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Campbell KH, Goffman D, Sfakianaki AK, Pettker CM, Funai EF, Savitz DA, Lipkind HS. 570: Maternal mortality in New York City 1995-2003: disparities and risk factors. Am J Obstet Gynecol 2012. [DOI: 10.1016/j.ajog.2011.10.588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Duzyj CM, Buhimschi IA, Laky C, Cozzini G, Zhao G, Wehrum M, Pettker CM, Abdel-Razeq SS, Buhimschi CS. 814: Evidence that endoglin and transforming growth factor-beta (TGFβ) participate in epithelial-to-mesenchymal transition (EMT) of extravillous trophoblasts in placenta accreta. Am J Obstet Gynecol 2012. [DOI: 10.1016/j.ajog.2011.10.832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Rosenberg VA, Buhimschi IA, Dulay AT, Abdel-Razeq SS, Oliver EA, Duzyj CM, Lipkind H, Pettker CM, Buhimschi CS. Modulation of amniotic fluid activin-a and inhibin-a in women with preterm premature rupture of the membranes and infection-induced preterm birth. Am J Reprod Immunol 2011; 67:122-31. [PMID: 21992678 DOI: 10.1111/j.1600-0897.2011.01074.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
PROBLEM Activins and inhibins are important modulators of inflammatory processes. We explored activation of amniotic fluid (AF) activin-A and inhibin-A system in women with intra-amniotic infection and preterm premature rupture of the membranes (PPROM). METHOD OF STUDY We analyzed 78 AF samples: '2nd trimester-control' (n=12), '3rd trimester-control' (n=14), preterm labor with intact membranes [positive-AF-cultures (n=13), negative-AF-cultures (n=13)], and PPROM [positive-AF-cultures (n=13), negative-AF-cultures (n=13)]. Activin-A levels were evaluated ex-vivo following incubation of amniochorion and placental villous explants with Gram-negative lipopolysaccharide (LPS) or Gram-positive (Pam3Cys) bacterial mimics. Ability of recombinant activin-A and inhibin-A to modulate inflammatory reactions in fetal membranes was explored through explants' IL-8 release. RESULTS Activin-A and inhibin-A were present in human AF and were gestational age-regulated. Activin-A was significantly upregulated by infection. Lower inhibin-A levels were seen in PPROM. LPS elicited release of activin-A from amniochorion, but not from villous explants. Recombinant activin-A stimulated IL-8 release from amniochorion, an effect that was not reversed by inhibin-A. CONCLUSION Human AF activin-A and inhibin-A are involved in biological processes linked to intra-amniotic infection/inflammation-induced preterm birth.
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Buhimschi CS, Bhandari V, Dulay AT, Nayeri UA, Abdel-Razeq SS, Pettker CM, Thung S, Zhao G, Han YW, Bizzarro M, Buhimschi IA. Proteomics mapping of cord blood identifies haptoglobin "switch-on" pattern as biomarker of early-onset neonatal sepsis in preterm newborns. PLoS One 2011; 6:e26111. [PMID: 22028810 PMCID: PMC3189953 DOI: 10.1371/journal.pone.0026111] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2011] [Accepted: 09/19/2011] [Indexed: 12/14/2022] Open
Abstract
Background Intra-amniotic infection and/or inflammation (IAI) are important causes of preterm birth and early-onset neonatal sepsis (EONS). A prompt and accurate diagnosis of EONS is critical for improved neonatal outcomes. We sought to explore the cord blood proteome and identify biomarkers and functional protein networks characterizing EONS in preterm newborns. Methodology/Principal Findings We studied a prospective cohort of 180 premature newborns delivered May 2004-September 2009. A proteomics discovery phase employing two-dimensional differential gel electrophoresis (2D-DIGE) and mass spectrometry identified 19 differentially-expressed proteins in cord blood of newborns with culture-confirmed EONS (n = 3) versus GA-matched controls (n = 3). Ontological classifications of the proteins included transfer/carrier, immunity/defense, protease/extracellular matrix. The 1st-level external validation conducted in the remaining 174 samples confirmed elevated haptoglobin and haptoglobin-related protein immunoreactivity (Hp&HpRP) in newborns with EONS (presumed and culture-confirmed) independent of GA at birth and birthweight (P<0.001). Western blot concurred in determining that EONS babies had conspicuous Hp&HpRP bands in cord blood (“switch-on pattern”) as opposed to non-EONS newborns who had near-absent “switch-off pattern” (P<0.001). Fetal Hp phenotype independently impacted Hp&HpRP. A Bayesian latent-class analysis (LCA) was further used for unbiased classification of all 180 cases based on probability of “antenatal IAI exposure” as latent variable. This was then subjected to 2nd-level validation against indicators of adverse short-term neonatal outcome. The optimal LCA algorithm combined Hp&HpRP switch pattern (most input), interleukin-6 and neonatal hematological indices yielding two non-overlapping newborn clusters with low (≤20%) versus high (≥70%) probability of IAI exposure. This approach reclassified ∼30% of clinical EONS diagnoses lowering the number needed to harm and increasing the odds ratios for several adverse outcomes including intra-ventricular hemorrhage. Conclusions/Significance Antenatal exposure to IAI results in precocious switch-on of Hp&HpRP expression. As EONS biomarker, cord blood Hp&HpRP has potential to improve the selection of newborns for prompt and targeted treatment at birth.
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Barber EL, Lundsberg LS, Belanger K, Pettker CM, Funai EF, Illuzzi JL. Indications contributing to the increasing cesarean delivery rate. Obstet Gynecol 2011; 118:29-38. [PMID: 21646928 PMCID: PMC3751192 DOI: 10.1097/aog.0b013e31821e5f65] [Citation(s) in RCA: 432] [Impact Index Per Article: 33.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To examine physician-documented indications for cesarean delivery in order to investigate the specific factors contributing to the increasing cesarean delivery rate. METHODS We analyzed rates of primary and repeat cesarean delivery, including indications for the procedure, among 32,443 live births at a major academic hospital between 2003 and 2009. Time trends for each indication were modeled to estimate the absolute and cumulative annualized relative risk of cesarean by indication over time and the relative contribution of each indication to the overall increase in primary cesarean delivery rate. RESULTS The cesarean delivery rate increased from 26% to 36.5% between 2003 and 2009; 50.0% of the increase was attributable to an increase in primary cesarean delivery. Among the documented indications, nonreassuring fetal status, arrest of dilation, multiple gestation, preeclampsia, suspected macrosomia, and maternal request increased over time, whereas arrest of descent, malpresentation, maternal-fetal indications, and other obstetric indications (eg, cord prolapse, placenta previa) did not increase. The relative contributions of each indication to the total increase in primary cesarean rate were: nonreassuring fetal status (32%), labor arrest disorders (18%), multiple gestation (16%), suspected macrosomia (10%), preeclampsia (10%), maternal request (8%), maternal-fetal conditions (5%), and other obstetric conditions (1%). CONCLUSION Primary cesarean births accounted for 50% of the increasing cesarean rate. Among primary cesarean deliveries, more subjective indications (nonreassuring fetal status and arrest of dilation) contributed larger proportions than more objective indications (malpresentation, maternal-fetal, and obstetric conditions).
