Obstetrician & Gynecologist (OB/GYN)
20 years of experience

Accepting new patients
Oak Lawn
5303 Harry Hines Blvd
Dallas, TX 75390
214-590-5218
Locations and availability (4)

Education ?

Medical School Score Rankings
The University of Texas Southwestern (1990)
  • Currently 4 of 4 apples
Top 25%

Awards & Distinctions ?

Associations
American Board of Obstetrics and Gynecology

Affiliations ?

Dr. Bloom is affiliated with 6 hospitals.

Hospital Affilations

Score

Rankings

  • Parkland Health & Hospital System
    5201 Harry Hines Blvd, Dallas, TX 75235
    • Currently 1 of 4 crosses
  • St. Paul Medical Center
  • Parkland Hospital
  • UT Southwestern St Paul Hospital
  • Dallas County Hospital District
  • University Hospital - St Paul
  • Publications & Research

    Dr. Bloom has contributed to 64 publications.
    Title Urodynamic Indices and Pelvic Organ Prolapse Quantification 3 Months After Vaginal Delivery in Primiparous Women.
    Date February 2012
    Journal International Urogynecology Journal
    Excerpt

    This study aims to describe multichannel urodynamic indices and pelvic organ prolapse quantification (POP-Q) in primiparous women 3 months after vaginal delivery.

    Title G6pc3 Mutations Are Associated with a Major Defect of Glycosylation: a Novel Mechanism for Neutrophil Dysfunction.
    Date October 2011
    Journal Glycobiology
    Excerpt

    Glucose-6-phosphatase, an enzyme localized in the endoplasmic reticulum (ER), catalyzes the hydrolysis of glucose-6-phosphate (G6P) to glucose and inorganic phosphate. In humans, there are three differentially expressed glucose-6-phosphatase catabolic genes (G6PC1-3). Recently, it has been shown that mutations in the G6PC3 gene result in a syndrome associating congenital neutropenia and various organ malformations. The enzymatic function of G6PC3 is dependent on G6P transport into the ER, mediated by G6P translocase (G6PT). Mutations in the gene encoding G6PT result in glycogen storage disease type-1b (GSD-1b). Interestingly, GSD-1b patients exhibit a similar neutrophil dysfunction to that observed in G6PC3-deficient patients. To better understand the causes of neutrophil dysfunction in both diseases, we have studied the neutrophil nicotinamide adenine dinucleotide phosphate (NADPH) oxidase of patients with G6PC3 and G6PT syndromes. Unexpectedly, sodium dodecyl sulfate-polyacrylamide gel electrophoresis experiments indicated hypo-glycosylation of gp91(phox), the electron-transporting component of the NADPH oxidase, in all of these patients. Rigorous mass spectrometric glycomic profiling showed that most of the complex-type antennae which characterize the neutrophil N-glycome of healthy individuals were severely truncated in the patients' neutrophils. A comparable truncation of the core 2 antenna of the O-glycans was also observed. This aberrant neutrophil glycosylation is predicted to have profound effects on the neutrophil function and merit designation of both syndromes as a new class of congenital disorders of glycosylation.

    Title Henoch-schönlein Purpura Complicating Adalimumab Therapy for Crohn's Disease.
    Date July 2011
    Journal World Journal of Gastrointestinal Pharmacology and Therapeutics
    Excerpt

    Anti-tumour necrosis factor-α (TNF) therapy has revolutionised the management of chronic inflammatory conditions. With ever increasing numbers of patients being treated with these agents, uncommon adverse reactions will inevitably occur more frequently. Cutaneous manifestations are associated with many of these chronic conditions and can complicate anti-TNF therapy in about 20% of cases. Vasculitic complications are rarely associated with anti-TNF therapy. Henoch-Schönlein purpura (HSP), a small vessel vasculitis, has been described following infliximab and etanercept therapy but never with adalimumab, a fully humanized TNF antibody. The risk of such immune-mediated reactions is theoretically less with adalimumab compared to infliximab but can still occur. Here we report the first case in the literature of HSP that can be attributed to the use of adalimumab in a 19-year-old male with recalcitrant Crohn's disease.

    Title Inflammatory Bowel Diseases in Patients with Adaptive and Complement Immunodeficiency Disorders.
    Date February 2011
    Journal Inflammatory Bowel Diseases
    Excerpt

    Crohn's disease and ulcerative colitis are idiopathic chronic inflammatory diseases that primarily affect the gastrointestinal tract. The underlying causes remain poorly understood, but there is a growing body of evidence advocating a likely primary pathogenic role for immunodeficiency in the development of Crohn's lesions. Concordantly, a number of congenital immunodeficiencies disrupting the cellular innate immune system strongly predispose to noninfectious, Crohn's-like inflammatory bowel disease. There are case reports and series suggesting that the same may be true for some of the congenital adaptive and complement immunodeficiencies. This review considers and critiques these potential associations.

    Title Delayed Resolution of Acute Inflammation in Ulcerative Colitis is Associated with Elevated Cytokine Release Downstream of Tlr4.
    Date January 2011
    Journal Plos One
    Excerpt

    Ulcerative colitis (UC) is widely viewed as a leukocyte-mediated disorder. Although strong evidence implicates an exuberant response to microbial components in its pathogenesis, no intrinsic immune defect has been identified and the underlying pathogenic mechanisms remain obscure.

