Thomas Murphy Goodwin

Pregnancy outcome and fetomaternal hemorrhage after noncatastrophic trauma

Two hundred five consecutive cases of noncatastrophic trauma occurring during the second half of pregnancy were evaluated prospectively. Pregnancy complications as a result of trauma occurred in 18 of 205 patients (8.8%): premature labor (n = 10), placental separation (n = 5), fetal injury (n = 1), and fetal death (n = 2). Multiple regression analysis of the data base showed obstetric findings (contractions, uterine tenderness, and bleeding) on presentation to be highly associated with complications (17/88; 19.3%). In their absence complications were rare (1/117; 0.9%). Detectable fetomaternal hemorrhage was significantly more common in trauma patients (18/205) than in control subjects (2/110) (p less than 0.01), but its role in managing trauma patients was limited to detection of rare massive hemorrhage (1/205) and detection of rare hemorrhage exceeding that covered by the standard Rho (D) immune globulin dose (2/205). Fetomaternal hemorrhage need not be quantitated in patients who lack obstetric findings on presentation. Despite rare reports of delayed abruptio placentae, it is doubtful that prolonged observation (greater than 2 to 3 hours) in the hospital is necessary in patients who lack obstetric findings on initial presentation.

Molecular epidemiology of preeclampsia.

Numerous articles have been published that address the possible genetic influences on the development of preeclampsia (PE). However, to our knowledge, a complete review of the results has not yet been completed. We undertook a MEDLINE search to identify English-language articles published after January 1, 1990 that examined the possible role of specific genes in the etiology of PE. After a brief introduction and a concise review of the prevailing etiologic hypotheses, we have categorized the candidate genes into six categories, based on their hypothesized role in PE etiology. The purpose of this paper is to review the literature, comment on its quality, and provide a reference for researchers interested in the molecular epidemiology of preeclampsia. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader will be able to list the prevailing etiologic hypotheses of preeclampsia, to outline the published data on possible genetic influence on the development of preeclampsia, and to clearly state the definition of preeclampsia.

Dose ranging study of the oxytocin antagonist atosiban in the treatment of preterm labor

Objective To evaluate the minimal effective dose regimen of the oxytocin antagonist atosiban in the treatment of acute preterm labor and the effect of a bolus on uterine activity within the first 2 hours compared with no bolus and the same infusion rate. Methods A randomized, double-blind (except the ritodrine group), parallel group, multicenter study compared four different intravenous atosiban regimens (6.5 mg bolus plus 300 μg/minute, placebo bolus plus 300 μg/minute, 2 mg bolus plus 100 μg/minute, and 0.6 mg plus 30 μg/minute) and intravenous ritodrine with respect to the cessation of uterine contractions for 1 hour or more during infusion, four or fewer contractions per hour in the last hour of therapy, and discontinuation because of adverse experiences. Three hundred two patients were enrolled. Results The lowest dose of atosiban (0.6 mg plus 30 μg/minute) was significantly less effective than ritodrine with respect to cessation of contractions and four or fewer contractions per hour in the last hour of therapy. Other atosiban regimens were comparable to ritodrine, except for the drug discontinuation rate for adverse experiences. Bolus therapy with high-dose atosiban resulted in a significantly greater proportion of patients who stopped contracting within the first 2 hours of treatment (17 of 63) compared with those not receiving a bolus (six of 58, P = .017). Because of adverse experiences, the study drug was discontinued in one of 244 atosiban patients and 15 of 58 ritodrine patients. Conclusion Atosibans effect on uterine activity in preterm labor was enhanced by bolus infusion and was similar to the effect of ritodrine, but with fewer side effects.

The psychosocial burden of hyperemesis gravidarum

Objective:To describe the psychosocial burden of hyperemesis gravidarum (HG) in a large cohort of affected women, focusing on previously unreported problems.Study Design:Women with HG described their pregnancy history in an open-ended survey administered internationally through an HG website during 2003 to 2005.Result:Of the 808 participants, 626 (77.5%) were American. A large majority (82.8%) reported that HG caused negative psychosocial changes, consisting of (1) socioeconomic changes, for example, job loss or difficulties, (2) attitude changes including fear regarding future pregnancies and (3) psychiatric sequelae, for example, feelings of depression and anxiety, which for some continued postpartum. Women who reported that their health-care provider was uncaring or unaware of the severity of their symptoms were nearly twice as likely to report these psychiatric sequelae (odds ratio 1.86, 95% confidence interval 1.06 to 3.29, P=0.032).Conclusion:Over 80% of a large cohort of women with HG reported that HG caused a negative psychosocial impact.