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Werner EF, Han CS, Pettker CM, Buhimschi CS, Copel JA, Funai EF, Thung SF. Universal cervical-length screening to prevent preterm birth: a cost-effectiveness analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2011; 38:32-7. [PMID: 21157771 DOI: 10.1002/uog.8911] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/29/2010] [Indexed: 05/15/2023]
Abstract
OBJECTIVE To determine whether routine measurement of second-trimester transvaginal cervical length by ultrasound in low-risk singleton pregnancies is a cost-effective strategy. METHODS We developed a decision analysis model to compare the cost-effectiveness of two strategies for identifying pregnancies at risk for preterm birth: (1) no routine cervical length screening and (2) a single routine transvaginal cervical length measurement at 18-24 weeks' gestation. In our model, women identified as being at increased risk (cervical length < 1.5 cm) for preterm birth would be offered daily vaginal progesterone supplementation. We assumed that vaginal progesterone reduces preterm birth at < 34 weeks' gestation by 45%. We also assumed that a decreased cervical length could result in additional costs (ultrasound scans, inpatient admission) without significantly improved neonatal outcomes. The main outcome measure was incremental cost-effectiveness ratio. RESULTS Our model predicts that routine cervical-length screening is a dominant strategy when compared to routine care. For every 100,000 women screened, $12,119,947 can be potentially saved (in 2010 US dollars) and 423.9 quality-adjusted life-years could be gained. Additionally, we estimate that 22 cases of neonatal death or long-term neurologic deficits could be prevented per 100,000 women screened. Screening remained cost-effective but was no longer the dominant strategy when cervical-length ultrasound measurement costs exceeded $187 or when vaginal progesterone reduced delivery risk at < 34 weeks by less than 20%. CONCLUSION In low-risk pregnancies, universal transvaginal cervical length ultrasound screening appears to be a cost-effective strategy under a wide range of clinical circumstances (varied preterm birth rates, predictive values of a shortened cervix and costs).
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Pettker CM, Thung SF, Raab CA, Donohue KP, Copel JA, Lockwood CJ, Funai EF. A Comprehensive Obstetrics Patient Safety Program Improves Safety Climate and Culture. Obstet Gynecol Surv 2011. [DOI: 10.1097/ogx.0b013e31822c186f] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Pettker CM, Thung SF, Raab CA, Donohue KP, Copel JA, Lockwood CJ, Funai EF. A comprehensive obstetrics patient safety program improves safety climate and culture. Am J Obstet Gynecol 2011; 204:216.e1-6. [PMID: 21376160 DOI: 10.1016/j.ajog.2010.11.004] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2010] [Revised: 09/11/2010] [Accepted: 11/02/2010] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The purpose of this study was to determine the effect of an obstetrics patient safety program on staff safety culture. STUDY DESIGN We implemented (1) obstetrics patient safety nurse, (2) protocol-based standardization of practice, (3) crew resource management training, (4) oversight by a patient safety committee, (5) 24-hour obstetrics hospitalist, and (6) an anonymous event reporting system. We administered the Safety Attitude Questionnaire on 4 occasions over 5 years (2004-2009) to all staff members that assessed teamwork and safety cultures, job satisfaction, working conditions, stress recognition, and perceptions of management. RESULTS We observed significant improvements in the proportion of staff members with favorable perceptions of teamwork culture (39% in 2004 to 63% in 2009), safety culture (33% to 63%), job satisfaction (39% to 53%), and management (10% to 37%). Individual roles (obstetrics providers, residents, and nurses) also experienced improvements in safety and teamwork, with significantly better congruence between doctors and nurses. CONCLUSION Safety programs can improve workforce perceptions of safety and an improved safety climate.
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Oliver EA, Buhimschi CS, Dulay AT, Baumbusch MA, Abdel-Razeq SS, Lee SY, Zhao G, Jing S, Pettker CM, Buhimschi IA. Activation of the receptor for advanced glycation end products system in women with severe preeclampsia. J Clin Endocrinol Metab 2011; 96:689-98. [PMID: 21325454 PMCID: PMC3047223 DOI: 10.1210/jc.2010-1418] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Activation of the receptor for advanced glycation end products (RAGE) mediates cellular injury. Soluble forms of RAGE [soluble RAGE (sRAGE), endogenous secretory (esRAGE)] bind RAGE ligands, thereby preventing downstream signaling and damage. OBJECTIVES The objective of the study was to characterize the changes in maternal serum, amniotic fluid, and cord blood soluble receptor for advanced glycation end products (sRAGE) during physiological gestation and to provide insight into mechanisms responsible for RAGE activation in preeclampsia. DESIGN AND SETTINGS This was a cross-sectional study at a tertiary university hospital. PATIENTS We studied 135 women in the following groups: nonpregnant controls (n = 16), healthy pregnant controls (n = 68), pregnant women with chronic hypertension (n = 13), or pregnant women with severe preeclampsia (sPE; n = 38). INTERVENTIONS AND MAIN OUTCOME MEASURES sRAGE and esRAGE levels were evaluated in vivo by ELISA in maternal serum, amniotic fluid, and cord blood and in vitro after stimulation of the amniochorion and placental explants with lipopolysaccharide or xanthine/xanthine oxidase. Placenta and amniochorion were immunostained for RAGE. Real-time quantitative PCR measured RAGE mRNA. RESULTS Pregnant women had significantly decreased serum sRAGE compared with nonpregnant subjects (P < 0.001). sPE women had higher serum and amniotic fluid sRAGE and esRAGE relative to those expected for gestational age (P < 0.001). Cord blood sRAGE remained unaffected by sPE. RAGE immunoreactivity and mRNA expression appeared elevated in the amniochorion of sPE women. Xanthine/xanthine oxidase (but not lipopolysaccharide) significantly up-regulated the release of sRAGE (P < 0.001) in the amniochorion explant system. CONCLUSIONS Fetal membranes are a rich source of sRAGE. Elevated maternal serum and amniotic fluid sRAGE and esRAGE, paralleled by increased RAGE expression in the amniochorion, suggest activation of this system in sPE.