    Title Case Records of the Massachusetts General Hospital. Case 32-2010. A Pregnant Woman with Abdominal Pain and Fluid in the Peritoneal Cavity.
    Date October 2010
    Journal The New England Journal of Medicine
    Title Neonatal Outcomes and Operative Vaginal Delivery Versus Cesarean Delivery.
    Date September 2010
    Journal American Journal of Perinatology
    Excerpt

    We compared outcomes for neonates with forceps-assisted, vacuum-assisted, or cesarean delivery in the second stage of labor. This is a secondary analysis of a randomized trial in laboring, low-risk, nulliparous women at >or=36 weeks' gestation. Neonatal outcomes after use of forceps, vacuum, and cesarean were compared among women in the second stage of labor at station +1 or below (thirds scale) for failure of descent or nonreassuring fetal status. Nine hundred ninety women were included in this analysis: 549 (55%) with an indication for delivery of failure of descent and 441 (45%) for a nonreassuring fetal status. Umbilical cord gases were available for 87% of neonates. We found no differences in the base excess (P = 0.35 and 0.78 for failure of descent and nonreassuring fetal status) or frequencies of pH below 7.0 (P = 0.73 and 0.34 for failure of descent and nonreassuring fetal status) among the three delivery methods. Birth outcomes and umbilical cord blood gas values were similar for those neonates with a forceps-assisted, vacuum-assisted, or cesarean delivery in the second stage of labor. The occurrence of significant fetal acidemia was not different among the three delivery methods regardless of the indication.

    Title Diminished Macrophage Apoptosis and Reactive Oxygen Species Generation After Phorbol Ester Stimulation in Crohn's Disease.
    Date April 2010
    Journal Plos One
    Excerpt

    Crohn's Disease (CD) is a chronic relapsing disorder characterized by granulomatous inflammation of the gastrointestinal tract. Although its pathogenesis is complex, we have recently shown that CD patients have a systemic defect in macrophage function, which results in the defective clearance of bacteria from inflammatory sites.

    Title Efficacy of Methotrexate in Crohn's Disease and Ulcerative Colitis Patients Unresponsive or Intolerant to Azathioprine /mercaptopurine.
    Date April 2010
    Journal Alimentary Pharmacology & Therapeutics
    Excerpt

    Despite the wide use of azathioprine/mercaptopurine (AZA/MP) therapy in the management of both Crohn's disease (CD) and ulcerative colitis (UC), approximately 20% of patients cannot tolerate the drugs and 30% do not respond.

    Title Second-stage Labor Duration in Nulliparous Women: Relationship to Maternal and Perinatal Outcomes.
    Date October 2009
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    The purpose of this study was to assess maternal and perinatal outcomes as a function of second-stage labor duration.

    Title Disordered Macrophage Cytokine Secretion Underlies Impaired Acute Inflammation and Bacterial Clearance in Crohn's Disease.
    Date October 2009
    Journal The Journal of Experimental Medicine
    Excerpt

    The cause of Crohn's disease (CD) remains poorly understood. Counterintuitively, these patients possess an impaired acute inflammatory response, which could result in delayed clearance of bacteria penetrating the lining of the bowel and predispose to granuloma formation and chronicity. We tested this hypothesis in human subjects by monitoring responses to killed Escherichia coli injected subcutaneously into the forearm. Accumulation of (111)In-labeled neutrophils at these sites and clearance of (32)P-labeled bacteria from them were markedly impaired in CD. Locally increased blood flow and bacterial clearance were dependent on the numbers of bacteria injected. Secretion of proinflammatory cytokines by CD macrophages was grossly impaired in response to E. coli or specific Toll-like receptor agonists. Despite normal levels and stability of cytokine messenger RNA, intracellular levels of tumor necrosis factor (TNF) were abnormally low in CD macrophages. Coupled with reduced secretion, these findings indicate accelerated intracellular breakdown. Differential transcription profiles identified disease-specific genes, notably including those encoding proteins involved in vesicle trafficking. Intracellular destruction of TNF was decreased by inhibitors of lysosomal function. Together, our findings suggest that in CD macrophages, an abnormal proportion of cytokines are routed to lysosomes and degraded rather than being released through the normal secretory pathway.

    Title Decreased Preterm Births in an Inner-city Public Hospital.
    Date April 2009
    Journal Obstetrics and Gynecology
    Excerpt

    To examine preterm births among African-American and Hispanic women who delivered at an inner-city public hospital in the context of contemporaneously increasing rates in the United States.

    Title Inflammatory Bowel Disease in Cgd Reproduces the Clinicopathological Features of Crohn's Disease.
    Date February 2009
    Journal The American Journal of Gastroenterology
    Excerpt

    Patients with chronic granulomatous disease (CGD), a rare congenital disorder characterized by defective neutrophil function, frequently develop an inflammatory bowel disease similar to Crohn's disease. The clinical presentations and concordance between the features of the bowel disease in these two conditions have never been formally evaluated.

    Title Impaired Neutrophil Chemotaxis in Crohn's Disease Relates to Reduced Production of Chemokines and Can Be Augmented by Granulocyte-colony Stimulating Factor.
    Date March 2007
    Journal Alimentary Pharmacology & Therapeutics
    Excerpt

    BACKGROUND: Defective neutrophil recruitment has been described as a primary pathogenic abnormality in Crohn's disease. Cantharidin-induced blisters provide a novel investigative tool to assess cellular influx and inflammatory mediator production during acute inflammation and allows the effects of therapy on these parameters to be measured. AIMS: To determine whether reduced neutrophil tissue penetration in Crohn's disease relates to impaired production of inflammatory mediators, and whether it can be reversed by granulocyte-colony stimulating factor (G-CSF). METHODS: Neutrophil and monocyte/macrophage populations and inflammatory mediators were measured in cantharidin blisters at 24 h. Neutrophil chemotaxis was assessed in vitro using blister fluid as the chemoattractant. The effect of s.c. G-CSF on blister phenotype was determined. RESULTS: Significantly fewer neutrophils migrated into blisters in Crohn's patients. The production of neutrophil chemokines, but not other inflammatory mediators, was reduced. This significantly correlated with reduced chemotaxis in vitro. Differences were unrelated to caspase-recruitment domain 15 genotype. G-CSF significantly increased blister neutrophil concentrations in control subjects and Crohn's patients. CONCLUSIONS: Reduced neutrophil migration during acute inflammation in Crohn's disease is associated with impaired production of appropriate chemoattractants. G-CSF therapy increases neutrophil tissue migration, which may partially account for its observed therapeutic effect.

