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1.
Eur J Obstet Gynecol Reprod Biol ; 246: 160-164, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32028144

RESUMO

OBJECTIVE: To evaluate the determinants of vaginal delivery and safety in women undergoing cervical ripening with a synthetic osmotic dilator (Dilapan-S) prior to induction of labor. METHODS: We conducted a secondary analysis of an international multicenter prospective observational study of Dilapan-S for cervical ripening in pregnancies greater than 32 weeks. Data were obtained in a standardized fashion and entered into a centralized electronic data capture system. The association between Bishop score and vaginal delivery was further evaluated with a multivariate receiver-operating characteristic (ROC) curve analysis. A Wilcoxon rank test and multivariable logistic regression were used for statistical analysis (significance: P < .05). RESULTS: Between May 2015 and July 2016, 444 pregnant women were included. Three hundred ten (70 %) delivered vaginally. Compared to patients who underwent cesarean delivery, those who delivered vaginally were more likely to have a history of prior vaginal delivery. Vaginal delivery rates were significantly correlated with Bishop scores of pre and post Dilapan-S and difference. After adjusting for age, BMI, number of dilators, cervical ripening time, and gestational age, both prior vaginal delivery and post-Dilapan-S Bishop scores were strong predictors of vaginal delivery (estimate coefficient: 0.1275 ± 0.03 P = .0002; 0.049 ± 0.01 P = .0001; respectively). Aggregate ROC accounting for these variables further supported these findings (AUC = 0.734). The lower confidence interval limit of vaginal delivery rates was above 50 % when post-Dilapan-S Bishop scores were ≥ 5. Cox regression analyses demonstrated that the duration of labor was significant shorter in women that had vaginal delivery. CONCLUSION: Bishop scores after cervical ripening with Dilapan-S are good predictors of vaginal delivery. Bishop scores < 5 post Dilapan-S may warrant further cervical ripening. Further level 1 trials are needed to compare osmotic dilators to other ripening methods.

2.
Arch Gynecol Obstet ; 301(1): 69-73, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31811413

RESUMO

OBJECTIVE: The objective of this study was to determine if high-dose antibiotic prophylaxis with cefazolin decreases the risk of surgical site infection (SSI) after a cesarean delivery. METHODS: We performed a retrospective cohort study of women who underwent a cesarean section. Two preoperative antibiotic regimens were compared: low dose versus high dose. The primary outcome was SSI. A sample size of 343 patients per group was calculated for a 50% reduction in risk for SSI. RESULTS: Seven hundred and thirty women were included with an incidence of SSI of 5%. Women who received the high-dose antibiotic regimen had lower rates of risk factors for SSI. The only exception was skin incision closure with staples. The rate of SSI did not differ between the low-dose and high-dose groups, even after adjusting for confounding variables [aOR 1.78, 95% CI (0.82-3.9)]. CONCLUSIONS: Higher doses of antibiotic prophylaxis did not decrease the rates of SSI after cesarean delivery.

3.
Am J Obstet Gynecol ; 221(3): 267.e1-267.e6, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31229429

RESUMO

BACKGROUND: Postpartum hemorrhage is the leading cause of maternal mortality in developing countries and the primary cause of one-quarter of all maternal deaths globally. Inaccuracy in estimating blood loss obscures the diagnosis of postpartum hemorrhage and its management. OBJECTIVE: Our objective was to compare assessment of blood loss using the quantitative Triton system (Gauss Surgical, Inc, Los Altos, CA) with other measures of blood loss in women undergoing cesarean delivery. STUDY DESIGN: Women scheduled for cesarean deliveries at our facility were included. Intraoperative blood loss was measured using the Triton, which was masked to the clinical team, as well as estimated by the surgeon (subjective estimated blood loss). The relation between the 2 methods (Triton and subjective estimated blood loss) and postoperative hemoglobin as well as delta hemoglobin (postoperative minus preoperative hemoglobin) was determined using the Spearman correlation. Triton measurement and subjective estimated blood loss were compared between women with delta hemoglobin in the upper quartile (cases) vs all other quartiles (control). Prediction of delta hemoglobin in the upper quartile also was evaluated for each method, and the area under the receiver operating characteristic curves was compared. RESULTS: The trial enrolled 242 patients. The mean blood loss estimated by the Triton device was significantly lower than that estimated by clinical judgment (415.3±260.6 vs 799.6±215.6 mL, P<.01). The Triton estimate correlated best with delta hemoglobin. Seventy patients had delta hemoglobin in the upper quartile (delta hemoglobin ≥2). There was a significant difference in the Triton blood loss measurement between cases and controls but no difference with subjective estimated blood loss. Triton, but not subjective estimated blood loss, was predictive of delta hemoglobin ≥2 g/dL (Triton: area under the receiver operating characteristic curve, 0.66; 95% confidence interval, 0.58-0.74; P<.01 vs subjective estimated blood loss: area under the receiver operating characteristic curve, 0.53; 95% confidence interval, 0.45-0.61; P=.45). CONCLUSIONS: The Triton system provides a better estimate of blood loss than the visual estimate. Clinical trials to evaluate its benefit are warranted.


