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OBJECTIVE: Preterm premature rupture of membranes (PPROM) continues to be a major cause of preterm births. The objective of this study was to compare the morbidity of patients with PPROM nonvertex presentations with patients with PPROM with vertex presentations. STUDY DESIGN: A retrospective analysis of data from 74 patients with PPROM with nonvertex presentations (study group) and 74 patients with PPROM with vertex presentations (control group) comprised the 2 study groups. All patients that met the study admission criteria were treated in a similar manner at 1 of 3 level-III hospitals. The gestational ages at delivery of all patients were between 23-34 weeks, and the gestational ages between case and control patients were matched for gestational age. RESULTS: A statistically significant (P = .03) higher incidence of a prolapsed umbilical cord was found in the study group (n = 8; 10.8%) relative to the control group (n = 1; 1.4%). More infants in the study group had low 5-minute Apgar scores (<5) and/or low cord pH (<7.20; n = 25 [33.8%]) than in the control group (n = 12 [16.2%]; P = .02). Five infants with breech presentations underwent a precipitous unplanned vaginal delivery. Significant morbidity was not detected in these 5 infants. CONCLUSION: After transfer to an antenatal ward, patients with PPROM with nonvertex presentations appear to have a significantly higher risk for prolapsed umbilical cords, lower Apgar scores, and/or lower umbilical cord blood pH values, when compared with their vertex counterparts. Additionally, there appears to be substantial risk of an unintended, vaginal breech delivery.
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Apresentação Pélvica , Ruptura Prematura de Membranas Fetais/epidemiologia , Adulto , Índice de Apgar , Estudos de Casos e Controles , Parto Obstétrico , Feminino , Idade Gestacional , Humanos , Concentração de Íons de Hidrogênio , Gravidez , Resultado da Gravidez , Prolapso , Estudos Retrospectivos , Cordão Umbilical/químicaRESUMO
OBJECTIVE: To determine preventability of in-hospital maternal mortality in the Ochsner Health System (OHS) in the US state of Louisiana. METHODS: A retrospective study was undertaken of all known cases of in-hospital maternal death (during pregnancy or within 42 days of termination) that occurred within OHS facilities in 1995-2013. Associations between characteristics and mortality and preventability were investigated. Incidence rate ratios (IRRs) were calculated in view of varying reference values. RESULTS: Among 16 eligible deaths, 12 (75%) were deemed potentially preventable. The incidences of overall and preventable maternal death were higher if the patient had late entry to prenatal care (IRR 6.3 [P=0.004] and 8.8 [P=0.004], respectively). Maternal mortality was increased if the patient had required transfer to the OHS (IRR 15.8 [P<0.001] overall and 15.8 [P=0.002] for preventable mortality). Deaths of patients with private insurance were more likely to be not preventable than were those of patients without such insurance (P=0.003). Uninsured patients had the highest MMR, with an IRR of 13.8 (P=0.014) when compared with Medicaid patients. CONCLUSION: The factors most predictive of mortality were late entry to prenatal care, critical status requiring transfer from an outside facility, and non-private insurance status.
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Mortalidade Hospitalar/tendências , Cobertura do Seguro , Morte Materna/prevenção & controle , Mortalidade Materna/tendências , Transferência de Pacientes/estatística & dados numéricos , Adulto , Causas de Morte , Feminino , Hospitais , Humanos , Incidência , Louisiana , Medicaid , Gravidez , Cuidado Pré-Natal , Análise de Regressão , Estudos Retrospectivos , Estados Unidos , Adulto JovemRESUMO
BACKGROUND: It is well documented that the American maternal mortality ratio has increased during the years 2000-2015. The Australian maternal mortality ratio, in contrast, has decreased during the same time period, a trend common among most Western countries. METHODS: This study was a retrospective cohort study of cases of in-hospital maternal deaths in the Ochsner Health System (Louisiana, United States) and the Queensland Health System (Australia) from 1995 to 2013. The aim was to determine if American and Australian women have a similar rate of preventable maternal death and if the deaths were attributable to the same factors. A multidisciplinary team assessed medical records to determine preventability. RESULTS: Sixteen eligible medical records were identified in the Ochsner Health System and 15 in the Queensland Health System. In the American cohort, deaths in the private insurance group (n=5) were least likely to be preventable (P=0.003). Australian maternal deaths were less likely to occur among women with late or no prenatal care than American maternal deaths; the risk difference was 44.5% for all deaths (95% confidence interval [CI]=9.7%, 79.4%; P=0.03) and 50.0% for potentially preventable deaths (95% CI=9.3%, 90.6%; P=0.04). CONCLUSION: Women from Louisiana, United States and Queensland, Australia have similar rates of preventable maternal death. No statistically significant factors explained trends in Australian maternal death; American maternal mortality was significantly associated with point of entry into prenatal care, likely influenced by insurance status. Furthermore, the majority of deaths in this group were complicated by hospital systems-based factors.