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Bhandari V, Buhimschi CS, Han CS, Lee SY, Pettker CM, Campbell KH, Dulay AT, Oliver EA, Werner EF, Buhimschi IA. Cord blood erythropoietin and interleukin-6 for prediction of intraventricular hemorrhage in the preterm neonate. J Matern Fetal Neonatal Med 2010; 24:673-9. [PMID: 20937006 DOI: 10.3109/14767058.2010.520048] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To evaluate cord blood erythropoietin (EPO) and interleukin-6 (IL-6) levels to predict preterm infants at risk of developing intraventricular hemorrhage (IVH). METHODS Levels of umbilical cord EPO, acid-base status and IL-6 were analyzed in 116 consecutive, preterm newborns (GA at delivery: 29 [23-34 ] weeks) born to mothers who had a clinically indicated amniocentesis to rule out infection. Early-onset neonatal sepsis (EONS) was diagnosed using symptoms, hematological criteria and blood cultures. RESULTS IVH was diagnosed by cranial ultrasounds. The prevalence of IVH in our population was 25% (29/116). There was a direct relationship between cord blood EPO and cord blood IL-6 concentration (r = 0.225, p = 0.014), independent of GA at birth. Elevated cord blood EPO levels (r = 0.182, p = 0.016) and GA at birth (r = -0.236, p = 0.004) remained significant independent factors associated with the risk of IVH, when evaluated with stepwise logistic regression analyses. Cord blood IL-6, pH, and EONS were not associated with IVH. These relationships remained following correction for GA at birth (p = 0.027). CONCLUSIONS Our results suggest that elevation in cord blood EPO may predict newborns at risk for IVH, independent of fetal inflammatory status. Further studies are warranted to confirm this association.
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Buhimschi CS, Baumbusch MA, Dulay AT, Lee S, Wehrum M, Zhao G, Bahtiyar MO, Pettker CM, Ali UA, Funai EF, Buhimschi IA. The role of urinary soluble endoglin in the diagnosis of pre-eclampsia: comparison with soluble fms-like tyrosine kinase 1 to placental growth factor ratio. BJOG 2009; 117:321-30. [PMID: 19943826 DOI: 10.1111/j.1471-0528.2009.02434.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Endoglin, an anti-angiogenic glycoprotein expressed on endothelial cells, has been proposed recently as a biomarker of pre-eclampsia (PE). Given that PE is characterised by an imbalance of angiogenic factors, we sought to determine the clinical utility of urinary soluble endoglin, relative to the soluble fms-like tyrosine kinase 1 to placental growth factor (PlGF) ratio, in the diagnosis of PE during gestation. DESIGN Prospective observational cohort. SETTING Tertiary referral university hospital. POPULATION Two hundred and thirty-four pregnant women were enrolled prospectively in the following groups: healthy controls, n = 63; gestational age (GA), median (interquartile range), 33 weeks (27-39 weeks); chronic hypertension, n = 27; GA, 33 weeks (30-36 weeks); mild PE, n = 38; GA, 37 weeks (34-40 weeks); severe PE, n = 106; GA, 32 weeks (29-37 weeks). METHODS Free urinary levels of soluble endoglin, soluble fms-like tyrosine kinase 1 and PlGF were measured by sensitive and specific immunoassay. Levels for all urinary analytes were normalised to creatinine. MAIN OUTCOME MEASURES Urinary soluble endoglin, and the soluble fms-like tyrosine kinase 1 to PlGF ratio. RESULTS In healthy controls, urinary soluble endoglin levels were increased significantly at term relative to those earlier in gestation. Severe PE was characterised by an increased urinary level of soluble endoglin, soluble fms-like tyrosine kinase 1, protein to creatinine ratio and soluble fms-like tyrosine kinase 1 to PlGF ratio compared with all other groups. There was a direct correlation between urinary soluble endoglin and proteinuria that remained after GA correction (R = 0.382, P < 0.001). Urinary soluble endoglin could not differentiate mild PE from severe preterm PE. Overall, soluble endoglin had the ability to discriminate PE from chronic hypertension and healthy controls only in women who were evaluated at <37 weeks of GA. The sensitivity, specificity and accuracy of urinary soluble endoglin alone in the diagnosis of PE or in the identification of women with PE requiring a mandated delivery before 37 weeks of gestation were 70%, 86% and 76%, respectively. These values were inferior to those of the soluble fms-like tyrosine kinase 1 to PlGF ratio (P < 0.001). The addition of urinary soluble endoglin did not improve the diagnostic accuracy of the soluble fms-like tyrosine kinase 1 to PlGF ratio alone. CONCLUSIONS We have provided evidence that soluble endoglin is present and elevated in the urine of women who develop preterm PE. Urinary soluble endoglin has only limited ability to determine the severity of PE and to distinguish between PE and chronic hypertension both preterm and at term. Compared with urinary soluble endoglin, the soluble fms-like tyrosine kinase 1 to PlGF ratio remains a better marker of disease presence, severity and outcome.