Assuntos
Perda Sanguínea Cirúrgica/estatística & dados numéricos , Cesárea , Hemorragia Pós-Parto/diagnóstico , Adulto , Feminino , Seguimentos , Humanos , Gravidez , Estudos Prospectivos , Curva ROC
4.
Am J Obstet Gynecol ; 221(6): 644.e1-644.e5, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31201807

RESUMO

OBJECTIVE: The objective of the study was to describe the characteristics and outcomes of patients with antenatal diagnosis of vasa previa and evaluate the predictive factors of resolution in a contemporary large, multicenter data set. STUDY DESIGN: This was a retrospective multicenter cohort study of all antenatally diagnosed cases of vasa previa, identified via ultrasound and electronic medical record, between January 2011 and July 2018 in 5 US centers. Records were abstracted to obtain variables at diagnosis, throughout pregnancy, and outcomes, including maternal and neonatal variables. Data were reported as median [range] or n (percentage). Descriptive statistics, receiver-operating characteristics, and logistic regression analysis were used as appropriate. RESULTS: One hundred thirty-six cases of vasa previa were identified in 5 centers during the study period, 19 (14%) of which resolved spontaneously at median estimated gestational age of 27 weeks [19-34]. All subjects with unresolved vasa previa underwent cesarean delivery at a median estimated gestational age of 34 weeks [27-39] with the median estimated blood loss of 800 mL [250-2000]. Rates for vaginal bleeding, preterm labor, premature rupture of membrane, and need for blood product transfusion were not different between the resolved and unresolved group (P = NS). The odds ratio for resolution in those with the estimated gestational age of less than 24 weeks at the time of diagnosis was 7.9 (95% confidence interval, 2.1-29.4) after adjustment for confounding variables. CONCLUSION: Our data suggest that outcomes in antenatally diagnosed cases of vasa previa are excellent. Furthermore, our data report a higher chance of resolution when the condition is diagnosed before 24 weeks of gestation.

5.
Obstet Gynecol ; 133(5): 933-939, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30969218

RESUMO

Acute stroke in pregnancy can be devastating. Although neurologists will at some point be involved in the management, most of these patients are likely to first be evaluated by an obstetric care provider. It is, therefore, important for obstetric care providers to have an understanding of the presentation and management of stroke, particularly in the initial period when the window of opportunity for therapy is critical. Once suspected, a head computed tomography (CT) without contrast media should be performed without delay to rule out a hemorrhagic component. Patients presenting within 4.5 hours of symptom onset and with an initial normal head CT scan are candidates for alteplase (tissue plasminogen activator [tPA]). Blood pressure (BP) control is paramount when administering tPA. During pregnancy, we recommend maintaining a BP between 140-160/90-110 mm Hg during tPA treatment. Pregnancy should not be a contraindication for mechanical thrombectomy in carefully selected patients. The use of therapeutic anticoagulation during the acute management of ischemic stroke is not indicated owing to an increased risk of hemorrhagic transformation. Supportive therapy should include aggressive treatment of fever, avoidance of hypotonic maintenance fluids, and maintenance of normal serum sodium levels. Serum glucose levels should be kept between 140 and 180 mg/dL. Antiplatelet agents are indicated for secondary prevention. The management of cerebral venous sinus thrombosis, carotid and vertebral dissections, and reversible cerebral vasoconstrictive disease should overall follow same guidelines as for nonpregnant individuals.


