Use of angiotensin-converting enzyme inhibitors in patients with diabetic nephropathy.

Diabetic nephropathy is the most common cause of end-stage renal failure in the Western world. It accounts for 15-25% of all renal failure in patients requiring chronic dialysis. About 20% of patients with insulin-dependent diabetes and less than 15% of patients with non-insulin-dependent diabetes develop clinically significant nephropathy. The prevalence of diabetic nephropathy in pregnant patients with insulin-dependent diabetes is estimated to be 6%. Angiotensin converting enzyme (ACE) inhibitors are the drug of choice in treating women with diabetic nephropathy. In addition, many of these drugs may be started before conception. Unfortunately, these agents might be fetotoxic when taken during pregnancy. This article reviews the epidemiology and natural history of diabetic nephropathy, discusses the renoprotective effect of ACE inhibitors, reviews the effect of ACE inhibitors on fetomaternal outcome when used prior to and during pregnancy in women with diabetic nephropathy and discusses the new class of drugs, angiotensin II receptor antagonists, in the management of diabetics who have or are prone to developing diabetic nephropathy.

Does the combined antenatal use of corticosteroids and antibiotics increase late-onset neonatal sepsis in the very low birth weight infant?

OBJECTIVE: The purpose of this study was to determine whether the combined use of maternal antenatal corticosteroids and antibiotic therapy is associated with an increased risk of late-onset neonatal sepsis among very low birth weight infants. STUDY DESIGN: The outcomes of infants admitted to the 3 Cincinnati neonatal intensive care units between May 1991 and May 2000 were retrospectively evaluated. Late-onset neonatal sepsis was defined either as the occurrence of a positive blood culture obtained after 72 hours of life with clinical signs of sepsis or as the need for >5 consecutive days of antibiotic therapy for presumed sepsis that initiated after 72 hours of life. Wilcoxon rank sum, chi-square test, and multiple logistic regression were used for analysis. RESULTS: Among the parturients delivering the study infants, 434 women (24%) received corticosteroids only, 175 women (9%) received antibiotics only, 819 women (46%) received both corticosteroids and antibiotics, and 370 women (20%) received neither corticosteroids nor antibiotics. Among 1978 study infants, there were 732 infants (41%) with late-onset neonatal sepsis. By univariate analysis, the odds ratio for late-onset neonatal sepsis caused by combined corticosteroid and antibiotic use was 0.96 (95% CI, 0.89%, 1.04%). Multiple logistic regression analysis was used to evaluate the risk of combined corticosteroids and antibiotic use after controlling for potential covariates and confounders. After controlling for outborn birth (odds ratio, 1.3; 95% CI, 1.0%-1.8%), increasing gestational age at delivery (odds ratio, 0.63; 95% CI, 0.60%-0.66%), interaction between white race and male gender (P =.01) and interaction between antibiotics and prolonged rupture of membranes (P =.02), the use of corticosteroids and antibiotics was not associated with an increased risk of late-onset neonatal sepsis (P =.9). CONCLUSION: The combined use of maternal corticosteroids and antibiotic therapy is not associated with an increased risk for late-onset neonatal sepsis.

A comparison of various routes and dosages of misoprostol for cervical ripening and the induction of labor.

