Lost in translation? English- and Spanish-speaking women's perceptions of gestational weight gain safety, health risks and counseling.

OBJECTIVE: To determine English- and Spanish-speaking women's perceptions on gestational weight gain (GWG) counseling. STUDY DESIGN: We administered a written survey to 279 pregnant women regarding GWG counseling and knowledge. We compared English- and Spanish-speaking women's responses using X(2)-tests and logistic regression analyses. RESULT: Seventy-four (27%) women completed the survey in Spanish and 205 (73%) in English. More Spanish compared with English speakers did not know if their provider recommended weight gain goals (26% vs 10%, odds ratio (OR) 3.2, confidence interval (CI) 1.5 to 6.5); if there are risks to excessive GWG for mother (27% vs 11%, OR 3.1, CI 1.5 to 6.4) or infant (38% vs 16%, OR 3.3, CI 1.7 to 6.3); or if exercise (15% vs 1%, OR 12.1, CI 3.0 to 69.1) or weight loss (35% v 12%, OR 4.0, CI 2.0 to 8.0) were safe during pregnancy. CONCLUSION: Significant differences exist between Spanish- and English-speaking women's perception of GWG counseling, which may be due to language or cultural barriers.

Noninvasive diagnosis by Doppler ultrasonography of fetal anemia due to maternal red-cell alloimmunization. Collaborative Group for Doppler Assessment of the Blood Velocity in Anemic Fetuses.

BACKGROUND: Invasive techniques such as amniocentesis and cordocentesis are used for diagnosis and treatment in fetuses at risk for anemia due to maternal red-cell alloimmunization. The purpose of our study was to determine the value of noninvasive measurements of the velocity of blood flow in the fetal middle cerebral artery for the diagnosis of fetal anemia. METHODS: We measured the hemoglobin concentration in blood obtained by cordocentesis and also the peak velocity of systolic blood flow in the middle cerebral artery in 111 fetuses at risk for anemia due to maternal red-cell alloimmunization. Peak systolic velocity was measured by Doppler velocimetry. To identify the fetuses with anemia, the hemoglobin values of those at risk were compared with the values in 265 normal fetuses. RESULTS: Fetal hemoglobin concentrations increased with increasing gestational age in the 265 normal fetuses. Among the 111 fetuses at risk for anemia, 41 fetuses did not have anemia; 35 had mild anemia; 4 had moderate anemia; and 31, including 12 with hydrops, had severe anemia. The sensitivity of an increased peak velocity of systolic blood flow in the middle cerebral artery for the prediction of moderate or severe anemia was 100 percent either in the presence or in the absence of hydrops (95 percent confidence interval, 86 to 100 percent for the 23 fetuses without hydrops), with a false positive rate of 12 percent. CONCLUSIONS: In fetuses without hydrops that are at risk because of maternal red-cell alloimmunization, moderate and severe anemia can be detected noninvasively by Doppler ultrasonography on the basis of an increase in the peak velocity of systolic blood flow in the middle cerebral artery.

Discordance between fetal RhD typing using molecular methods and neonatal typing with serology.

Polymerase chain reaction (PCR)-based genotyping on amniotic fluid in an RhD-negative alloimmunized woman predicted an RhD-negative fetal blood type. The neonate was RhD-positive and developed hemolytic disease. Discrepant results were also observed on paternal testing. PCR analysis with a different set of primers correctly predicted the RhD-positive fetal and paternal blood type. Use of more than one set of primers and parental testing can avoid some of the problems associated with use of PCR genotyping.

Just a beta....

Traditional implementation of clinical information systems follows a predictable project management process. The selection, development, implementation, and evaluation of the system and the project management aspects of those phases require considerable time and effort. The purpose of this paper is to describe the beta site implementation of a knowledge-based clinical information system in a specialty area of a southeastern hospital that followed a less than traditional approach to implementation. Highlighted are brief descriptions of the hospital's traditional process, the nontraditional process, and key findings from the experience. Preliminary analysis suggests that selection of an implementation process is contextual. Selection of elements from each of these methods may provide a more useful process. The non-traditional process approached the elements of communication, areas of responsibility, training, follow-up and leadership differently. These elements are common to both processes and provide a focal point for future research.

The effect of tocolytic agents (indomethacin and terbutaline) on fetal breathing and body movements: a prospective, randomized, double-blind, placebo-controlled clinical trial.