Assuntos
Isquemia Encefálica/terapia , Complicações Cardiovasculares na Gravidez/terapia , Acidente Vascular Cerebral/terapia , Isquemia Encefálica/complicações , Administração de Caso , Feminino , Fibrinolíticos/uso terapêutico , Hemorragia/complicações , Humanos , Neuroimagem , Inibidores da Agregação de Plaquetas/uso terapêutico , Guias de Prática Clínica como Assunto , Gravidez , Acidente Vascular Cerebral/etiologia , Trombectomia , Ativador de Plasminogênio Tecidual , Tomografia Computadorizada por Raios X
6.
Am J Obstet Gynecol ; 220(3): 275.e1-275.e9, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30790569

RESUMO

OBJECTIVE: The objective of the study was to test the hypothesis that Dilapan-S is not inferior to the Foley balloon for preinduction cervical ripening at term. STUDY DESIGN: Pregnant women ≥37 weeks scheduled for induction with unfavorable cervix (≤3 cm dilated and ≤60% effaced) were randomly assigned to 12 hours of either Foley balloon inflated with 60 mL saline or Dilapan-S for cervical ripening. If the cervix remained unfavorable, then 1 more round of the assigned dilator was used. Management following ripening was left up to the clinical providers. The primary outcome was vaginal delivery. A satisfaction survey was also obtained after the preinduction period. Sample size was based on a noninferiority margin of 10%, 90% power, and an estimated frequency of vaginal delivery of 71% in Foley balloon and 76% in Dilapan-S. RESULTS: From November 2016 through February 2018, 419 women were randomized (209 to Foley balloon; 210 to Dilapan-S). In the intent-to-treat analysis, vaginal delivery was more common in Dilapan-S vs Foley balloon (81.3% vs 76.1%), with an absolute difference with respect to the Foley balloon of 5.2% (95% confidence interval, -2.7% to 13.0%) indicating noninferiority for the prespecified margin. The difference was not large enough to show superiority. Noninferiority was confirmed in the per-protocol population (n = 204 in the Foley balloon, n = 188 in Dilapan-S), supporting the robustness of the results. Secondary outcomes were not different between groups, except for a longer time the device remained in place in Dilapan-S compared with the Foley balloon. Maternal and neonatal adverse events were not significantly different between groups. A priori interaction analyses showed no difference in the effect on vaginal delivery by cervical dilation at randomization, parity, or body mass index >30 kg/m2. Patients with Dilapan-S were more satisfied than patients with the Foley balloon as far as sleep (P = .01), relaxing time (P = .001), and performance of desired daily activities (P = .001). CONCLUSION: Dilapan-S is not inferior to the Foley balloon for preinduction cervical ripening at term. Advantages of Dilapan-S over Foley include Food and Drug Administration approval, safe profile, no protrusion from the introitus, no need to keep under tension, and better patient satisfaction.


Assuntos
Cateterismo/instrumentação , Maturidade Cervical , Trabalho de Parto Induzido/instrumentação , Polímeros , Adolescente , Adulto , Cateterismo/métodos , Parto Obstétrico/métodos , Parto Obstétrico/estatística & dados numéricos , Feminino , Humanos , Trabalho de Parto Induzido/métodos , Satisfação do Paciente , Gravidez , Método Simples-Cego , Adulto Jovem
7.
Am J Perinatol ; 36(4): 406-421, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30130821

RESUMO

OBJECTIVE: To assess available evidence regarding the use of oxytocin in conjunction with Foley balloon (FB) for cervical ripening. METHODS: Databases from MEDLINE (U.S. National Library of Medicine, 1980-May 12, 2017), MEDLINE (Ovid, 1980-June 30, 2017), the Cochrane Library Controlled Trials Register, ClinicalTrials.gov, and Web of Science were queried for studies on FB cervical ripening with or without oxytocin in pregnant women. Search terms included: "balloon dilatation" OR "mechanical methods" OR "mechanical method" OR "mechanical dilation" OR "mechanical dilatation" OR "mechanical dilations" OR "mechanical dilatations" OR "balloon" OR "Foley" AND "Pitocin" OR "oxytocin." All relevant references were reviewed. Literature for inclusion and methodological quality were reviewed based on the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. RESULTS: Out of 344 citations, six randomized clinical trials (1,133 patients) fulfilled our inclusion criteria. The pooled estimate showed that the cesarean delivery (CD) rate did not differ (relative risk [RR]: 0.91 (95% confidence interval [CI] [0.76-1.10]; p = 0.23) between patients who underwent preinduction cervical ripening with FB alone versus those who received oxytocin in addition to FB. Heterogeneity was not significant among studies (I 2 0.0%; p = 0.64). Furthermore, no differences in other outcomes such as composite and maternal outcomes were detected between these two groups. Compared with simultaneous use of oxytocin with FB, the Foley alone cervical ripening group had a longer induction to delivery time, and lower deliveries within 12 and 24 hours. Subgroup analysis showed that only multiparous women in the Foley alone group had lower rate of vaginal delivery within 24 hours (RR: 0.74, 95% CI [0.61-0.89], p = 0.002) along with a trend toward higher CD rates. CONCLUSION: Adding oxytocin to FB at the time of preinduction cervical ripening does not reduce cesarean rates nor improve maternal or neonatal outcomes. Multiparous women who received FB alone seem to have lower rates of vaginal deliveries within 24 hours, but these results should be interpreted with caution.