    Title Fetal Pulse Oximetry and Cesarean Delivery.
    Date November 2006
    Journal The New England Journal of Medicine
    Excerpt

    BACKGROUND: Knowledge of fetal oxygen saturation, as an adjunct to electronic fetal monitoring, may be associated with a significant change in the rate of cesarean deliveries or the infant's condition at birth. METHODS: We randomly assigned 5341 nulliparous women who were at term and in early labor to either "open" or "masked" fetal pulse oximetry. In the open group, fetal oxygen saturation values were displayed to the clinician. In the masked group, the fetal oxygen sensor was inserted and the values were recorded by computer, but the data were hidden. Labor complicated by a nonreassuring fetal heart rate before randomization was documented for subsequent analysis. RESULTS: There was no significant difference in the overall rates of cesarean delivery between the open and masked groups (26.3% and 27.5%, respectively; P=0.31). The rates of cesarean delivery associated with the separate indications of a nonreassuring fetal heart rate (7.1% and 7.9%, respectively; P=0.30) and dystocia (18.6% and 19.2%, respectively; P=0.59) were similar between the two groups. Similar findings were observed in the subgroup of 2168 women in whom a nonreassuring fetal heart rate was detected before randomization. The condition of the infants at birth did not differ significantly between the two groups. CONCLUSIONS: Knowledge of the fetal oxygen saturation is not associated with a reduction in the rate of cesarean delivery or with improvement in the condition of the newborn. (ClinicalTrials.gov number, NCT00098709 [ClinicalTrials.gov].).

    Title Decision-to-incision Times and Maternal and Infant Outcomes.
    Date August 2006
    Journal Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: To measure decision-to-incision intervals and related maternal and neonatal outcomes in a cohort of women undergoing emergency cesarean deliveries at multiple university-based hospitals comprising the National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. METHODS: All women undergoing a primary cesarean delivery at a Network center during a 2-year time span were prospectively ascertained. Emergency procedures were defined as those performed for umbilical cord prolapse, placental abruption, placenta previa with hemorrhage, nonreassuring fetal heart rate pattern, or uterine rupture. Detailed information regarding maternal and neonatal outcomes, including the interval from the decision time to perform cesarean delivery to the actual skin incision, was collected. RESULTS: Of the 11,481 primary cesarean deliveries, 2,808 were performed for an emergency indication. Of these, 1,814 (65%) began within 30 minutes of the decision to operate. Maternal complication rates, including endometritis, wound infection, and operative injury, were not related to the decision-to-incision interval. Measures of newborn compromise including umbilical artery pH less than 7 and intubation in the delivery room were significantly greater when the cesarean delivery was commenced within 30 minutes, likely attesting to the need for expedited delivery. Of the infants with indications for an emergency cesarean delivery who were delivered more than 30 minutes after the decision to operate, 95% did not experience a measure of newborn compromise. CONCLUSION: Approximately one third of primary cesarean deliveries performed for emergency indications are commenced more than 30 minutes after the decision to operate, and the majority were for nonreassuring heart rate tracings. In these cases, adverse neonatal outcomes were not increased. LEVEL OF EVIDENCE: II-2.

    Title Risk of Uterine Rupture with a Trial of Labor in Women with Multiple and Single Prior Cesarean Delivery.
    Date August 2006
    Journal Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: To determine whether the risk for uterine rupture is increased in women attempting vaginal birth after multiple cesarean deliveries. METHODS: We conducted a prospective multicenter observational study of women with prior cesarean delivery undergoing trial of labor and elective repeat operation. Maternal and perinatal outcomes were compared among women attempting vaginal birth after multiple cesarean deliveries and those with a single prior cesarean delivery. We also compared outcomes for women with multiple prior cesarean deliveries undergoing trial of labor with those electing repeat cesarean delivery. RESULTS: Uterine rupture occurred in 9 of 975 (0.9%) women with multiple prior cesarean compared with 115 of 16,915 (0.7%) women with a single prior operation (P = .37). Multivariable analysis confirmed that multiple prior cesarean delivery was not associated with an increased risk for uterine rupture. The rates of hysterectomy (0.6% versus 0.2%, P = .023) and transfusion (3.2% versus 1.6%, P < .001) were increased in women with multiple prior cesarean deliveries compared with women with a single prior cesarean delivery attempting trial of labor. Similarly, a composite of maternal morbidity was increased in women with multiple prior cesarean deliveries undergoing trial of labor compared with those having elective repeat cesarean delivery (odds ratio 1.41, 95% confidence interval 1.02-1.93). CONCLUSION: A history of multiple cesarean deliveries is not associated with an increased rate of uterine rupture in women attempting vaginal birth compared with those with a single prior operation. Maternal morbidity is increased with trial of labor after multiple cesarean deliveries, compared with elective repeat cesarean delivery, but the absolute risk for complications is small. Vaginal birth after multiple cesarean deliveries should remain an option for eligible women. LEVEL OF EVIDENCE: II-2.