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Pettker CM, Thung SF, Dulay A, Han C, Ali U. Predicting neonatal acidemia by computer analysis: Costa et al. Am J Obstet Gynecol 2009. [DOI: 10.1016/j.ajog.2009.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Buhimschi CS, Bhandari V, Dulay AT, Lee S, Zhao G, Pettker CM, Abdel-Razeq SS, Thung S, Han Y, Buhimschi IA. 6: Comprehensive proteomic mapping of cord blood to identify novel biomarkers and functional protein networks characteristic of early onset neonatal sepsis (EONS). Am J Obstet Gynecol 2008. [DOI: 10.1016/j.ajog.2008.09.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Dulay AT, Zhao G, Lee SJ, Abdel-Razeq SS, Bahtiyar M, Pettker CM, Buhimschi CS, Buhimschi IA. 449: Amniotic fluid (AF) soluble toll-like receptor (TLR)-2 has functional ability to modulate the intensity of an intra-amniotic innate inflammatory response elicited by gram positive bacteria. Am J Obstet Gynecol 2008. [DOI: 10.1016/j.ajog.2008.09.478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Buhimschi CS, Baumbusch MA, Dulay AT, Lee S, Wehrum M, Zhao G, Pettker CM, Bahtiyar M, Funai E, Buhimschi IA. 768: The role of urinary endoglin in diagnosing severe preeclampsia: A prospective comparison with soluble fms-like tyrosine kinase (sFlt-1) to placental growth factor (PlGF) ratio. Am J Obstet Gynecol 2008. [DOI: 10.1016/j.ajog.2008.09.799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Buhimschi CS, Abdel-Razeq S, Cackovic M, Pettker CM, Dulay AT, Bahtiyar MO, Zambrano E, Martin R, Norwitz ER, Bhandari V, Buhimschi IA. Fetal heart rate monitoring patterns in women with amniotic fluid proteomic profiles indicative of inflammation. Am J Perinatol 2008; 25:359-72. [PMID: 18512201 PMCID: PMC2724874 DOI: 10.1055/s-2008-1078761] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
We hypothesized that abnormal fetal heart rate monitoring patterns (FHR-MPs) occur more often in pregnancies complicated by intra-amniotic inflammation. Therefore, our objective was to examine the relationships among FHR-MP abnormalities, intra-amniotic inflammation and/or infection, acute histological chorioamnionitis, and early-onset neonatal sepsis (EONS) in pregnancies complicated by preterm birth. Additionally, the ability of various FHR-MPs to predict EONS was investigated. FHR-MPs from 87 singleton premature neonates delivered within 48 hours from amniocentesis (gestational age, mean +/- SD: 28.9 +/- 3.3 weeks) were analyzed blindly using strict National Institute of Child Health and Human Development criteria. Strips were evaluated at three time points: at admission, at amniocentesis, and prior to delivery. Intra-amniotic inflammation was established based on a previously validated proteomic fingerprint (mass-restricted score). Diagnoses of histological chorioamnionitis and EONS were based on well-recognized pathological, clinical, and laboratory criteria. We determined that fetuses of women with severe intra-amniotic inflammation had a higher FHR baseline throughout the entire monitoring period and an increased frequency of a nonreactive FHR-MP at admission. Of all FHR-MPs, a nonreassuring test at admission had 32% sensitivity, 95% specificity, 73% positive predictive value, 77% negative predictive value, and 76% accuracy in predicting EONS. Although a nonreassuring FHR-MP at admission was significantly associated with EONS after correcting for gestational age (odds ratio, 5.6; 95% confidence interval, 1.2 to 26.2; P = 0.030), the majority of the neonates that developed EONS had an overall reassuring FHR-MP. Nonreassuring FHR-MPs at either amniocentesis or delivery had no association with EONS. We conclude that in cases complicated by preterm birth, a nonreassuring FHR-MP at the initial evaluation is a specific but not a sensitive predictor of EONS. An abnormal FHR-MP can thus raise the level of awareness that a fetus with EONS may be born, but it is not a useful clinical indicator of the need for antibiotic treatment of the neonate.
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Sfakianaki AK, Buhimschi IA, Pettker CM, Magloire LK, Turan OM, Hamar BD, Buhimschi CS. Ultrasonographic evaluation of myometrial thickness in twin pregnancies. Am J Obstet Gynecol 2008; 198:530.e1-10. [PMID: 18279826 DOI: 10.1016/j.ajog.2007.11.022] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2007] [Revised: 08/26/2007] [Accepted: 11/08/2007] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The objective of the study was to evaluate longitudinally the in vivo changes in myometrial thickness (MT) during gestation in patients carrying twin gestations in relation to pregnancy outcome. STUDY DESIGN Serial abdominal ultrasounds were performed prospectively in 92 patients carrying twin gestations through each trimester. Ninety-seven patients pregnant with singletons served as controls. For twins, the primary endpoint was spontaneous delivery at less than 35 weeks' gestational age (GA). The myometrium was defined sonographically as the echohomogeneous layer between the serosa and the decidua and was measured at the anterior, fundal, and lower uterine segment (LUS) walls. The estimated fetal weight, maximum vertical pocket of amniotic fluid, and placental thickness were also assessed ultrasonographically at the same time as the MT and served as estimates for the contribution of each to the uterine volume. In twins, cervical length measurements were performed transvaginally, as clinically indicated. Data analysis included 2-way analysis of variance and linear, nonlinear, and multivariate regression. RESULTS A total of 41.3% of twin pregnancies (38 of 92) delivered preterm (< 35 weeks). There were no significant changes in measurements at the anterior and fundal site over time throughout pregnancy and no differences in these sites between twin and singleton gestations. Conversely, in both twins and singletons, there was a significant and gradual thinning of the LUS myometrium during gestation. In the absence of uterine contractions or symptoms of preterm labor, twins that delivered preterm had a significantly thinner LUS at an earlier gestation, compared with twins that delivered at term (P < .001), suggesting that LUS thinning occurred earlier in these cases. There was a significant correlation between cervical length and LUS thinning during gestation in twins that delivered 35 weeks GA or later (r = 0.352; P < .001) but not in those that delivered preterm (< 35 weeks GA; r = 0.125; P = .326). CONCLUSION Twin pregnancy is characterized by a significant, selective, and gradual thinning of the LUS during gestation, which does not occur in the anterior and fundal myometrium. Thinning of the LUS occurs earlier in twin pregnancies destined to deliver preterm. These observations suggest that similar to the cervix, the LUS changes dynamically during twin pregnancy and that this too may be assessed through ultrasound imaging.