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OBJECTIVE: To review our experiences with ureterolithiasis and nephrolithiasis in pregnancy and compare their outcomes with those in the rest of the obstetric population. STUDY DESIGN: A database of obstetric deliveries was used to identify patients with (cases) and without (controls) urolithiasis and to compare demographics and pregnancy complications between the groups. Furthermore, retrospective chart review of the cases group was utilized to obtain additional pertinent information. RESULTS: Over a 3-year period, there were 21,010 deliveries, 86 of which had symptomatic urolithiasis, for an incidence of 1 in 244 pregnancies. Renal calculi occurred more commonly in Caucasians than African Americans. Patients were more likely to become symptomatic in the second or third trimester, and most stones passed spontaneously. Pregnancy complications were similar between the groups; however, there was a higher percentage of preterm premature rupture of membranes in the nephrolithiasis cases (7.0% vs. 2.9%, P < .05). CONCLUSION: Nephrolithiasis and ureterolithiasis occurred more commonly in Caucasians during pregnancy. The majority of patients became symptomatic in the last two-thirds of pregnancy and usually passed the calculus spontaneously. A higher incidence of preterm premature rupture of membranes was noted in pregnancies complicated by urolithiasis.
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Complicações na Gravidez/diagnóstico , Complicações na Gravidez/terapia , Resultado da Gravidez , Cálculos Urinários/diagnóstico , Cálculos Urinários/terapia , Adulto , Distribuição por Idade , Estudos de Casos e Controles , Feminino , Seguimentos , Idade Gestacional , Humanos , Incidência , Cálculos Renais/diagnóstico , Cálculos Renais/epidemiologia , Cálculos Renais/terapia , Gravidez , Complicações na Gravidez/epidemiologia , Probabilidade , Valores de Referência , Estudos Retrospectivos , Fatores de Risco , Ultrassonografia Pré-Natal , Cálculos Ureterais/diagnóstico , Cálculos Ureterais/epidemiologia , Cálculos Ureterais/terapia , Cálculos Urinários/epidemiologiaRESUMO
OBJECTIVE: To evaluate morbidity, particularly respiratory, in well-dated, near-term twins delivered electively and to compare them to those delivered either spontaneously or for obstetric indications. STUDY DESIGN: Charts from twin deliveries were reviewed for inclusion in this study. Inclusion criteria were well-dated twins (American College of Obstetricians and Gynecologists criteria for dating) and absence of (1) corticosteroids, (2) intravenous tocolysis, (3) lung maturity studies, (4) fetal malformations, (5) diabetes, and (6) medical indications for delivery in the elective delivery group. Those meeting the criteria were divided into elective and nonelective (both spontaneous and indicated) delivery groups. Outcome variables included incidence of transient tachypnea and respiratory distress syndrome in each group. RESULTS: During the study period, 168 sets of twins met the admission criteria. Controlling for gestational age, no difference was noted in the incidence of respiratory distress syndrome, transient tachypnea and admission to the special care nursery. Infants born during the 36th week of gestation were more likely to be admitted to the special care nursery (37.8% vs. 10.6%, P < .05) and had a greater incidence of respiratory complications (23.2% vs. 6.7%, P < .01) than those born after 37 weeks. No difference was identified between the 37th and 38th weeks. CONCLUSION: In this large series of well-dated twin pregnancies, there was no evidence of increased respiratory morbidity or special care nursery admissions with elective delivery at or beyond 37 weeks. Twins delivered during the 36th week of gestation had increased respiratory morbidity and special care nursery admissions.
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Doenças em Gêmeos/etiologia , Trabalho de Parto Induzido/efeitos adversos , Síndrome do Desconforto Respiratório do Recém-Nascido/etiologia , Fatores Etários , Fatores de Confusão Epidemiológicos , Doenças em Gêmeos/diagnóstico , Doenças em Gêmeos/epidemiologia , Feminino , Idade Gestacional , Humanos , Incidência , Recém-Nascido , Kentucky/epidemiologia , Morbidade , Gravidez , Resultado da Gravidez , Terceiro Trimestre da Gravidez , Síndrome do Desconforto Respiratório do Recém-Nascido/diagnóstico , Síndrome do Desconforto Respiratório do Recém-Nascido/epidemiologia , Estudos Retrospectivos , Fatores de RiscoRESUMO
A 24-year-old pregnant woman had a bowel obstruction secondary to a gravid uterus. A multispecialty team approach resulted in a restorative proctocolectomy, which led to resolution of acute symptoms and a successful pregnancy.