    Title Elastic Scattering Spectroscopy for the Diagnosis of Colonic Lesions: Initial Results of a Novel Optical Biopsy Technique.
    Date May 2006
    Journal Gastrointestinal Endoscopy
    Excerpt

    BACKGROUND: Biopsy and polypectomy frequently are performed for lesions that carry a low risk of malignant transformation in the colon. Elastic scattering spectroscopy (ESS) is a novel optical biopsy technique that can distinguish, almost instantaneously, between normal and abnormal tissue in vivo, without the need to remove tissue. We assessed the diagnostic potential of ESS in the colon to differentiate normal colonic mucosa, chronic colitis, hyperplastic polyps, adenomatous polyps (with dysplasia), and adenocarcinoma. METHODS: ESS spectra were obtained from 138 sites in 45 patients at colonoscopy. They were then compared with conventional biopsy specimens taken from the same site, including normal colonic mucosa, hyperplastic polyps, adenomatous polyps, chronic colitis, and colon cancer. Spectral analysis was carried out with a validated computerized model that used principal component analysis followed by linear discriminant analysis. Cross validation was carried out by using 60% of the data as a "training set" and the remaining 40% of the data as a "test set." RESULTS: A total of 483 spectra were analyzed (290 normal, 19 hyperplastic, 69 adenomatous polyps, 74 chronic colitis, and 31 colorectal cancer). The sensitivity and the specificity of differentiating adenomas from hyperplastic polyps was 84% and 84%, respectively; for cancer from adenomatous polyps, 80% and 75%, respectively; for colitis from normal tissue, 77% and 82%, respectively; and for dysplastic mucosa (from polyps) from colitis, 85% and 88%, respectively. CONCLUSIONS: ESS holds promise for differentiating colonic lesions with good accuracy and, therefore, is a potentially useful tool to make an instantaneous diagnosis during colonoscopy. It could prove a valuable aid for targeting biopsies in dysplasia surveillance in inflammatory bowel disease and for deciding which small polyps should be removed.

    Title A Randomized Trial of Coached Versus Uncoached Maternal Pushing During the Second Stage of Labor.
    Date April 2006
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: The objective of this study was to compare obstetrical outcomes associated with coached versus uncoached pushing during the second stage of labor. STUDY DESIGN: Upon reaching the second stage, previously consented nulliparous women with uncomplicated labors and without epidural analgesia were randomly assigned to coached (n = 163) versus uncoached (n = 157) pushing. Women allocated to coaching received standardized closed glottis pushing instructions by certified nurse-midwives with proper ventilation encouraged between contractions. These midwives also attended those women assigned to no coaching to ensure that any expulsive efforts were involuntary. RESULTS: The second stage of labor was abbreviated by approximately 13 minutes in coached women (P = .01). There were no other clinically significant immediate maternal or neonatal outcomes between the 2 groups. CONCLUSION: Although associated with a slightly shorter second stage, coached maternal pushing confers no other advantages and withholding such coaching is not harmful.

    Title The Mfmu Cesarean Registry: Uterine Atony After Primary Cesarean Delivery.
    Date October 2005
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: The purpose of this study was to define independent risk factors for uterine atony after primary cesarean delivery, and to assess their overall association with atony in the study cohort. STUDY DESIGN: This was a 13-university center prospective observational study. All women who underwent primary cesarean from January 1, 1999 to December 31, 2000 were eligible. Trained and certified research nurses performed systematic data abstraction. The definition of atony required both the clinical diagnosis and the use of methergine or a prostaglandin preparation. Risk factors for uterine atony were assessed in univariable and multivariable logistic regression analyses, and these analyses then used to inform an assessment of the association of the various risk factors with the occurrence of uterine atony in the overall cohort. RESULTS: Twenty-three thousand, three hundred and ninety pregnancies were analyzed. Uterine atony occurred in 1416 women (6%). Several variables were independently associated with atony in a multivariable model, including multiple gestation (odds ratio [OR] 2.40, 95% CI 1.95-2.93), maternal Hispanic race (2.21, 1.90-2.57), induced or augmented labor for >18 hours (2.23, 1.92-2.60), infant birth weight >4500 g (2.05, 1.53-2.69), and clinically diagnosed chorioamnionitis (1.80, 1.55-2.09). However, because the various risk factors were not very powerful, approximately half of the cases of atony were associated with the 2/3 of women lacking a given risk factor or combination of risk factors. CONCLUSION: Although certain risk factors and uterine atony were clearly associated, the associations are of limited practical clinical use.

    Title Illusory Correlation for Body Type and Happiness: Covariation Bias and Its Relationship to Eating Disorder Symptoms.
    Date September 2005
    Journal The International Journal of Eating Disorders
    Excerpt

    OBJECTIVE: The current study investigates covariation bias (illusory correlation) in the perceived association between happiness and body type, as well as the association between covariation bias and eating disorder symptoms. METHOD: Undergraduate women (n = 186) rated pictures of women on a variety of attributes, including happiness, degree of overweight, and attractiveness. Later, they were asked to judge the level of covariation between these attributes that was present in the stimuli that they had rated. Participants also completed the Eating Disorder Examination-Self-Report Questionnaire (EDE-Q). RESULTS: Participants reported that there was a negative association between weight and happiness in the stimuli that they had rated, even though the true correlation in the data was zero. This covariation bias was stronger among participants with higher levels of eating disorder symptoms. DISCUSSION: The results suggest a cognitive bias that may play a role in maintaining and enhancing concerns about shape and weight in symptomatic women.