8.
Reprod Sci ; 26(9): 1243-1248, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-30486735

RESUMO

OBJECTIVE: There is no consensus on which risk stratification approach to use for thromboprophylaxis in pregnancy, and most available risk assessment models (RAMs) for venous thromboembolism (VTE) events have not been validated in pregnancy. Our objective was to compare the performance of some of the most commonly used VTEs RAMs in our patient population in the peripartum period. STUDY DESIGN: This is a retrospective cohort of women who delivered at our institution in 2015 and 2016. We excluded patients with history of prior or current VTEs or those already receiving anticoagulants. Antepartum, intrapartum, and postpartum records were reviewed. Data were collected on known risk factors for VTEs in order to calculate scores for 3 RAMs on admission for delivery: Padua, Caprini, and Royal College of Obstetricians and Gynaecologists (RCOG). The primary objective was to the estimate the performance of the various RAMs in preventing postpartum VTEs. We calculated the proportion of women who would have been high risk, determined the number of VTEs cases within high- and low-risk categories, as well as calculated the number needed to treat (NNT) for each RAM. We performed analyses using different RAM scores cutoffs, VTEs outcome rates, and effectiveness of anticoagulation to prevent VTEs. The P value <.05 was considered statistically significant. RESULTS: A total of 6094 women were included. Three women had VTEs for an overall rate of 0.04% (N = 3; 95% confidence interval [CI]: 0.01-0.15). The proportion of women categorized as high risk for VTEs were 62% (95% CI: 61-64) for RCOG, 0.8% (95% CI: 0.6-1.0) for Padua, and 94% (95% CI: 94-95) for Caprini. Of the 3 VTEs, the RCOG model classified 1 woman as high risk and Padua model classified 3 women as high risk; whereas the Caprini did not identify any women as high risk. Assuming 100% effectiveness of thromboprophylaxis, the observed NNT was 3838 using RCOG, not able to calculate using Padua (no VTEs cases occurred in the high-risk group, thus none were prevented), and 1927 using Caprini. CONCLUSION: The rates of VTEs in pregnancy are very low and the available RAMs do not identify most of them. The RCOG and Caprini RAMs would categorize a large proportion of women as high risk and are associated with high NNTs. The Padua RAM appears to have the lowest NNT but missed all the VTEs in our cohort.

9.
AJP Rep ; 8(4): e223-e226, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30345158

RESUMO

Background The gold standard for antenatal diagnosis of placenta previa is the transvaginal ultrasonography. In placenta previa cases, separation of placental and uterine tissues is challenging even for the most experienced surgeons. Life-threatening obstetrical complications from cesarean deliveries with placenta previa include peripartum hemorrhage, coagulopathy, blood transfusion, peripartum hysterectomy, and multiple organ failure. Cases We detailed the 3 cases of placenta previa that underwent bilateral uterine artery ligation; if hemostasis was not achieved, horizontal mattress sutures were placed in the lower uterine segment. All patients were discharged with minimal morbidity. Conclusion For patients with placenta previa and low risk for placenta creta, counseling should include the risk for maternal morbidity and criteria for pursuing peripartum hysterectomy. Our devascularization, a stepwise surgical approach, shows promising outcomes in placenta previa cases. Précis We propose a novel surgical approach, using a progressive devascularization surgical technique, for management of women with placenta previa, undergoing cesarean delivery.