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Dulay AT, Buhimschi IA, Zhao G, Luo G, Abdel-Razeq S, Cackovic M, Rosenberg VA, Pettker CM, Thung SF, Bahtiyar MO, Bhandari V, Buhimschi CS. Nucleated red blood cells are a direct response to mediators of inflammation in newborns with early-onset neonatal sepsis. Am J Obstet Gynecol 2008; 198:426.e1-9. [PMID: 18395034 DOI: 10.1016/j.ajog.2008.01.040] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2007] [Revised: 01/16/2008] [Accepted: 01/24/2008] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The objective of the study was to test the hypothesis that inflammation modulates fetal erythroblastosis and/or the release of nucleated red blood cells (NRBCs) independent of hypoxia or fetal stress. We sought to determine whether fetal inflammation is associated with an elevation in neonatal NRBC count in the setting of inflammation-associated preterm birth. STUDY DESIGN The relationships between peripheral NRBC count, histological chorioamnionitis, umbilical cord interleukin (IL)-6, erythropoietin (EPO), cortisol, and acid-base status were analyzed in 68 preterm singletons, born to mothers who had an amniocentesis to rule out infection. Proteomic profiling of amniotic fluid identified presence of intraamniotic inflammation according to established parameters. NRBC counts were assessed within 1 hour of birth. Early-onset neonatal sepsis (EONS) was established based on hematological and microbiological indices. IL-6, EPO, and cortisol levels were measured by immunoassays. Fetal acid-base status was determined within 10 minutes of delivery. Parametric or nonparametric statistics were used. RESULTS Fetuses with EONS (n = 19) were delivered at earlier gestational ages (mean +/- SD: 27.1 +/- 2.8 weeks, P = .001) and more often by mothers with intraamniotic inflammation (P = .022) and histological chorioamnionitis (P < .001). Neonates with EONS had higher absolute NRBC counts (P = .011). NRBC counts were directly correlated with cord blood IL-6 levels (P < .001) but not with EPO, cortisol or parameters of acid-base status levels regardless of EONS status. These relationships remained following correction for gestational age, diabetes, intrauterine growth restriction, and steroid exposure. CONCLUSION In the setting of inflammation-associated preterm birth and in the absence of hypoxia, elevations in NRBCs in the early neonatal period may be a direct response of exposure to inflammatory mediators in utero.
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Pettker CM, Azpurua H, Bahtiyar MO, Sfakianaki A, Thung SF, Buhimschi IA, Buhimschi CS. 137: Ultrasonographic evaluation of cervical length (CL) and myometrial thickness (MT) as predictors of latency interval in PPROM. Am J Obstet Gynecol 2007. [DOI: 10.1016/j.ajog.2007.10.149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Dulay AT, buhimschi IA, Zhao G, Luo G, Abdel-Razeq SS, Cackovic M, Rosenberg VA, Pettker CM, Thung SF, Bahtiyar MO, Bhandari V, Buhimschi CS. 50: Nucleated red blood cells (NRBC) are a direct response to mediators of inflammation in newborns with early onset neonatal sepsis (EONS). Am J Obstet Gynecol 2007. [DOI: 10.1016/j.ajog.2007.10.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Buhimschi CS, Thung SF, Bahtiyar MO, Rosenberg VA, Dulay AT, Abdel-Razeq SS, Pettker CM, Luo G, Zhao G, Sfakianaki A, Lipkind HS, Funai EF, Bhandari V, Buhimschi IA. 199: Early onset neonatal sepsis (EONS): Accompanied by an increased interleukin-6 (IL-6) cytokine index, linked to histological chorioamnionitis. Am J Obstet Gynecol 2007. [DOI: 10.1016/j.ajog.2007.10.212] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Hamar BD, Saber SB, Cackovic M, Magloire LK, Pettker CM, Abdel-Razeq SS, Rosenberg VA, Buhimschi IA, Buhimschi CS. Ultrasound Evaluation of the Uterine Scar After Cesarean Delivery. Obstet Gynecol 2007; 110:808-13. [PMID: 17906013 DOI: 10.1097/01.aog.0000284628.29796.80] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To survey the uterine scar thickness by ultrasonography in women randomly assigned to one- or two-layer hysterotomy closure after primary cesarean delivery. METHODS This was a randomized, blinded trial of uterine scar closure with ultrasonographic follow-up. Thirty consecutive patients undergoing primary cesarean delivery were enrolled and randomly assigned to one- or two-layer closure of the hysterotomy. Ultrasound surveillance of the uterine scar thickness was performed at baseline (before surgery) and 48 hours, 2 weeks, and 6 weeks post partum. RESULTS Patient compliance with the postpartum surveillance protocol was 90%, and the uterine scar was visualized in 99% of attempted ultrasonographic examinations. There were no differences between groups at baseline or at any of the follow-up evaluations. An initial 5- to 6-fold increase in uterine scar thickness was observed, followed by a gradual decrease with the 6-week measurements still thicker than baseline. Repeated measures analysis of variance showed significant variation across time points starting either at baseline (P<.001) or at 48 hour postoperatively (P<.001), but this variation did not depend on closure type (P=.79 for all visits and P=.81 beginning with 48-hour postoperative time point). CONCLUSION The process of uterine scar remodeling can be successfully monitored by ultrasonography. Uterine scar thickness diminishes progressively after both one- or two-layer closure but does not vary with mode of hysterotomy closure. The uterine scar thickness remains increased even at 6 weeks post partum, suggesting that the process of uterine scar remodeling extends beyond the traditional postpartum period. CLINCAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00224250
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Pettker CM, Buhimschi IA, Magloire LK, Sfakianaki AK, Hamar BD, Buhimschi CS. Value of placental microbial evaluation in diagnosing intra-amniotic infection. Obstet Gynecol 2007; 109:739-49. [PMID: 17329528 DOI: 10.1097/01.aog.0000255663.47512.23] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the ability of microbiologic and pathologic examination of the placenta to accurately diagnose intraamniotic infection and inflammation. METHODS One hundred eighty-three women with a clinically indicated amniocentesis were enrolled prospectively. We applied our analysis to 56 women with evidence of preterm labor or preterm premature rupture of membranes who delivered within 48 hours of amniotic fluid testing results. Twenty-three patients, assessed for fetal lung maturity in the third trimester, served as controls. Amniotic fluid was cultured for aerobic, anaerobic, Ureaplasma, and Mycoplasma species. We used mass spectrometry to assess the degree of intraamniotic inflammation (Mass Restricted scoring). After delivery, microbiologic and histologic studies of the placenta were performed. These results were interpreted in comparison with the direct microbiologic and inflammatory analysis of the amniotic fluid. A sample size of 45 patients was required to show a test accuracy of 80% or more. RESULTS Ninety-two percent of women with positive amniotic fluid cultures tested with at least one positive placenta culture. Eighty percent of women who had negative amniotic fluid cultures also tested with a positive placenta culture. The accuracy of placental cultures in predicting amniotic fluid infection varied from 44% to 57%. Placental pathology showed an accuracy of only 58% in diagnosing intraamniotic inflammation. CONCLUSION Placental microbiologic and histologic studies poorly reflect the infectious and inflammatory status of the amniotic fluid. Results of such studies should be interpreted with caution in the management and future counseling of women with preterm labor or preterm premature rupture of membranes. LEVEL OF EVIDENCE II.