    Title Complications of Anesthesia for Cesarean Delivery.
    Date September 2005
    Journal Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: To quantify anesthesia-related complications associated with cesarean delivery in a well-described, prospectively ascertained cohort from multiple university-based hospitals in the United States and to evaluate whether certain factors would identify women at increased risk for a failed regional anesthetic. METHODS: A prospective observational study was conducted of women (n = 37,142) with singleton gestations undergoing cesarean delivery in the centers forming the National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Detailed information was collected regarding choice of anesthesia and procedure-related complications, including failed regional anesthetic and maternal death. Potential risk factors for a failed regional anesthetic were analyzed. RESULTS: Of the women studied, 34,615 (93%) received a regional anesthetic. Few (3.0%) regional procedures failed, and related maternal morbidity was rare. Increased maternal size, higher preoperative risk, rapid decision-to-incision interval, and placement later in labor were all significantly related to an increased risk of a failed regional procedure. Of the general anesthetics, 38% were administered when the decision-to-incision interval was less than 15 minutes. Women deemed at the greatest preoperative risk (American Society of Anesthesiologists score > or = 4) were approximately 7-fold more likely to receive a general anesthetic (odds ratio 6.9, 95% confidence interval 5.83-8.07). There was one maternal death, due to a failed intubation, in which the anesthetic procedure was directly implicated. CONCLUSION: Regional techniques have become the preferred method of anesthesia for cesarean delivery. Procedure-related complications are rare and attest to the safety of modern obstetric anesthesia for cesarean delivery in the United States.

    Title Hospitalization for Women with Arrested Preterm Labor: a Randomized Trial.
    Date August 2005
    Journal Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: To determine whether hospitalization of women with arrested preterm labor has an effect on delivery at 36 weeks or greater when compared with women discharged home. METHODS: All women with a singleton gestation and a diagnosis of arrested preterm labor with intact membranes between 24 and 33 weeks, 4 days of gestation were randomly assigned to home or hospital management. Upon completion of a dexamethasone course, women assigned to outpatient management were promptly discharged, and women in the inpatient group were advised to continue hospitalization until 34 weeks. Decreased activity was encouraged in both groups. Bed rest was not strictly enforced. The primary outcome was delivery at 36 weeks or greater. RESULTS: A total of 101 women of a planned 188 were enrolled at the time of an interim analysis. There was no difference in the primary study outcome between the 2 groups and the trial was terminated. Among the hospitalized women, 71% reached 36 weeks or greater, compared with 72% of those discharged home (P = .89). The mean cervical dilatation in hospitalized women was 2.7 +/- 0.5 cm, compared with 2.6 +/- 0.5 cm in women discharged home (P = .16). The overall length of hospital stay for the women allocated to hospitalization was 16 +/- 13 days. CONCLUSION: Compared with hospitalization, outpatient management of women with arrested preterm labor and intact membranes had no effect on the rate of preterm birth. LEVEL OF EVIDENCE: I.

    Title A Prospective Observational Study of Domestic Violence During Pregnancy.
    Date August 2005
    Journal Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: To assess whether women reporting domestic violence are at increased risk for adverse pregnancy outcomes. METHODS: A screening questionnaire, previously validated for the identification of female victims of domestic violence, was offered to women presenting to our Labor and Delivery Unit. The survey prompted women to indicate whether her partner or family member physically hurt her, insulted or talked down to her, threatened her with harm, or screamed or cursed at her. The primary study outcome was to detect a 3-fold increase in low birth weight infants (< or = 2,500 g) in women reporting physical abuse, compared with those not reporting domestic violence. RESULTS: A total of 16,041 women were approached to be interviewed. Of these, 949 (6%) women responded affirmatively to one or more of the survey questions, and another 94 (0.6%) declined to be interviewed. The incidence of low birth weight infants was significantly increased in women who reported verbal abuse, compared with the no-abuse group (7.6% versus 5.1%, respectively, P = .002). Physical abuse was associated with an increased risk of neonatal death (1.5% versus 0.2%, P = .004). Interestingly, women who declined to be interviewed had significantly increased rates of low birth weight infants (12.8% versus 5.1%, P < .001), preterm birth at 32 weeks of gestation or less (5.3% versus 1.2%, P = .002), placental abruptions (2.1% versus 0.2%, P < .001), and neonatal intensive care admissions (7.4% versus 2.2%, P = .008) when compared with women in the no-abuse group, respectively. CONCLUSION: Women who declined to be surveyed regarding domestic violence were at increased risk for adverse pregnancy outcome. LEVEL OF EVIDENCE: II-2.

    Title Obstetric Antecedents for Postpartum Pelvic Floor Dysfunction.
    Date June 2005
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: The purpose of this study was to evaluate prospectively the association between selected obstetric antecedents and symptoms of pelvic floor dysfunction in primiparous women up to 7 months after childbirth. STUDY DESIGN: All nulliparous women who were delivered between June 1, 2000, and August 31, 2002, were eligible for a postpartum interview regarding symptoms of persistent pelvic floor dysfunction. Responses from all women who completed a survey at or before their 6-month contraceptive follow-up visit were analyzed. Obstetric antecedents to stress, urge, and anal incontinence were identified, and attributable risks for each factor were calculated. RESULTS: During the study period, 3887 of 10,643 primiparous women (37%) returned within 219 days of delivery. Symptoms of stress and urge urinary incontinence, were significantly reduced (P < .01) in women who underwent a cesarean delivery. Symptoms of urge urinary incontinence doubled in women who underwent a forceps delivery (P = .04). Symptoms of anal incontinence were increased in women who were delivered of an infant who weighed >4000 g (P = .006) and more than doubled in those women who received oxytocin and had an episiotomy performed (P = .01). CONCLUSION: The likelihood of symptoms of pelvic floor dysfunction up to 7 months after delivery was greater in women who received oxytocin, who underwent a forceps delivery, who were delivered of an infant who weighed >4000 g, or who had an episiotomy performed. Women who underwent a cesarean delivery had fewer symptoms of urge and stress urinary incontinence.