10.
J Assist Reprod Genet ; 35(5): 871-877, 2018 May.
Artigo em Inglês | MEDLINE | ID: mdl-29508122

RESUMO

PURPOSE: The aim was to study the association between embryonal mitochondrial DNA (mtDNA) content and embryo quality and implantation outcomes. METHODS: A retrospective chart review was performed with data collected from a private IVF center database. The study population included female infertility patients with ages ranging from 31 to 38 years old, and the main outcome measures were embryo quality and transfer outcomes. RESULTS: From a total of 1510 blastocyst biopsies, the majority of embryos consisted of grade 1 (High), followed by grade 2 (mid), and grade 3 (poor). Embryos with higher mtDNA content were found to be of poorer quality (grade 3) relative to grades 1 and 2 (P = 0.003). Using a logistic model, mtDNA best predicted lowest and highest grades, but not mid-grade embryos. There was no correlation between mtDNA content and the subjects' age (R2 = 0.0018). In an analysis of only euploid embryos (N = 717), there was no longer an association between mtDNA content and embryo quality (P = 0.834). There was no difference in mtDNA content between groups of embryos that did and did not implant (P = 0.53). There was also no association noted between mtDNA content and ongoing pregnancy. Compared to day 6, day 5 blastocysts contain significantly higher amounts of mtDNA (P = 0.0005), lower rates of aneuploidy (P < 0.001), and were more likely to be high-quality blastocysts (grade 1) (P < 0.001). CONCLUSION: Although the mtDNA content shows some association to the morphologic grade of an embryo, this association does not persist in an analysis of only euploid embryos. Mitochondrial DNA content also does not appear to be associated with implantation or ongoing pregnancy. Day 5 blastocysts have significantly higher mtDNA content compared to day 6 blastocysts.


Assuntos
Blastocisto/fisiologia , DNA Mitocondrial/genética , Implantação do Embrião/genética , Transferência Embrionária , Adulto , Aneuploidia , DNA Mitocondrial/análise , Feminino , Humanos , Infertilidade Feminina/genética , Infertilidade Feminina/terapia , Gravidez , Estudos Retrospectivos , Resultado do Tratamento
11.
Am J Perinatol ; 35(8): 737-740, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29278864

RESUMO

OBJECTIVE: It is unknown whether the heart operates in the ascending or flat portion of the Starling curve during normal pregnancy. Pregnant women do not respond to the passive leg-raising maneuver secondary to mechanical obstruction of the inferior vena cava by the gravid uterus. Our objective was to evaluate if administration of a fluid bolus increases baseline stroke volume (SV) among healthy pregnant patients during the third trimester. STUDY DESIGN: Healthy pregnant women who underwent elective term cesarean sections were included. A noninvasive cardiac output monitor was used to measure hemodynamic variables at baseline and after administration of a 500-mL crystalloid bolus. RESULTS: Forty-five women were included in the study. Fluid administration was associated with a statistically significant increase in SV from a baseline value of 71 ± 11 to 90 ± 19 mL (95% confidence interval [CI]: 13.67-21.49; p < 0.01) and a significant decrease in maternal heart rate from a baseline of 87 ± 9 beats per minute to 83 ± 8 after the fluid bolus (95% CI: -6.81 to -2.78; p = 0.03). No changes in peripheral vascular resistances or any other measured hemodynamic parameters were noted with volume expansion. CONCLUSION: In healthy term pregnancy, the heart operates in the ascending portion of the Starling's curve, rendering it fluid responsive.


Assuntos
Perna (Membro)/fisiologia , Posicionamento do Paciente , Postura , Terceiro Trimestre da Gravidez/fisiologia , Volume Sistólico , Adulto , Pressão Sanguínea , Feminino , Frequência Cardíaca , Hemodinâmica , Humanos , Monitorização Fisiológica , Gravidez , Estudos Prospectivos , Resistência Vascular , Adulto Jovem
12.
Obstet Gynecol ; 130(6): 1386-1387, 2017 12.
Artigo em Inglês | MEDLINE | ID: mdl-29189684
13.
Obstet Gynecol ; 130(4): 765-769, 2017 10.
Artigo em Inglês | MEDLINE | ID: mdl-28885402

RESUMO

Obstetric hemorrhage remains the most common cause of maternal mortality worldwide. It is believed that increased fibrinolytic activity, secondary to release and activation of endothelial tissue plasminogen activator, is involved in its pathogenesis. Tranexamic acid (TXA), an antifibrinolytic agent, has been shown to be beneficial in trauma patients if used within 3 hours of injury. A recent large randomized controlled trial showed that TXA given to hemorrhaging women within 3 hours after delivery was associated with decreased risk of death resulting from bleeding with no increase in thromboembolic complications. Limited evidence suggests that prophylactic TXA reduces blood loss at the time of delivery and decreases transfusion rates in the obstetric population. Tranexamic acid appears to be a safe and effective option in the treatment of obstetric hemorrhage. In addition, the limited available evidence supports the need for a well-designed adequately powered clinical trial to test its benefit as a prophylactic agent.