The prevalence of intrahepatic cholestasis of pregnancy in a primarily Latina Los Angeles population

Objective:To establish the prevalence of intrahepatic cholestasis of pregnancy (ICP) in a primarily Latina population in the United States.Study design:Over a period of 16 months, a convenience sample of subjects admitted to labor and delivery in the third trimester was enrolled. Each subject completed a questionnaire rating their severity of pruritus on a numeric scale of 1 to 10. Serum was analyzed via radioimmunoassay for total bile acid concentration. ICP was defined as pruritus score >4 and a total serum bile acid concentration of ⩾20 μmol/l. Ethnicity was determined from hospital record demographic data.Results:All invited participants enrolled in the study. Three hundred and forty subjects were enrolled. Three hundred and sixteen subjects (93%) were identified as Latina. The serum bile acid concentration range for the entire study population was 1 to 580 μmol/l with a mean of 10.4±34.9 μmol/l. Twenty-four (7.1%) subjects had a serum bile acid concentration ⩾20 μmol/l. A pruritus score >4 was found in 19.7% (67/340). Of the 24 subjects with a bile acid concentration ⩾20 μmol/l, 19 also had a pruritus score >4. Thus, the prevalence of ICP in this population was 5.6% (19/340). In subjects with ICP, the mean serum bile acid concentration was 89.5±124.0 μmol/l. When controlling for confounders, women with ICP were associated with higher rates of chorioamnionitis (P=0.043) and their fetuses had higher rates of thick meconium (P=0.053).Conclusions:The overall prevalence of ICP in this population was 5.6%, 10 to 100 times higher than previously reported data from the United States. Larger studies of perinatal morbidity examining the diagnostic criteria of cholestasis need to be conducted.

High Prevalence of Severe Nausea and Vomiting of Pregnancy and Hyperemesis Gravidarum among Relatives of Affected Individuals

OBJECTIVE The goal of this study was to determine the prevalence of severe nausea and vomiting of pregnancy/hyperemesis gravidarum among relatives of affected individuals. STUDY DESIGN Family history data were obtained on 1224 self-reported cases of hyperemesis gravidarum. Cases completed an online survey administered by the Hyperemesis Education and Research Foundation between 2003 and 2006. RESULTS Approximately 28% of cases reported their mother had severe nausea and vomiting or hyperemesis gravidarum while pregnant with them. Of the 721 sisters with a pregnancy history, 137 (19%) had hyperemesis gravidarum. Among the most severe cases, those requiring total parenteral nutrition or nasogastric feeding tube, the proportion of affected sisters was even higher, 49/198 (25%). Nine percent of cases reported having at least two affected relatives including sister(s), mother, grandmother, daughters, aunt(s), and cousin(s). CONCLUSION There is a high prevalence of severe nausea and vomiting of pregnancy/hyperemesis gravidarum among relatives of hyperemesis gravidarum cases in this study population. Because the incidence of hyperemesis gravidarum is most commonly reported to be 0.5%, this study provides strong but preliminary evidence for a genetic component to extreme nausea and vomiting of pregnancy.

Increased concentration of the free β-subunit of human chorionic gonadotropin in hyperemesis gravidarum

Objective. The amount of free β subunit hCG (free β) has been reported to be increased in trophoblast disease and Downs syndrome, conditions also associated with high total hCG. Increased total hCG has been reported in hyperemesis gravidarum. We sought to determine if sera from singleton gestations with hyperemesis gravidarum contained a higher proportion of free β hCG compared to controls of comparable gestational age.

Health-related quality of life in women with nausea and vomiting of pregnancy: the importance of psychosocial context

Objective:To test whether women with hyperemesis gravidarum (HG) demonstrated lower health-related quality of life (HRQoL) scores compared with those with nausea and vomiting of pregnancy (NVP).Study Design:Women with HG or NVP were examined during the first trimester. Multivariate models identified characteristics of women at risk for low HRQoL, as measured by an NVP-specific HRQoL test and a generic HRQoL test, the Short Form (SF)-36.Result:Although the SF-36 assessment did not discriminate between the two groups, the NVP-specific test showed that women with HG (N=29) were 3–6 times more likely than women with NVP (N=48) to have low HRQoL. Both tests demonstrated that perceived physical symptoms and multiple psychosocial factors, such as depression and marital status, seemed to be equally or more important than having HG.Conclusion:Although a low HRQoL was associated with an HG diagnosis, multiple physical symptoms and psychosocial factors placed both groups of women at risk.

Congenital hypofibrinogenemia in pregnancy.

A new case of congenital hypofibrinogenemia in pregnancy is reported and the literature is reviewed from an obstetric perspective. An association with spontaneous abortion, abruption, and postpartum hemorrhage is documented and management options are presented.

Favorable Outcome of Pregnancy with an Elective Use of Epoprostenol and Sildenafil in Women with Severe Pulmonary Hypertension

Background: Pulmonary hypertension carries significant maternal and fetal risk during pregnancy and the postpartum period. As maternal mortality is high, specific targeted therapy for pulmonary hypertension may be required during pregnancy. Cases: We describe 2 pregnant patients who presented with severe secondary pulmonary arterial hypertension during their last trimester. They were electively treated in the late antepartum and early postpartum periods with sildenafil and intravenous epoprostenol and successfully delivered healthy infants via cesarean section without postpartum complications. Conclusion: Although pulmonary hypertension is associated with a risk of maternal mortality and most women are advised against pregnancy, new therapies may improve the outcome of pregnancy in patients with pulmonary hypertension.