    Title A Randomized Trial of the Effects of Coached Vs Uncoached Maternal Pushing During the Second Stage of Labor on Postpartum Pelvic Floor Structure and Function.
    Date June 2005
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: The purpose of this study was to determine if refraining from coached pushing during the second stage of labor affects postpartum urogynecologic measures of pelvic floor structure and function. STUDY DESIGN: Nulliparous women at term were randomized to coached (n = 67) vs uncoached (n = 61) pushing. At 3 months' postpartum women underwent urodynamic testing, pelvic organ prolapse examination (POPQ), and pelvic floor neuromuscular assessment. RESULTS: Urodynamic testing revealed decreased bladder capacity (427 mL vs 482 mL, P = .051) and decreased first urge to void (160 mL vs 202 mL, P = .025) in the coached group. Detrusor overactivity increased 2-fold in the coached group (16% vs 8%), although this difference was not statistically significant (P = .17). Urodynamic stress incontinence was diagnosed in the coached group in 11/67 (16%) vs 7/61 (12%) in the uncoached group (P = .42). CONCLUSION: Coached pushing in the second stage of labor significantly affected urodynamic indices, and was associated with a trend towards increased detrusor overactivity.

    Title Special Section: the Therapeutic Community in the 21st Century. Introduction.
    Date November 2004
    Journal The Psychiatric Quarterly
    Title The Art and Challenges of Long-term and Short-term Democratic Therapeutic Communities.
    Date November 2004
    Journal The Psychiatric Quarterly
    Excerpt

    This paper, cowritten by Kingsley Norton, since 1989 Director of Henderson Hospital (a therapeutic community founded by Maxwell Jones in 1947 in the United Kingdom), and Sandra Bloom, Founder of the Sanctuary Model in the United States, compares and contrasts the practice of the democratic therapeutic community (TC) as applied to the notion of long-term care (up to twelve months), to that of the democratic therapeutic milieu (TM) as applied to short-term care (up to one month).

    Title Selectivity of Metal Binding and Metal-induced Stability of Escherichia Coli Nikr.
    Date September 2004
    Journal Biochemistry
    Excerpt

    NikR from Escherichia coli is a nickel-responsive transcription factor that regulates the expression of a nickel ion transporter. Metal analysis reveals that NikR can bind a variety of divalent transition metals, including Ni(II), Cu(II), Zn(II), Co(II), and Cd(II). The selectivity of metal binding to NikR was investigated by using electronic absorption spectroscopy and small-molecule competitors. The relative affinities, Mn(II) < Co(II) < Ni(II) < Cu(II) > or = Zn(II), follow the Irving-Williams series of metal-complex stabilities. Similar metal affinities were measured for the isolated metal-binding domain of NikR. To determine if any of these metal ions confer a differential effect on NikR, the stability of the metal-bound complexes was examined. In both thermal and chemical denaturation experiments, nickel binding stabilizes the protein more than any of the other metals tested. Thermal denaturation experiments indicate that metal dissociation occurs after loss of secondary structure, but there was no evidence for metal binding to unfolded protein following reversible chemical denaturation. These experiments demonstrate that, although several different metals can bind to NikR, nickel exerts a selective allosteric effect. The implications of these experiments on the in vivo role of NikR as a nickel metalloregulator are discussed.

    Title Metal-selective Dna-binding Response of Escherichia Coli Nikr.
    Date September 2004
    Journal Biochemistry
    Excerpt

    The NikR transcription factor from Escherichia coli is a Ni(II)-dependent repressor that regulates production of the nickel ion transporter encoded by the nik operon. In the previous paper in this issue (Wang, S. C., Dias, A., Bloom, S. L., and Zamble, D. B. (2004) Selectivity of Metal Binding and Metal-Induced Stability of Escherichia coli NikR, Biochemistry 43, 10018-10028) we demonstrated that NikR can bind 1 equiv of Ni(II) or several other divalent transition metals with similar affinities, but that the Ni(II)-loaded protein is less susceptible to thermal or chemical denaturation than other divalent metal complexes. Here, we investigate the metal selectivity of the DNA-binding activity of NikR. Stoichiometric nickel induces binding of nanomolar NikR to the recognition sequence in the nik promoter, but single equivalents of other divalent metals such as Cd(II), Co(II), and Cu(II) also induce a similar DNA-binding affinity. In the presence of excess nickel, DNA-binding experiments indicate that NikR binds to the nik promoter as a tetramer with much higher affinity (20 pM), and it is this response that is selective for nickel. The DNA binding induced by an excess of other divalent metals is weaker, and is enhanced by the addition of stoichiometric nickel. Nickel titrations into a DNA-binding assay reveal a nickel affinity of 30 nM for a second metal-binding site, and in the presence of 30 nM metal only nickel induces detectable DNA binding by Ni(II)-NikR. These experiments support the hypothesis that there are two metal-binding sites and that both contribute to the nickel-selective DNA-binding response. A model for the in vivo activity of NikR is discussed.