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Buhimschi IA, Zhao G, Pettker CM, Bahtiyar MO, Magloire LK, Thung S, Fairchild T, Buhimschi CS. The receptor for advanced glycation end products (RAGE) system in women with intraamniotic infection and inflammation. Am J Obstet Gynecol 2007; 196:181.e1-13. [PMID: 17306673 DOI: 10.1016/j.ajog.2006.09.001] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2006] [Revised: 07/05/2006] [Accepted: 09/07/2006] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Receptor for advanced glycation end products (RAGE) is a multiligand cell-surface receptor part of the immunoglobulin superfamily with crucial roles in inflammation. S100A12/ENRAGE, a biomarker of amniotic fluid (AF) inflammation, is a ligand for RAGE. sRAGE, a competitive soluble RAGE receptor, inhibits RAGE ligands. Here we aimed to investigate the presence and changes in components of the RAGE system in women with intra-amniotic infection and inflammation. STUDY DESIGN AF was retrieved by amniocentesis in 113 women stratified as follows: (1) positive AF culture (+AFC; GA = 27 [20-33] wk; n = 27); (2) negative AF culture (-AFC; GA = 30 [20-36] wk; n = 27); (3) second trimester control (2T-CRL; GA = 19 [15-25] wk; n = 31); (4) third trimester control (3T-CRL; GA = 36 [31-38] wk; n = 28). We used mass spectrometry (SELDI) to detect S100A12/ENRAGE in AF. sRAGE levels were measured using specific immunoassays. Placental pathology was interpreted in relationship to the presence or absence of histologic acute inflammation and immunoreactivity of S100A12/ENRAGE and RAGE. mRNA expression of S100A12/ENRAGE, sRAGE, and RAGE in amniochorion and placental villous tissue was investigated using quantitative real-time polymerase chain reaction (PCR). RESULTS Presence of the S100A12/ENRAGE biomarker SELDI peak was confirmed in 70% of the +AFC but in only 10% of the -AFC samples (P < .001). The inflammatory biomarker was absent in all control samples. We further determined that the competitive inhibitor sRAGE is temporally regulated during gestation and that its AF levels are not influenced by the presence of either intra-amniotic infection or inflammation. Histologic choriamnionitis associated with intense staining for S100A12/ENRAGE, particularly in inflammatory cells. The immunoreactivity for extracellular domain of RAGE was localized exclusively to amnion epithelial, decidual, and extravillous trophoblast cells. Yet, acute histologic chorioamnionitis was related to increased gene expression of S100A12/ENRAGE in fetal membranes and decreased sRAGE and RAGE in the placenta. CONCLUSION The S100A12/ENRAGE system is markedly upregulated in women with intra-amniotic infection and correlates with the degree of inflammation. Further studies remain to elucidate whether the gestational age dependence of the inhibitor molecule sRAGE may explain the higher incidence of infection-related preterm deliveries and especially rupture of the membranes at earlier gestational age.
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Buhimschi CS, Bhandari V, Hamar BD, Bahtiyar MO, Zhao G, Sfakianaki AK, Pettker CM, Magloire L, Funai E, Norwitz ER, Paidas M, Copel JA, Weiner CP, Lockwood CJ, Buhimschi IA. Proteomic profiling of the amniotic fluid to detect inflammation, infection, and neonatal sepsis. PLoS Med 2007; 4:e18. [PMID: 17227133 PMCID: PMC1769412 DOI: 10.1371/journal.pmed.0040018] [Citation(s) in RCA: 137] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2006] [Accepted: 11/09/2006] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Proteomic analysis of amniotic fluid shows the presence of biomarkers characteristic of intrauterine inflammation. We sought to validate prospectively the clinical utility of one such proteomic profile, the Mass Restricted (MR) score. METHODS AND FINDINGS We enrolled 169 consecutive women with singleton pregnancies admitted with preterm labor or preterm premature rupture of membranes. All women had a clinically indicated amniocentesis to rule out intra-amniotic infection. A proteomic fingerprint (MR score) was generated from fresh samples of amniotic fluid using surface-enhanced laser desorption ionization (SELDI) mass spectrometry. Presence or absence of the biomarkers of the MR score was interpreted in relationship to the amniocentesis-to-delivery interval, placental inflammation, and early-onset neonatal sepsis for all neonates admitted to the Newborn Special Care Unit (n = 104). Women with "severe" amniotic fluid inflammation (MR score of 3 or 4) had shorter amniocentesis-to-delivery intervals than women with "no" (MR score of 0) inflammation or even "minimal" (MR score of 1 or 2) inflammation (median [range] MR 3-4: 0.4 d [0.0-49.6 d] versus MR 1-2: 3.8 d [0.0-151.2 d] versus MR 0: 17.0 d [0.1-94.3 d], p < 0.001). Nonetheless, a "minimal" degree of inflammation was also associated with preterm birth regardless of membrane status. There was a significant association between the MR score and severity of histological chorioamnionitis (r = 0.599, p < 0.001). Furthermore, neonatal hematological indices and early-onset sepsis significantly correlated with the MR score even after adjusting for gestational age at birth (OR for MR 3-4: 3.3 [95% CI, 1.1 to 9.2], p = 0.03). When compared with other laboratory tests routinely used to diagnose amniotic fluid inflammation and infection, the MR score had the highest accuracy to detect inflammation (white blood cell count > 100 cells/mm3), whereas the combination of Gram stain and MR score was best for rapid prediction of intra-amniotic infection (positive amniotic fluid culture). CONCLUSIONS High MR scores are associated with preterm delivery, histological chorioamnionitis, and early-onset neonatal sepsis. In this study, proteomic analysis of amniotic fluid was shown to be the most accurate test for diagnosis of intra-amniotic inflammation, whereas addition of the MR score to the Gram stain provides the best combination of tests to rapidly predict infection.