OBJECTIVE: The null hypothesis of this study is that maternal administration of indomethacin or terbutaline will not affect fetal breathing and body movements. STUDY DESIGN: Thirty patients with a low-risk pregnancy, gestational age 26 to 32 weeks, and no signs of preterm labor were randomly assigned to receive either terbutaline (5 mg), indomethacin (50 mg), or a placebo. Ultrasonographic evaluation of fetal breathing and body movements was performed for 1 hour before and 1 hour after treatment. The total amount of time of fetal breathing and body movements in each group was subject to statistical analysis that included analysis of variance and covariance and a multiple comparison procedure. RESULTS: Indomethacin increased fetal breathing from 20.8 +/- 13.1 minutes to 42.2 +/- 14.8 minutes (p < 0.01), whereas terbutaline increased fetal breathing movements from 19.8 +/- 9.0 minutes to 35.2 +/- 12.4 minutes (p < 0.01). No significant treatment effect was detected on fetal body movements. CONCLUSION: Between 26 and 32 weeks' gestation, a single dosage of indomethacin or terbutaline increases fetal breathing movements by 103% and 78%, respectively.

Hemodynamic profile of severe pregnancy-induced hypertension.

Cases of severe pregnancy-induced hypertension or eclampsia were studied in forty-five women by catheterization of the right side of the heart to define the presenting hemodynamic profile associated with this disorder. These women could not be easily categorized into one specific hemodynamic pattern. Most patients had high-normal to elevated systemic vascular resistance indices (mean 2726 +/- 120 dynes.sec.cm-5.m2). The mean cardiac index was 4.14 +/- 0.13 L.min-1.m2. The severity of hypertension was largely attributable to a disproportionate rise in the systolic component (mean 193 +/- 3 mm Hg) compared with diastolic blood pressure (mean 110 +/- 3 mm Hg). Women with eclampsia had significantly lower arterial blood pressure and systemic vascular resistance indices when compared with those of the rest of the study group. Analysis of Starling curves indicated that all patients had normal or hyperdynamic left ventricular function. A modest correlation was observed between central venous pressure and pulmonary capillary wedge pressure (r = 0.59). This disparity most likely results from the maintenance of normal to high cardiac output in the presence of an increased left ventricular afterload. The majority of patients with severe pregnancy-induced hypertension do have normal to high cardiac indices and pulmonary capillary wedge pressures accompanied by normal or hyperdynamic left ventricular function. This is true despite the presence of severe hypertension.

Influence of crystalloid versus colloid infusion on peripartum colloid osmotic pressure changes.

Plasma colloid osmotic pressure acts to retain fluid in the intravascular space. Intravenous crystalloids have been identified as one of the major factors contributing to the consistent peripartum decline in colloid osmotic pressure. This study was undertaken to compare the effect of two crystalloid infusions (1000 and 2000 mL Plasma-Lyte A) and a colloid infusion (1000 mL 5% albumin) on the peripartum colloid osmotic pressure. Before elective cesarean section, 45 parturients received one of the three infusions. The lowest mean maternal colloid osmotic pressure (16.6 +/- 1.1 mmHg, P less than .05 compared with baseline) occurred in the 2000-mL crystalloid infusion group eight to 16 hours postpartum. Although the colloid osmotic pressure fell in all groups postpartum, this reduction was significantly (P less than .05) less during the first 24 hours in the colloid infusion group. Minimizing this disruption of the colloid osmotic pressure to pulmonary capillary wedge pressure gradient may be clinically important in selected patients.

Cardiovascular alterations in severe pregnancy-induced hypertension: effects of intravenous nitroglycerin coupled with blood volume expansion.

Control of blood pressure in severe pregnancy-induced hypertension has often relied on agents with an unpredictable onset and duration of action. Because intravenous nitroglycerin is a potent, rapidly acting agent with a hemodynamic half-life measured in minutes, we evaluated its cardiovascular effects with and without volume expansion in six patients with severe pregnancy-induced hypertension. Nitroglycerin alone reduced mean arterial pressure by 27.5% without any significant changes in heart rate, central venous pressure, or stroke volume. The pulmonary capillary wedge pressure fell from 9 +/- 3 to 4 +/- 2 mm Hg (p less than 0.05) while the cardiac index decreased from 3.51 +/- 0.67 to 2.87 +/- 0.76 L/min X m2. Oxygen delivery fell significantly (p less than 0.05), from 617 +/- 78 to 491 +/- 106 ml/min X m2. While volume expansion alone had no effect on mean arterial pressure, the combination of blood volume expansion and nitroglycerin resulted in a marked resistance to the hypotensive effect of nitroglycerin. Cardiac index, pulmonary capillary wedge pressure, and oxygen utilization were not significantly different from baseline values when volume expansion preceded nitroglycerin. We conclude that the ease with which nitroglycerin reduces blood pressure is dependent on the individual patient's volume status. Although volume expansion allows one to maintain cardiac index, pulmonary capillary wedge pressure, and oxygen utilization when used in combination with nitroglycerin, this benefit may be offset by a concomitant reduction in hypotensive capability.