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Pregnancy causes anatomic and physiologic changes in the gastrointestinal tract. Pregnant women with intestinal disease such as Crohn disease or ulcerative colitis pose a management challenge in clinical diagnosis, radiologic evaluation, and treatment secondary to potential risk to the fetus. Heightened physician awareness on possible etiologies such as appendicitis, diverticulitis, and rarely colorectal cancer is required for rapid diagnosis and treatment to improve maternal/fetal outcome. A multidisciplinary approach to evaluation is a necessity because radiologic procedures and treatment medications commonly used in nonpregnant patients may have a potential harmful effect on the fetus. The authors review several gastrointestinal conditions encountered during pregnancy and address presentation, diagnosis, and treatment of each condition.
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PURPOSE AND DESIGN: The purpose of this cross-sectional, exploratory study is to describe perinatal moods and complementary alternative therapy (CAT) use among childbearing women living in New Orleans, post-Hurricane Katrina. How women coped with the disaster with limited access to mental health services was not known. METHOD: A convenience sample of 199 postpartal/expectant mothers completed two questionnaires. The Edinburgh Postnatal Depression Scale measured risk for perinatal depression (>10 for depression risk) and the Perinatal Alternative Therapy Index (PATI) obtained subjects' self-perceived overall scores for anxiety and overall mood, frequency and type of use of alternative therapies, and health behaviors. Open-ended questions solicited qualitative data. FINDINGS: The mean EPDS score was 8.47, yet 37% of the postpartum subjects had scores >or=10, indicating risk for depression, while 25% of the women in the prenatal group had scores >or=10. Ninety-five percent of women reported using CATs to improve their mood during pregnancy. Two themes emerged from the qualitative data: (a) Distress and Instability: The Katrina Effect and (b) Life Transitions. CONCLUSION: Post-Katrina, most women were proactive in seeking ways to improve their mood. Knowing that there are effective, alternative therapies to improve mood during the perinatal period, nurses and other care providers can offer more information about these nonmedical, accessible interventions.
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Terapias Complementares/estatística & dados numéricos , Tempestades Ciclônicas , Depressão Pós-Parto/prevenção & controle , Desastres , Mães/psicologia , Aceitação pelo Paciente de Cuidados de Saúde/psicologia , Adaptação Psicológica , Adulto , Afeto , Estudos Transversais , Depressão Pós-Parto/diagnóstico , Depressão Pós-Parto/epidemiologia , Depressão Pós-Parto/psicologia , Feminino , Humanos , Acontecimentos que Mudam a Vida , Nova Orleans/epidemiologia , Pesquisa Metodológica em Enfermagem , Escalas de Graduação Psiquiátrica , Pesquisa Qualitativa , Autocuidado/métodos , Autocuidado/psicologia , Inquéritos e QuestionáriosRESUMO
OBJECTIVE: The purpose of this study was to determine if dilation and curettage has an effect on future pregnancy outcome. METHODS: Retrospective review of the electronic medical records of all patients who underwent D&C between January 1, 2002, and December 31, 2006, was performed. Patients who had one or more subsequent pregnancies were selected and evaluated for pregnancy outcome. Frequency and incidence of subsequent pregnancy complications were determined by Chi square and Fisher's exact tests and compared to reported statistics. RESULTS: The incidence of postpartum hemorrhage was significantly higher than previously reported averages (p < 0.0004). We found no difference in the incidence of preterm delivery, preeclampsia, placental abruption, malpresentation, cervical incompetence, first trimester bleeding, and miscarriage when compared with previously reported data. Pregnancy outcomes among patients with a history of cervical dilation and those without were not significantly different. CONCLUSION: The current study suggests that dilation and curettage may predispose to postpartum hemorrhage. It is important to consider the effects of surgical management for miscarriage on future pregnancy outcomes.