Assuntos
Antifibrinolíticos/administração & dosagem , Hemorragia Pós-Parto/tratamento farmacológico , Ácido Tranexâmico/administração & dosagem , Feminino , Humanos , Hemorragia Pós-Parto/prevenção & controle , Gravidez , Resultado do Tratamento
14.
J Crit Care ; 40: 41-45, 2017 08.
Artigo em Inglês | MEDLINE | ID: mdl-28319910

RESUMO

Septic shock remains one of the major causes of morbidity and mortality in the critically ill. Despite early goal therapy and administration of cathecholaminergic agents, up to 30% of patients succumb to the disease. In this manuscript, we first summarize the standard of care of patients with septic shock and current guidelines. We review the physiologic role of vasopressin and its role in septic shock management. We then review the most up-to-date evidence on the potential role of V1a receptor agonists such as Selepressin, in septic shock. Exciting new trials are being completed in order to elucidate the role of V1a receptor agonists as potential first-line vasopressor alternatives in the therapy of circulatory shock in septic patients.


Assuntos
Estado Terminal , Receptores de Vasopressinas/agonistas , Choque Séptico/tratamento farmacológico , Vasoconstritores/uso terapêutico , Vasopressinas/uso terapêutico , Humanos , Vasoconstritores/administração & dosagem , Vasopressinas/administração & dosagem
15.
Obstet Gynecol ; 128(5): 1105-1110, 2016 11.
Artigo em Inglês | MEDLINE | ID: mdl-27741183

RESUMO

Guillain-Barré syndrome has been reported in pregnancy and is a potentially lethal condition. It affects the nervous system with acute onset of symmetric ascending weakness and may result in frank respiratory failure and autonomic dysfunction. Most patients recall symptoms of a respiratory or gastrointestinal illness in the weeks preceding the onset of weakness. Recent evidence suggests a potential role of the Zika virus as a trigger for the syndrome. The diagnosis of Guillain-Barré is clinical. Supportive measures include venous thromboembolism prophylaxis, aggressive physical therapy, pressure ulcer prevention, enteral nutrition, and respiratory support. The mainstay of management comprises plasmapheresis or administration of intravenous immunoglobulins. Affected patients must be closely monitored for development of respiratory failure and autonomic dysfunction. Treatment during pregnancy should follow the same principles as for nonpregnant individuals.


Assuntos
Síndrome de Guillain-Barré , Complicações na Gravidez , Doenças Autoimunes , Feminino , Síndrome de Guillain-Barré/diagnóstico , Síndrome de Guillain-Barré/terapia , Síndrome de Guillain-Barré/virologia , Humanos , Gravidez , Complicações na Gravidez/diagnóstico , Complicações na Gravidez/terapia , Complicações na Gravidez/virologia , Prognóstico , Infecção por Zika virus/complicações
16.
AJP Rep ; 6(3): e272-6, 2016 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-27516921

RESUMO

BACKGROUND: Despite its seldom occurrence, fetal tachycardia can lead to poor fetal outcomes including hydrops and fetal death. Management can be challenging and result in maternal adverse effects secondary to high serum drug levels required to achieve effective transplacental antiarrhythmic drug therapy. CASE: A 33-year-old woman at 33 weeks of gestation with a diagnosis of a fetal sustained superior ventricular tachycardia developed chest pain, shortness of breath, and bigeminy on electrocardiogram secondary to digoxin toxicity despite subtherapeutic serum drug levels. She required supportive care with repletion of corresponding electrolyte abnormalities. After resolution of cardiac manifestations of digoxin toxicity, the patient was discharged home. The newborn was discharged at day 9 of life on maintenance amiodarone. CONCLUSION: We describe an interesting case of digoxin toxicity with cardiac manifestations of digoxin toxicity despite subtherapeutic serum drug levels. This case report emphasizes the significance of instituting an early diagnosis of digoxin toxicity during pregnancy, based not only on serum drug levels but also on clinical presentation. In cases of refractory supportive care, digoxin Fab fragment antibody administration should be considered. With timely diagnosis and treatment, excellent maternal and perinatal outcomes can be achieved.

