: In nulliparas with continuous low-concentration epidural analgesia, delaying pushing until a strong urge is felt does not reduce the duration of pushing in the second stage of labor.

Adult↗

PubMed2003

Isolated low second-trimester maternal serum beta-human chorionic gonadotropin is not associated with adverse pregnancy outcome.

OBJECTIVE: We investigated whether low human chorionic gonadotropin from maternal serum screening is associated with adverse pregnancy outcome. STUDY DESIGN: Women between 15 and 20 completed weeks of gestation who had a maternal serum screen performed from June 1999 to November 2001 were studied. Cases included women with human chorionic gonadotropin values of 0.5 and <2.0 multiples of the median, and estriol values of >0.6 and <2.0 multiples of the median. Control subjects were selected randomly from the population of women with normal values for all three analytes. RESULTS: There were 146 case subjects and 292 control subjects. There was no increased risk in the study group compared with the control subjects for preterm delivery, intrauterine fetal death, low birth weight, abruptio placentae, preeclampsia, or preterm premature rupture of membranes. CONCLUSION: An isolated low human chorionic gonadotropin level from second-trimester maternal serum screening is not associated with adverse pregnancy outcome.

Abruptio Placentae↗