OBJECTIVE: The purpose of this study was to compare the efficacy of different routes of misoprostol administration for cervical ripening and the induction of labor. STUDY DESIGN: Three hundred thirty women at > or = 32 weeks gestation with a Bishop score < or = 6 and an indication for induction were randomized to 1 of 3 double-blinded groups: (1) 25 microg orally administered misoprostol plus 25 microg vaginally administered misoprostol, (2) orally administered placebo plus 25 microg vaginally administered misoprostol, or (3) 25 microg orally administered misoprostol plus vaginally administered placebo. Doses were repeated every 4 hours until onset of labor or a maximum of 12 doses were given. The primary outcome of the trial was vaginal delivery within 24 hours of the initiation of induction. Secondary outcomes were the time from induction to delivery, need for oxytocin augmentation, mode of delivery, frequency of side effects, and neonatal and maternal outcome. Analysis of variance, chi-square test, and logistic regression were used for analysis. RESULTS: There were no significant differences in maternal characteristics or indications for induction. The percentage of women who achieved vaginal delivery within 24 hours was highest in the vaginally administered misoprostol group: 67% compared with 53% in the oral-plus-vaginal group (P < .05) and 36% in the oral group (P < .05). The median time to vaginal delivery was shorter in the vaginal and oral-plus-vaginal misoprostol groups, 13.5 hours and 14.3 hours, respectively, when compared with 23.9 hours in the oral group (P < .05). The rate of cesarean delivery was lowest in the vaginal misoprostol group (17% compared with 30% in the oral-plus-vaginal group and 32% in the oral group; P < .05). Uterine tachysystole occurred least frequently in the oral misoprostol group (10% compared with 32% in the vaginal group and 34% in the oral-plus-vaginal group; P < .05). Uterine hyperstimulation also occurred least frequently in the oral misopro-stol group (4% compared with 15% in the vaginal group and 22% in the oral-plus-vaginal group; P < .05). CONCLUSION: At the doses studied, induction of labor with vaginally administered misoprostol is more efficacious than either oral-plus-vaginal or oral-only route of administration.

Is vaginal delivery preferable to elective cesarean delivery in fetuses with a known ventral wall defect?

OBJECTIVE: We sought to test the hypothesis that vaginal delivery compared with elective cesarean delivery results in improved neonatal outcome in fetuses with a known isolated ventral wall defect. STUDY DESIGN: We performed a retrospective chart review. RESULTS: Between 1989 and 1999, we identified 102 infants with a confirmed antenatal diagnosis of an isolated ventral wall defect with either the diagnosis of an omphalocele or gastroschisis. Sixty-six infants were delivered by cesarean and 36 were delivered vaginally. There were no significant demographic differences between the study groups or between the two sites except that one center (Cincinnati) usually delivered these fetuses by cesarean whereas the other (Louisville) usually delivered such fetuses vaginally. Overall, there were a greater number of infants with gastroschisis than omphalocele (gastroschisis, n = 71; omphalocele, n = 31). After we controlled for primary versus staged closure of ventral wall defect and gestational age at delivery; the medians and interquartile ranges for cesarean and vaginal delivery were 39 (25, 63) days versus 42 (26, 75) days, respectively (P =.32), for neonatal length of stay and 13 (9, 18) days versus 13 (9, 26) days, respectively (P =.16), for days to enteral feeding. After we controlled for the size of the defect and the amount of bowel resected, the odds of primary closure given a vaginal delivery was about half that given a cesarean delivery (odds ratio, 0.56; 95% confidence interval, 0.18-1. 69), but this was not statistically significant. There was no statistically significant difference in the rates of neonatal death (2 [3%] vs 2 [6%]; P =.61) and neonatal sepsis (2 [3%] vs 4 [11%]; P =.18) for cesarean versus vaginal delivery. Maternal length of stay after delivery was found to be 1 day less after vaginal delivery [vaginal, 2 (2, 2) days; cesarean, 3 (2, 3) days; P =.0001]. There were 5 instances of maternal complications, and all 5 pregnancies were delivered by cesarean (P =.16). CONCLUSION: Fetuses with an antenatal diagnosis of an isolated ventral wall defect may safely be delivered vaginally, and cesarean delivery should be performed for obstetric indications only.

Chorioamnionitis: is continuation of antibiotic therapy necessary after cesarean section?