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Buhimschi CS, Turan O, Funai EF, Turan S, Copel JA, Bahtiyar MO, Pettker CM, Norwitz ER, Buhimschi IA. Intra-amniotic inflammation activates the fetal hypothalamic-pituitary adrenal axis in utero as identified by 3D ultrasound assessment of fetal adrenal gland volume. Am J Obstet Gynecol 2006. [DOI: 10.1016/j.ajog.2006.10.121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Hamar BD, Buhimschi IA, Sfakianaki AK, Pettker CM, Magloire LK, Funai EF, Copel JA, Buhimschi CS. Serum and urine inhibin A but not free activin A are endocrine biomarkers of severe pre-eclampsia. Am J Obstet Gynecol 2006; 195:1636-45. [PMID: 16959203 DOI: 10.1016/j.ajog.2006.05.019] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2006] [Revised: 04/25/2006] [Accepted: 05/11/2006] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Elevation of total serum inhibin A and activin A has been interpreted as evidence of placental dysfunction in women who develop pre-eclampsia. We sought to evaluate serum and urine levels of inhibin A and free activin A in normal and hypertensive pregnancies. STUDY DESIGN Inhibin A and free activin A were measured by immunoassay in simultaneously collected serum and urine samples from 75 women: (1) severe pre-eclampsia (n = 30); (2) mild pre-eclampsia (n = 11); (3) chronic hypertension (n = 9); (4) pregnant control women (n = 16); and (5) nonpregnant control women (n = 9). Urine levels were normalized to milligrams urine creatinine, and fractional excretions were calculated. RESULTS Serum and urine inhibin A were increased and fractional excretion was decreased in pregnancy. Serum, urine, and fractional excretion of inhibin A were increased in severe pre-eclampsia, compared with other gravidas. The only difference observed in free activin A was a decrease in serum free activin A in chronic hypertension, compared with severe pre-eclampsia and pregnant control women. Urine inhibin A showed the greatest discrimination between severe pre-eclampsia and pregnant control women: a cut-off of 45 pg/mg urine creatinine had 96.8% sensitivity, 87.5% specificity, and 93.6% accuracy. Women with urine inhibin A greater than 90 pg/mg urine creatinine had a 17-fold relative risk (95% confidence interval 9.7-459.5) of a clinically indicated delivery due to pre-eclampsia. CONCLUSION Serum and urine levels of inhibin A are altered in severe pre-eclampsia. Urine inhibin A may have application in the diagnosis and management of pre-eclampsia. Those with chronic hypertension have lower serum but not urine free activin A levels, compared with severe pre-eclampsia and mild pre-eclampsia.
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Hamar BD, Saber SB, Cackovic M, Magloire LK, Pettker CM, Abdel-Razeq SS, Rosenberg VA, Buhimschi IA, Buhimschi CS. Ultrasound evaluation of uterine incision healing after cesarean delivery – a randomized controlled study of one-versus two-layer closure. Am J Obstet Gynecol 2006. [DOI: 10.1016/j.ajog.2006.10.171] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Graham G, Malone FD, Pettker CM, Sullivan L, Ball R, Luthy D, Comstock C, Hankins G, Eddleman K, Gross S, Dugoff L, Craigo S, Timor I, Carr S, Wolfe H, D'alton M. Preconception multivitamin or folic acid consumption and pregnancy outcome: A population-based screening study. Am J Obstet Gynecol 2006. [DOI: 10.1016/j.ajog.2006.10.794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Buhimschi IA, Pettker CM, Magloire LK, Thung SF, Zhao G, Salafia CM, Buhimschi CS. Proteomic analysis of the human amniotic fluid (AF) to predict histological chorioamnionitis (HCA) in utero. Am J Obstet Gynecol 2006. [DOI: 10.1016/j.ajog.2006.10.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Magloire LK, Buhimschi CS, Pettker CM, Sfakianaki AK, Hamar BD, Bhandari V, Buhimschi IA. Lactate dehydrogenase isoform activity mapping in patients with intra-amniotic infection. Am J Obstet Gynecol 2006; 195:1045-52. [PMID: 16875649 DOI: 10.1016/j.ajog.2006.05.048] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2006] [Revised: 05/23/2006] [Accepted: 05/31/2006] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Five distinct lactate dehydrogenase isoenzymes have been described. We sought to illustrate the specific amniotic fluid lactate dehydrogenase isoenzyme activity profiles in women with intra-amniotic infection. STUDY DESIGN Amniotic fluid was retrieved from 82 women who were stratified in the following groups: (1) positive amniotic fluid cultures (n = 23 women; gestational age, 26 weeks [range, 21-32 weeks]); (2) negative amniotic fluid cultures (n = 22 women; gestational age, 30 weeks [range, 16-36 weeks]); (3) second trimester control (normal genetic karyotype; n = 17 women; gestational age, 18 weeks [range, 16-22 weeks]); and (4) third trimester control (fetal lung maturity testing; n = 20 women; gestational age, 36 weeks [range, 31-38 weeks]). The optical density of each isoform was determined relative to a standard with 5 known lactate dehydrogenase isoenzyme activities. Total lactate dehydrogenase activity was measured by the clinical laboratory immediately after retrieval and by a kinetic UV spectrophotometric assay at the time of the isoelectric focusing. RESULTS Infection increased total lactate dehydrogenase activity: positive amniotic fluid cultures (median, 762.4 [range, 169.3-3374.8]) vs negative amniotic fluid cultures (median, 203.7 [range, 57.8-1939.3]; U/L; P < .001]). Lactate dehydrogenase isoform profiling identified significant and specific increases in lactate dehydrogenase isoforms 3, 4 (P < .01), and 5 (P < .05) in positive amniotic fluid cultures compared to the negative amniotic fluid cultures group. A selective up-regulation in lactate dehydrogenase isoform 5 was identified at term in healthy subjects. CONCLUSION Intra-amniotic infection is characterized by an increase in the activities of lactate dehydrogenase isoforms 3, 4, and 5; advancing gestational age demonstrates an up-regulation of isoform 5 only.
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Abstract
BACKGROUND Burkitt's lymphoma is a rapidly growing and, if untreated, rapidly fatal tumor derived from B-lymphocytes. The occurrence of Burkitt's lymphoma during pregnancy is rare. CASE A patient with Burkitt's lymphoma presented at 12 weeks of gestation with abdominal and tooth pain. An 11 x 11 x 15 cm mass was seen on abdominal/pelvic ultrasonogram. She underwent a left salpingo-oophorectomy with removal of the mass, as well as a tooth extraction. The pathology examination confirmed lymphoma in the left ovary and in the tissue surrounding the extracted tooth. After surgical resection, she was treated with multiagent chemotherapy beginning at 13 4/7 weeks of gestation. At 39 weeks, she delivered a viable female infant weighing 2,270 g. CONCLUSION The finding of an adnexal mass in conjunction with head and neck symptoms led to consideration of Burkitt's lymphoma. Prompt treatment with multiagent chemotherapy should be considered for pregnant patients with Burkitt's lymphoma.