    Title A Hospital-sponsored Quality Improvement Study of Pain Management After Cesarean Delivery.
    Date July 2004
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: We undertook this study to systematically assess prevailing pain management regimes used at our hospital in women after cesarean delivery. STUDY DESIGN: Between August 1999 and July 2000, all women delivered by cesarean section at Parkland Hospital were assigned to 1 of 4 different pain management strategies: (1). intramuscular (IM) meperidine, (2). patient-controlled analgesia (PCA) meperidine, (3). IM morphine sulfate, and (4). PCA morphine sulfate. A combination of methods were used to compare these different pain management strategies. A survey questionnaire, using Likert scale responses, was administered to evaluate maternal satisfaction with pain control. Visual Analog Scale (VAS) scores and information regarding breastfeeding and rooming-in were also collected. RESULTS: A total of 1256 women were allocated to the 4 analgesia study groups. The median meperidine dosages for the IM and PCA groups were 350 mg and 600 mg, respectively (P <or=.01). Conversely, the median IM morphine dose (65 mg) was significantly higher than that for the PCA group (60 mg). The percentage of women reporting moderate or worse pain (VAS scores 4 or more) was significantly lower in those women who received PCA meperidine compared with IM meperidine. Women who received morphine reported less severe pain compared with meperidine, regardless of route of administration. The patients' subjective report of satisfaction with pain management was not related to the method or drug used for pain control (P=.13). Fewer women assigned to morphine therapy stopped breastfeeding (P=.02) and more roomed-in with their infants (P <.01). CONCLUSION: Pain relief was superior with the morphine regimens used and was positively associated with breastfeeding and infant rooming-in.

    Title Corticosteroid Use in Special Circumstances: Preterm Ruptured Membranes, Hypertension, Fetal Growth Restriction, Multiple Fetuses.
    Date August 2003
    Journal Clinical Obstetrics and Gynecology
    Title Creating Sanctuary in Residential Treatment for Youth: from the "well-ordered Asylum" to a "living-learning Environment.".
    Date May 2003
    Journal The Psychiatric Quarterly
    Excerpt

    This paper addresses the need for a coherent conceptual therapeutic approach to guide work with disturbed children and adolescents in residential treatment centers. The paper identifies changes in the population currently in care; examines the two dominant approaches that historically have shaped the standard treatment models used by most residential centers; and discusses four longstanding debates that have complicated the development of a consistent therapeutic approach for residential programs. It concludes with a description of The Sanctuary Model. Integrating a variety of treatment approaches, this trauma-based systems approach to care was first used with adult inpatients traumatized as children. It is now being introduced by a major social agency into three of its residential centers to provide a systematic treatment model for use in their schools, living units, and treatment sessions.

    Title Assessing the Implementation and Effects of a Trauma-focused Intervention for Youths in Residential Treatment.
    Date May 2003
    Journal The Psychiatric Quarterly
    Excerpt

    This paper describes methods being used to implement and assess the effects of a trauma-focused intervention in residential treatment programs for youths with emotional and behavioral problems, and histories of maltreatment and exposure to family or community violence. Preliminary baseline profiles of the therapeutic environments and youths are also presented. The intervention, referred to as the Sanctuary Model (Bloom, 1997), is based in social psychiatry, trauma theories, therapeutic community philosophy, and cognitive-behavioral approaches. Within the context of safe, supportive, stable, and socially responsible therapeutic communities, a trauma recovery treatment framework is used to teach youths effective adaptation and coping skills to replace nonadaptive cognitive, social, and behavioral strategies that may have emerged earlier as means of coping with traumatic life experiences.

    Title Multiple Opportunities for Creating Sanctuary.
    Date May 2003
    Journal The Psychiatric Quarterly
    Excerpt

    This article describes the experience of five change agents from a diverse group of settings: two residential treatment programs for children and adolescents, a group home for disturbed adolescents, a residential substance abuse program for urban women, and an acute care psychiatric inpatient unit. What all of these innovators share is a willingness to engage in the challenging and complex process of changing their systems to better address the needs of the traumatized children, adolescents, and adults who populate their various programs. Using the Sanctuary Model as originally applied to a specialty inpatient psychiatric program for adult survivors of childhood abuse as their guide, the leaders of each of these organizations discuss the process of change that they are directing.

    Title Cesarean Delivery: a Randomized Trial of Epidural Analgesia Versus Intravenous Meperidine Analgesia During Labor in Nulliparous Women.
    Date April 2002
    Journal Anesthesiology
    Excerpt

    BACKGROUND: Controversy concerning increased cesarean births as a result of epidural analgesia for relief of labor pain has been attributed, in large part, to difficulties interpreting published studies because of design flaws. In this study, the authors compared epidural analgesia to intravenous meperidine analgesia using patient-controlled devices during labor to evaluate the effects of labor epidural analgesia, primarily on the rate of cesarean deliveries while minimizing limitations attributable to study design. METHODS: Four hundred fifty-nine nulliparous women in spontaneous labor at term were randomly assigned to receive either epidural analgesia or intravenous meperidine analgesia. Epidural analgesia was initiated with 0.25% bupivacaine and was maintained with 0.0625% bupivacaine and fentanyl 2 microg/ml at 6 ml/h with 5-ml bolus doses every 15 min as needed using a patient-controlled pump. Women in the intravenous analgesia group received 50 mg meperidine with 25 mg promethazine hydrochloride as an initial bolus, followed by 15 mg meperidine every 10 min as needed, using a patient-controlled pump. A written procedural manual that prescribed the intrapartum obstetric management was followed for each woman randomized in the study. RESULTS: A total of 226 women were randomized to receive epidural analgesia, and 233 women were randomized to receive intravenous meperidine analgesia. Protocol violations occurred in 8% (38 of 459) of women. There was no difference in the rate of cesarean deliveries between the two analgesia groups (epidural analgesia, 7% [16 of 226; 95% confidence interval, 4-11%] vs. intravenous meperidine analgesia, 9% [20 of 233; 95% confidence interval, 5-13%]; P = 0.61). Significantly more women randomized to epidural analgesia had forceps deliveries compared with those randomized to meperidine analgesia (12% [26 of 226] vs. 3% [7 of 233]; P < 0.001). Women who received epidural analgesia reported lower pain scores during labor and delivery compared with women who received intravenous meperidine analgesia. CONCLUSIONS: Epidural analgesia compared with intravenous meperidine analgesia during labor does not increase cesarean deliveries in nulliparous women.