OBJECTIVE: Our purpose was to determine whether the continuation of antibiotics postoperatively after cesarean section in patients whose labors were complicated by chorioamnionitis would reduce the incidence of endometritis. STUDY DESIGN: Patients with a clinical diagnosis of chorioamnionitis treated with ampicillin during labor and who required cesarean delivery for obstetric indications received preoperative intravenous clindamycin and gentamicin and were randomized into 2 groups. Group 1 received no scheduled postoperative antibiotics and group 2 continued to receive clindamycin 900 mg every 8 hours and gentamicin 1.5 mg/kg every 8 hours until afebrile for a minimum of 24 hours (temperature

Preterm premature rupture of membranes: aggressive tocolysis versus expectant management.

The objective of our study is to determine whether aggressive tocolysis in patients with preterm premature rupture of membranes between 24 and 34 weeks gestation improves neonatal outcome. Patients with documented preterm premature rupture of membranes between 24 and 34 weeks gestation were prospectively randomized to group I, aggressive tocolysis with intravenous magnesium sulfate, or to group II, no tocolysis. The lecithin/sphingomyelin ratio was determined upon hospital admission and every 48-96 hours until delivery. Both groups received weekly steroids and antibiotics pending culture results and were promptly delivered when chorioamnionitis, fetal stress, or an Lecithin/sphingomyelin ratio of > or = 2.0 occurred. The study group involved 145 patients. No statistically significant differences between groups I (n = 78) and II (n = 67) were observed regarding demographic characteristics, gestational age at enrollment or at delivery, latency, development of clinical chorioamnionitis, birth weight, number of days in neonatal intensive care unit, days on oxygen or ventilatory support, frequency of hyaline membrane disease, necrotizing enterocolitis, intraventricular hemorrhage, neonatal sepsis, or neonatal mortality. Our data suggest that tocolysis in patients with preterm premature rupture of membranes does not significantly improve perinatal outcome.

Perforation rate using a single pair of orthopedic gloves vs. a double pair of gloves in obstetric cases.

Our purpose was to determine the perforation rate for a single pair of orthopedic gloves vs. a double pair of regular gloves in obstetric cases. Faculty, residents, medical students, and surgical technicians were assigned randomly to use either double gloves or single orthopedic gloves. After each procedure, the gloves were examined by filling with water, occluding the cuff, and observing for streams of water. The perforation rate for the double gloves (both inner and outer glove at the same location) was 7% (12/169), similar to the 7% (12/172) for single orthopedic gloves (P < 0.9). After adjusting for procedure type there was no association between the type of gloves and perforation rate. Fifty-four percent of all perforations were not recognized intraoperatively. Of those individuals with glove perforations, 4/24 (17%) observed blood on the hand at the end of the procedure. Double-gloved users complained more frequently than single-gloved users of loss of dexterity (77/169, 46%, 95% CI 38-53%) vs. (6/172, 3.5%, 95% CI 0.7-6%) (P < 0.001) and numbness (12/169, 7%, 95% CI 3.2-11%) vs (1/172 0.6%, 95% CI 0.55-1.7%) (P < 0.005). Although the use of a single pair of orthopedic gloves is more costly than a double pair of regular gloves ($78 vs. $15 per box), it is as safe and as effective as a double pair of gloves in maintaining a sterile barrier. The primary advantage of a single pair of orthopedic gloves is that surgical dexterity is minimally compromised when compared to double gloves.

Oral terbutaline in the outpatient management of preterm labor.

OBJECTIVE: Our purpose was to prove our hypothesis that once preterm uterine contractions and/or labor is controlled with intravenous tocolysis, oral terbutaline, as a maintenance drug, does not prolong pregnancy. STUDY DESIGN: Before discharge, 184 patients between 24 and 35 completed weeks' gestation were prospectively randomized to continued bed rest either with or without oral terbutaline. Assignment was made with stratification into four groups: group 1, those patients with a Bishop score > or = 5 with oral terbutaline (n = 50); group 2, those with a Bishop score > or = 5 without oral terbutaline (n = 53); group 3, those with a Bishop score < 5 with oral terbutaline (n = 41); group 4, those with a Bishop score < 5 without oral terbutaline (n = 40). Oral terbutaline was discontinued at 37 completed weeks. RESULTS: No statistically significant differences were found in the number of readmissions, the number of unscheduled hospital visits, and the neonatal outcomes among the four groups. The gestational age at delivery and percent of deliveries at > or = 37 weeks were not significantly different when group 1 was compared with group 2 and group 3 was compared with group 4. CONCLUSION: Oral terbutaline maintenance does not improve pregnancy outcome in patients who have had initial successful intravenous tocolysis.