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Buhimschi CS, Sfakianaki AK, Hamar BG, Pettker CM, Bahtiyar MO, Funai E, Norwitz ER, Copel JA, Lockwood CJ, Buhimschi IA. A low vaginal "pool" amniotic fluid glucose measurement is a predictive but not a sensitive marker for infection in women with preterm premature rupture of membranes. Am J Obstet Gynecol 2006; 194:309-16. [PMID: 16458622 DOI: 10.1016/j.ajog.2005.07.070] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2005] [Accepted: 07/19/2005] [Indexed: 11/29/2022]
Abstract
OBJECTIVE We sought to identify the use of vaginal amniotic fluid (vAF) glucose measurements in predicting infection of the amniotic fluid retrieved by transabdominal amniocentesis (aAF) in women with preterm premature rupture of the membranes (PPROM). STUDY DESIGN Fluid was retrieved by aAF was retreived from 35 consecutive women with PPROM on whom an amniocentesis was clinically indicated to rule out intra-amniotic infection/inflammation and successfully completed. aAF was cultured for aerobic, anaerobic bacteria, Ureaplasma and Mycoplasma species. Clinical laboratory analysis for aAF included glucose concentration, Gram stain, lactate dehydrogenase, and white and red blood cell count. vAF was analyzed only for glucose concentration. Glucose concentration for the paired abdominal-vaginal AF samples (aAF-vAF) was determined by using well-established clinical and research laboratory methods. At the end of enrollment we stratified our patients into 2 groups: (1) positive microbial cultures (+)AFC (n = 17, gestational age [GA]: 27.3 +/- 0.7 weeks) or (2) negative microbial cultures (-)AFC (n = 18, GA: 31.3 +/- 0.5 weeks). Cohen kappa measure of concordance and receiver operating characteristic (ROC) curve analysis were used to test the ability of the vaginal "pool" glucose measurements to discriminate between women with positive or negative AF cultures. RESULTS Women with (+)AFC ruptured and delivered at an earlier GA compared with the (-)AFC group (p < .001). The latency period was similar (P = .35). There was a significant linear correlation between aAF and vAF glucose concentrations (r = 0.783, P < .001). Women with intra-amniotic infection (IAI) had significantly lower aAF [mean +/- SEM (+)AFC: 11.4 +/- 3.2 vs (-)AFC 23.0 +/- 2.8 mg/dL, P = .01] and vAF glucose levels [(+)AFC: 10.1 +/- 2.8 vs (-)AFC: 19.8 +/- 2.9 mg/dL, P = .02] compared with the noninfected group. Cohen kappa measure of concordance indicated "substantial" agreement between aAF and vAF glucose measurements (kappa = 0.719, 95% CI = 0.491-0.947). The sensitivity of the vAF glucose level to detect IAI ranged from 82% to 47%, whereas specificity ranged from 100% to 56% depending on the threshold we used. A vaginal "pool" (vAF) glucose measurement less than 5 mg/dL had 47.1% sensitivity, 100% specificity, 100% positive predictive value, 66.7% negative predictive value, and 74.2% accuracy in identifying women with (+)AFC. CONCLUSION Vaginal glucose determination is a readily available, inexpensive, rapid AF marker that can be measured practically in any clinical laboratory. vAF glucose measurements less than 5 mg/dL have predictive value, but low sensitivity for detection of IAI.
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Buhimschi CS, Pettker CM, Magloire LK, Martin R, Norwitz E, Funai E, Buhimschi IA. Proteomic technology and delayed interval delivery in multiple pregnancies. Int J Gynaecol Obstet 2005; 90:48-50. [PMID: 15916765 DOI: 10.1016/j.ijgo.2005.03.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2004] [Accepted: 03/23/2005] [Indexed: 11/30/2022]
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Sfakianaki (F) AK, Pettker CM, Magloire LK, Hamar BD, Buhimschi IA, Copel JA, Buhimschi CS. Longitudinal ultrasonographic evaluation of myometrial thickness (MT) in twin pregnancies. Am J Obstet Gynecol 2005. [DOI: 10.1016/j.ajog.2005.10.627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Magloire (F) LK, Buhimschi CS, Pettker CM, Sfakianaki AK, Hamar B, Bhandari V, Buhimschi I. Profiling of lactate dehydrogenase (LDH) isoform activity in women with intra-amniotic infection/inflammation (IAI/I). Am J Obstet Gynecol 2005. [DOI: 10.1016/j.ajog.2005.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Buhimschi (F) C, Hamar B, Bahtiyar M, Zhao G, Sfakianaki A, Pettker CM, Magloire L, Norwitz E, Funai E, Paidas M, Weiner C, Copel J, Lockwood CJ, Buhimschi IA. Detection of intraamniotic inflammation/infection by proteomic profiling. Prospective comparison with rapid diagnostic tests (glucose, WBC, LDH, Gram stain), IL-6 and MMP-8. Am J Obstet Gynecol 2005. [DOI: 10.1016/j.ajog.2005.10.085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Shah S, Ogden AT, Pettker CM, Raffo A, Itescu S, Oz MC. A study of the effect of energy healing on in vitro tumor cell proliferation. J Altern Complement Med 1999; 5:359-65. [PMID: 10471016 DOI: 10.1089/acm.1999.5.359] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
This study examined the effect of energy healing on in vitro tumor cell growth using the cell culture model similar to that embraced by oncologists to assess the effect of chemotherapeutic agents. After selecting an energy healer based on his ability to influence this model, we assessed the effects of energy treatment compared to cells left at ambient temperature and to a control treatment consisting of a medical student mimicking the healer. A chi-square test comparing a medical student's and the practitioner's ability to inhibit tumor cell growth by 15% associates our practitioner with inhibition of tumor cell proliferation (p = 0.02). We also found that the magnitude of change was too close to the assay's intrinsic margin of error, thus making our quantitative data difficult to interpret. Although energy healing appears to influence several indices of growth in in vitro tumor cell proliferation, these assays are limited in their ability to define and prove the existence of this phenomenon. More sensitive biological assays are needed for further study in this field.
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