17.
Reprod Sci ; 23(11): 1593-1599, 2016 11.
Artigo em Inglês | MEDLINE | ID: mdl-27170663

RESUMO

OBJECTIVE: Using an animal model of preeclampsia induced by overexpression of soluble fms-like tyrosine kinase 1 (sFlt-1), we previously showed that pravastatin prevents the development of a preeclampsia phenotype. Our objective is to determine whether pravastatin treatment may be explained by its effects on apoptotic/survival pathways in the placenta. METHODS: Pregnant CD1 mice at day 8 of gestation (length of gestation 19 days) were randomly allocated to injection via tail vein with either adenovirus carrying sFlt-1 or adenovirus carrying the murine immunoglobulin G2α Fc fragment (mFc virus control group). Mice from the sFlt group were randomly assigned to receive pravastatin (5 mg/kg/d) in their drinking water from day 9 until killing (sFlt-1 + Pravastatin) or water (sFlt-1). The mFc control received water only. Mice were killed on day 18, and the placentas were collected. Protein mitogen-activated protein kinase (MAPK) pathway substrates were assayed using Bioplex Multiplex Immunoassay (Bio-Rad, Hercules, California). Data are reported as mean ± standard error of the mean or median (interquartile range) when appropriate. One-way analysis of variance followed by post hoc analysis was performed. Two-sided P value < .05 was considered statistically significant. RESULTS: The sFlt-1 + Pravastatin mice had significantly higher placental protein concentrations of prosurvival/ antiapoptotic factors (activating transcription factor 2, pp38, phosphorylated c-jun N-terminal kinase, and phosphorylated extracellular signal-regulated kinase) and of heat-shock protein 27 and signal transducer and activator of transcription 3, 2 factors crucial for embryonic and placental development during oxidative stress, compared to sFlt-1 mice (P < .05) and similar to the mFc control group. No differences were noted in substrates of the proapoptotic pp53 pathway. CONCLUSION: Pravastatin ability to prevent preeclampsia phenotype may be mediated through pleiotropic mechanisms involving a prosurvival/ antiapoptotic MAPK pathway in the placenta. Our results further support continued research in the role for statins in the prevention of preeclampsia.


Assuntos
Apoptose/efeitos dos fármacos , Placenta/efeitos dos fármacos , Placenta/metabolismo , Pravastatina/administração & dosagem , Pré-Eclâmpsia/metabolismo , Animais , Modelos Animais de Doenças , Feminino , Proteínas de Choque Térmico HSP27/metabolismo , Sistema de Sinalização das MAP Quinases/efeitos dos fármacos , Camundongos , Fosforilação , Pré-Eclâmpsia/prevenção & controle , Gravidez , Fator de Transcrição STAT3/metabolismo , Receptor 1 de Fatores de Crescimento do Endotélio Vascular/metabolismo
18.
Am J Perinatol ; 33(14): 1357-1364, 2016 12.
Artigo em Inglês | MEDLINE | ID: mdl-27135955

RESUMO

Objective The objective of this study was to localize by neuroimaging the altered structural brain development of these offspring using an autism model of transgenic mice lacking contactin-associated protein-like 2 (Cntnap2). Materials and Methods Pregnant dams were randomly allocated to fructose solution (10% W/V) as only drinking fluid or water. Cntnap2 heterozygous (+/-) offspring from each group were euthanized at 6 months of age and their whole brains evaluated by magnetic resonance imaging. T2-weighted images were acquired to evaluate the volumes of 29 regions of interest involved in autism spectrum disorder (ASD) pathogenesis. Whole brains were washed and processed for Nissl staining. Mann-Whitney U test and one-way analysis of variance were used for statistical analysis (significance: p < 0.05). Results The corpus callosum, anterior commissure, and caudate putamen were significantly smaller in Cntnap2 (+/-) male offspring exposed to fructose. No brain alterations were found in the female counterparts. Nissl staining of the caudate putamen revealed higher neuronal cell count in the male fructose offspring. Female group revealed an increase in caudate putamen neuronal cell count. Conclusion Metabolic dysregulation in pregnancy alters fetal brain development in genetically predisposed offspring. This is consistent with findings in human studies and supports the role of intrauterine factors in the etiology of autism.


Assuntos
Transtorno do Espectro Autista/diagnóstico por imagem , Transtorno do Espectro Autista/patologia , Encéfalo/embriologia , Encéfalo/patologia , Frutose/administração & dosagem , Fenômenos Fisiológicos da Nutrição Materna , Animais , Transtorno do Espectro Autista/genética , Modelos Animais de Doenças , Feminino , Desenvolvimento Fetal , Imagem por Ressonância Magnética , Masculino , Proteínas de Membrana/genética , Camundongos , Camundongos Endogâmicos C57BL , Camundongos Transgênicos , Proteínas do Tecido Nervoso/genética , Gravidez , Distribuição Aleatória , Fatores Sexuais
19.
Am J Obstet Gynecol ; 215(3): 378.e1-6, 2016 09.
Artigo em Inglês | MEDLINE | ID: mdl-27060421