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OBJECTIVE: The purpose of this study was to determine whether 3 days of broad-spectrum antibiotic therapy, which is intended to prolong latency in patients with preterm premature rupture of membranes, is comparable to 7 days of therapy. STUDY DESIGN: Patients with preterm premature rupture of membranes at three separate study sites were asked to participate in this intent-to-treat, prospective, randomized trial. They were assigned randomly to either 3 or 7 days of ampicillin-sulbactam (3 g intravenously every 6 hours). The primary outcome of interest was the latency period from membrane rupture to delivery. RESULTS: Forty-two individuals were enrolled in each group. No difference was noted in the latency interval between the two groups (3 days, 214 +/- 225 hours, vs 7 days, 229 +/- 218 hours). A significantly higher number of patients in the 3-day group completed therapy (80.1% vs 47.6%, P =.003). No other parameters were significantly different between the two groups. No adverse events or trends were noted in either group. CONCLUSION: There appears to be no difference in the latency period between 3 and 7 days of ampicillin-sulbactam antibiotic therapy. More patients are needed to exclude a type II error.
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Ampicilina/administração & dosagem , Quimioterapia Combinada/administração & dosagem , Ruptura Prematura de Membranas Fetais , Sulbactam/administração & dosagem , Adulto , Feminino , Humanos , Recém-Nascido , Infusões Intravenosas , Kentucky , Gravidez , Resultado da Gravidez , Estudos Prospectivos , Tennessee , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVE: Current treatment of preeclampsia no longer mandates delivery for proteinuria of >5 g per 24 hours. We sought to determine whether delayed delivery of preeclampsia with massive proteinuria (>10 g/24 h) increased maternal or neonatal morbidity. STUDY DESIGN: Records of all women with preeclampsia who were delivered at <37 weeks of gestation between January 1, 1997, and June 30, 2001, were reviewed. Patients with underlying renal disease or multiple gestation were excluded. Patients were characterized as having mild (<5 g/24 h), severe (5-9.9 g/24 h), or massive (>10 g/24 h) proteinuria. Outcomes were compared using the chi(2) test, one-way analysis of variance, or Fisher exact test. RESULTS: Two hundred nine patients met the inclusion criteria: 125 patients had mild proteinuria, 43 patients had severe proteinuria, and 41 patients had massive proteinuria. No significant differences in maternal morbidity were seen. Massive proteinuria was associated with earlier onset of preeclampsia, earlier gestational age at delivery, and higher rates of prematurity complications. After correction for prematurity, massive proteinuria has no significant effect on neonatal outcomes. CONCLUSION: Women with preeclampsia and massive proteinuria did not have increased maternal morbidity compared with women with severe or mild proteinuria. Massive proteinuria appears to be a marker for early-onset disease and progression to severe preeclampsia. Neonatal morbidity appears to be a function of prematurity rather than of massive proteinuria itself.
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Pré-Eclâmpsia/complicações , Resultado da Gravidez , Proteinúria/complicações , Descolamento Prematuro da Placenta/complicações , Adulto , Peso ao Nascer , Pressão Sanguínea , Creatinina/sangue , Eclampsia/complicações , Feminino , Morte Fetal/etiologia , Idade Gestacional , Síndrome HELLP/complicações , Humanos , Mortalidade Infantil , Recém-Nascido , Recém-Nascido Prematuro , Terapia Intensiva Neonatal , Trabalho de Parto Prematuro/complicações , Contagem de Plaquetas , GravidezRESUMO
OBJECTIVE: This study was undertaken to determine whether induction of labor with oral misoprostol will result in fewer cesarean deliveries than intravenous oxytocin in nulliparous women with premature rupture of membranes at term. STUDY DESIGN: Three hundred five women at 10 centers were randomly assigned to receive oral misoprostol, 100 microg every 6 hours to a maximum of two doses or intravenous oxytocin. The primary outcome measure was cesarean deliveries. Secondary outcomes were time from induction to vaginal delivery and measures of maternal and neonatal safety. RESULTS: The study was stopped prematurely because of recruitment difficulties. We present the results for the 305 enrolled women. There was no difference in the proportion of women who underwent cesarean delivery (20.1% in the misoprostol group, 19.9% in the oxytocin group). The time interval from induction to vaginal delivery was also similar (11.9 hours for the misoprostol group, and 11.8 hours for the oxytocin group). Maternal and neonatal safety outcomes were similar for the two treatments. More infants born to women in the misoprostol group received intravenous antibiotics in the neonatal period (16.4% vs 6.9%, P=.01), although there were no differences in chorioamnionitis or in proven neonatal infections. Women receiving misoprostol were less likely to have postpartum hemorrhage than those receiving oxytocin (1.9% vs 6.2%, P=.05). CONCLUSION: Oral misoprostol does not offer any advantage in time from induction to vaginal delivery or risk of cesarean section.