Small hyperechoic ventricle: a benign foci of the fetal cardiac sonographic finding?

The objective of our study was to determine the significance of antenatally detected, small hyperechoic foci in the fetal cardiac ventricle. In a 13-month period, we identified 25 fetuses with such a finding, an incidence rate of 0.46%. The hyperechoic foci in 24/25 fetuses were seen during follow-up serial scans. The size ranged from 1 to 6 mm. All had a normal fetal echocardiogram at 20-22 weeks' gestation. Eleven of the 24 neonates had a normal postnatal echocardiogram in the first 4 weeks of birth. One neonate had a previously undiagnosed transposition of the great vessels and no residual hyperechoic focus. Twelve had an echogenic focus located at the level of the chordae tendineae and papillary muscles in the left ventricle. In each of these 12 neonates, there was normal ventricular function determined by measuring the shortening fraction, and a competent atrioventricular valve. When hyperechoic foci are identified, baseline antenatal echocardiography should be performed to confirm their benignity. With an otherwise normal fetal and clinical neonatal evaluation, serial antenatal and confirmatory postnatal echocardiography are unnecessary. A possible relationship to other cardiac anomalies or aneuploidies requires further study.

Quantitative and qualitative platelet abnormalities during pregnancy.

In a 1-year period, 15 of 4048 pregnant women were found to have thrombocytopenia during their first prenatal visit. Their qualitative and quantitative platelet abnormalities were followed up prospectively for 1 to 6 months post partum. Platelet counts returned to normal in 14 of 15 patients 4 to 6 weeks post partum. von Willebrand factor antigen and ristocetin cofactor activity were low in three of 15 patients 4 to 6 weeks post partum, but had been normal during the antepartum period. Two of these three patients had prolonged bleeding times ante partum and post partum. All three patients subsequently were found to have mild type I von Willebrand disease. Six patients had detectable platelet antibodies. Neonatal thrombocytopenia was found in one term infant of a patient with mild thrombocytopenia and negative platelet antibodies. This study suggests that mild, transient, isolated thrombocytopenia can occur in an otherwise normal pregnancy and its incidence may be lower than previously reported. Extensive testing is not indicated unless there is an associated prolonged bleeding time. The possibility of von Willebrand disease or a qualitative platelet disorder should be considered.

Immunoreactive ACTH, beta-endorphin, and cortisol levels in plasma following spinal manipulative therapy.

This study examines the possibility of a humorally mediated analgesic response to spinal manipulative therapy by determination of plasma levels of beta-endorphin, adrenocorticotropic hormone (ACTH), and cortisol before and after intervention. Forty male subjects (20 symptomatic, 20 asymptomatic) were allocated into four equal groups. Two treatment groups were given spinal manipulative therapy, and two groups underwent a sham procedure. Blood samples were taken via indwelling butterfly needles pre- and postintervention in all four groups, and levels of immunoreactive ACTH, immunoreactive beta-endorphin, and cortisol determined by radioimmunoassay. No differences in ACTH or beta-endorphin were found between sham and treated groups, or between pre- and postintervention in any group; cortisol levels fell over the course of the study in all groups. The findings thus appear to exclude a humoral role for beta-endorphin in mediating the analgesic response to spinal manipulative therapy; in addition, they suggest that such therapy is not a stressor that activates the hypothalamo-pituitary-adrenal axis.