Role of intravenous nitroglycerin in the treatment of severe pregnancy-induced hypertension complicated by pulmonary edema.

Intravenous nitroglycerin would appear to be an ideal agent for the treatment of severe pregnancy-induced hypertension complicated by cardiogenic pulmonary edema. Nitroglycerin infusion effectively reduces preload by venous dilatation and, at higher doses, results in arterial vasodilatation. Because of these pharmacologic properties, the effects of intravenous nitroglycerin were studied in three patients with severe pregnancy-induced hypertension complicated by pulmonary edema. The major cardiovascular effects of nitroglycerin were to reduce the mean pulmonary capillary wedge pressure from 27 +/- 4 to 14 +/- 6 mm Hg, which result in a change in the colloid osmotic pressure to pulmonary capillary wedge pressure gradient from -10 to 2 mm Hg. No significant changes occurred in heart rate, central venous pressure, or cardiac index. Analysis of oxygen-related parameters revealed a significant (p less than 0.05) increase in oxygen delivery and extraction accompanied by a 53% increase in oxygen consumption. The changes in oxygen-related variables appeared to be secondary to a fall in mixed venous oxygen tension from 39 +/- 4 to 33 +/- 1 torr. These changes occurred without any significant improvement in arterial oxygen tension. We conclude that while intravenous nitroglycerin expeditiously corrects the hydrostatic derangements of pulmonary edema seen in pregnancy-induced hypertension, a rapid improvement in arterial oxygenation does not occur.

Cardiovascular alterations in severe pregnancy-induced hypertension seen with an intravenously given hydralazine bolus.

The acute cardiovascular effects of a 10 milligram bolus of hydralazine was found to cause a significant increase in heart rate and cardiac index while decreasing mean arterial pressure and systemic vascular resistance index. A wide spectrum of individual responses was seen in terms of peak effects and duration of effects. The role of hydralazine in patients with severe pregnancy-induced hypertension was discussed and possible alternative therapy is suggested.

Intrapartum to postpartum changes in colloid osmotic pressure.

A study was undertaken to determine the effect of route of delivery on plasma colloid osmotic pressure. Plasma colloid osmotic pressure was measured on admission to the hospital and 8 to 24 hours post partum in 72 patients at term with uncomplicated prenatal histories. Thirty-six patients underwent uncomplicated vaginal deliveries (local anesthesia, 18; conduction anesthesia, 18) and 36 patients had cesarean sections (conduction anesthesia, 18; general anesthesia, 18). The mean (+/- SD) intrapartum colloid osmotic pressure of the overall group was 21.0 +/- 2.1 mm Hg, and it declined significantly (p less than 0.01) to 15.4 +/- 2.1 mm Hg post partum. A comparison of the intrapartum and postpartum reductions in colloid osmotic pressure between patients who underwent vaginal delivery and those who underwent cesarean section revealed no significant differences. Furthermore, the mean reductions in colloid osmotic pressure when all four groups were compared by type of anesthesia were not significantly different. Fifteen patients (20.8%) in the study had a postpartum colloid osmotic pressure of less than 13.6 mm Hg, and five (6.9%) had a postpartum colloid pressure of less than 12.5 mm Hg. Our results indicate that, for normal pregnancy, colloid osmotic pressure is uniformly lowered in the post partum and, in some cases, to levels that have been reported to be dangerously low.

Cardiovascular alterations in severe pregnancy-induced hypertension: acute effects of intravenous magnesium sulfate.

The central hemodynamic effects of intravenous magnesium sulfate were studied in five patients with severe pregnancy-induced hypertension. All five patients had a Swan-Ganz and a radial artery catheter placed prior to initiation of magnesium sulfate therapy. Four grams of magnesium sulfate was given over 15 minutes followed by a continuous infusion of 1.5 gm per hour. There was a 12.5% increase in cardiac index immediately after the infusion but cardiac index returned to pretherapy values by 15 minutes after infusion. The mean arterial pressure was significantly (p less than 0.01) decreased 30 minutes after the 4 gm loading dose but had returned to baseline values by 1 hour. There were no other significant changes in any of the hemodynamic or oxygen-related variables measured. Our data confirm previous hemodynamic studies in patients with severe pregnancy-induced hypertension indicating a hyperdynamic state with large fluctuations in systemic and pulmonary vascular resistances. In addition, magnesium sulfate has been shown to have a transient hypotensive effect on mean arterial pressure, related to bolus infusion, that is not present with continuous infusion.