RESUMO

BACKGROUND: Consumption of fructose-rich diets in the United States is on the rise and thought to be associated with obesity and cardiometabolic diseases. OBJECTIVE: We sought to determine the effects of antenatal exposure to high-fructose diet on offspring's development of metabolic syndrome-like phenotype and other cardiovascular disease risk factors later in life. STUDY DESIGN: Pregnant C57BL/6J dams were randomly allocated to fructose solution (10% wt/vol, n = 10) or water (n = 10) as the only drinking fluid from day 1 of pregnancy until delivery. After weaning, pups were started on regular chow, and evaluated at 1 year of life. We measured percent visceral adipose tissue and liver fat infiltrates using computed tomography, and blood pressure using CODA nonivasive monitor. Intraperitoneal glucose tolerance testing with corresponding insulin concentrations were obtained. Serum concentrations of glucose, insulin, triglycerides, total cholesterol, leptin, and adiponectin were measured in duplicate using standardized assays. Fasting homeostatic model assessment was also calculated to assess insulin resistance. P values <.05 were considered statistically significant. RESULTS: Maternal weight, pup number, and average weight at birth were similar between the 2 groups. Male and female fructose group offspring had higher peak glucose and area under the intraperitoneal glucose tolerance testing curve compared with control, and higher mean arterial pressure compared to control. Female fructose group offspring were heavier and had higher percent visceral adipose tissue, liver fat infiltrates, homeostatic model assessment of insulin resistance scores, insulin area under the intraperitoneal glucose tolerance testing curve, and serum concentrations of leptin, and lower concentrations of adiponectin compared to female control offspring. No significant differences in these parameters were noted in male offspring. Serum concentrations of triglycerides or total cholesterol were not different between the 2 groups for either gender. CONCLUSION: Maternal intake of high fructose leads to fetal programming of adult obesity, hypertension, and metabolic dysfunction, all risk factors for cardiovascular disease. This fetal programming is more pronounced in female offspring. Limiting intake of high fructose-enriched diets in pregnancy may have significant impact on long-term health.


Assuntos
Dieta , Frutose/administração & dosagem , Hipertensão/etiologia , Resistência à Insulina , Obesidade/etiologia , Efeitos Tardios da Exposição Pré-Natal , Animais , Glicemia/análise , Fígado Gorduroso/etiologia , Feminino , Frutose/efeitos adversos , Teste de Tolerância a Glucose , Gordura Intra-Abdominal/anatomia & histologia , Leptina/sangue , Camundongos Endogâmicos C57BL , Gravidez
20.
Obstet Gynecol ; 127(2): 241-7, 2016 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-26942349

RESUMO

OBJECTIVE: To assess available evidence regarding the use of extracorporeal membrane oxygenation (ECMO) in pregnant and postpartum women with acute respiratory distress syndrome (ARDS) secondary to H1N1 infection. DATA SOURCES: Databases from MEDLINE (U.S. National Library of Medicine, 1946 to April 1, 2015), the Cochrane Library Controlled Trials Register, ClinicalTrials.gov, and Web of Science were queried for studies on ECMO in pregnant or postpartum patients with ARDS. Search terms included: "ARDS," "ECMO," "pregnant," and "postpartum." TABULATION, INTEGRATION, AND RESULTS: All relevant references in any language were reviewed. Literature for inclusion and methodologic quality were reviewed based on the meta-analyses and systematic reviews of observational studies (Meta-analysis Of Observational Studies in Epidemiology) guidelines. Of 266 citations, five retrospective studies (39 patients) fulfilled our inclusion criteria. No randomized controlled trials were found. The pooled estimate of the survival rate among pregnant and postpartum patients who received ECMO for ARDS secondary to H1N1 was 74.6% (95% confidence interval [CI] 60.7-88.6%). Neonatal outcomes were reported in two studies and the rate of live birth was 70% (95% CI 43.7-95.2). Heterogeneity was not significant among studies (I ranged from 0% to 21%; P>.25). CONCLUSION: The role of ECMO in pregnant and postpartum women with ARDS from H1N1 remains unclear and the benefits suggested from our review should be interpreted with caution.


Assuntos
Oxigenação por Membrana Extracorpórea , Vírus da Influenza A Subtipo H1N1 , Influenza Humana/complicações , Transtornos Puerperais/terapia , Síndrome do Desconforto Respiratório do Adulto/terapia , Feminino , Humanos , Gravidez , Síndrome do Desconforto Respiratório do Adulto/virologia
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