    Title Recurrence of Preterm Birth in Singleton and Twin Pregnancies.
    Date September 2001
    Journal Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: To assess recurrence of preterm birth and its impact on an obstetric population. METHODS: Women with consecutive births at our hospital beginning with their first pregnancy were identified (n = 15,945). The first pregnancy was categorized as delivered between 24 and 34 weeks' gestation or 35 weeks or beyond, singleton or twin, and spontaneous or induced. The risk of preterm delivery in these same women during subsequent pregnancies was then analyzed. RESULTS: Compared with women who delivered a singleton at or beyond 35 weeks' gestation in their first pregnancy, those who delivered a singleton before 35 weeks were at a significant increased risk for recurrence (odds ratio [OR] 5.6, 95% confidence interval [CI] 4.5, 7.0), whereas those who delivered twins were not (OR 1.9, 95% CI 0.46, 8.14). The OR for recurrent spontaneous preterm birth presenting with intact membranes was 7.9 (95% CI 5.6, 11.3) compared with 5.5 (95% CI 3.2, 9.4) with ruptured membranes. Of those women with a recurrent preterm birth, 49% delivered within 1 week of the gestational age of their first delivery and 70% delivered within 2 weeks. Among 15,863 nulliparous women with singleton births at their first delivery, a history of preterm birth in that pregnancy could predict only 10% of the preterm births that ultimately occurred in the entire obstetric population. CONCLUSION: In a population-based study at our hospital, women who initially delivered preterm and thus were identified to be at risk for recurrence ultimately accounted for only 10% of the prematurity problem in the cohort.

    Title Antenatal Dexamethasone and Decreased Birth Weight.
    Date April 2001
    Journal Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: To test the hypothesis that antenatal dexamethasone treatment to promote fetal lung maturation results in decreased birth weight corrected for gestational age. METHODS: The birth weights of all dexamethasone-treated, singleton, live-born infants delivered at our hospital were compared with our overall obstetric population; a group of untreated infants frequency matched approximately 3:1 according to maternal race, infant sex, and gestational age at delivery; and an historical cohort of infants with an indication for dexamethasone but delivered in the 12 months before the introduction of corticosteroid therapy at our hospital. RESULTS: Dexamethasone-treated infants (n = 961), when compared with either the overall population (n = 122,629) or matched controls (n = 2808), had significantly lower birth weights after adjustment for week of gestation (P <.001). Compared with the historical cohort of infants, the average birth weight of dexamethasone-treated infants was smaller by 12 g at 24-26 weeks, 63 g at 27-29 weeks, 161 g at 30-32 weeks, and 80 g at 33-34 weeks' gestation. CONCLUSION: Antenatal dexamethasone administered to promote fetal maturation is associated with diminished birth weight.

    Title Sexual Violence: the Victim.
    Date September 2000
    Journal New Directions for Mental Health Services
    Excerpt

    Molestation and rape in childhood or adulthood is sexual violence. This chapter discusses issues for sexual violence victims and suggests several best practices for this population.

    Title Treating Traumatized Patients and Victims of Violence.
    Date September 2000
    Journal New Directions for Mental Health Services
    Excerpt

    This chapter presents a thorough exposition of treating traumatized patients and victims of violence, addressing many aspects of trauma and victimization critical to a vast proportion of the work that mental health professionals find themselves doing.

    Title An Appraisal of Treatment Guidelines for Antepartum Community-acquired Pneumonia.
    Date August 2000
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: The optimal strategy for the initial evaluation and management, including criteria for hospitalization, of pregnant women with pneumonia has not been defined. Our purpose was to evaluate a treatment protocol for antepartum pneumonia and to identify criteria for selection of women for potential outpatient treatment. STUDY DESIGN: A protocol based on British and American Thoracic Society guidelines was introduced and included prompt hospitalization and empiric initiation of erythromycin therapy. Maternal and neonatal outcomes were analyzed to assess the efficacy of the protocol. A second analysis involved the retrospective application of published guidelines to ascertain for which women outpatient management might have been appropriate. RESULTS: There were no maternal deaths among the 133 women studied, and in 14 (10%) women there was a misdiagnosis at admission. Erythromycin monotherapy was judged adequate in all but one of the 99 women so treated. Using a modified version of the American Thoracic Society guidelines, we project that only 25% of the women hospitalized with pneumonia could have been managed safely as outpatients. CONCLUSION: Most pregnant women with pneumonia respond well to monotherapy with erythromycin. Outpatient management may be a reasonable option for selected women.

    Title Pregnancy Outcomes After Antepartum Diagnosis of Oligohydramnios at or Beyond 34 Weeks' Gestation.
    Date May 2000
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: Our purpose was to assess whether antepartum oligohydramnios is associated with adverse perinatal outcomes. STUDY DESIGN: Women delivered between July 1, 1991, and September 30, 1996, who underwent ultrasonography at >/=34 weeks' gestation were analyzed. Oligohydramnios was defined as an amniotic fluid index </=50 mm. Perinatal outcomes in pregnancies with oligohydramnios were compared with those with an amniotic fluid index of >50 mm. RESULTS: In our analysis of 6423 pregnancies, 147 (2.3%) were complicated by oligohydramnios. This complication was associated with increased labor induction (42% vs 18%; P <.001), stillbirth (1. 4% vs 0.3%; P <.03), nonreassuring fetal heart rate (48% vs 39%; P <. 03), admission to the neonatal intensive care nursery (7% vs 2%; P <. 001), meconium aspiration syndrome (1% vs 0.1%; P <.001), and neonatal death (5% vs 0.3%; P <.001). CONCLUSION: Antepartum oligohydramnios is associated with increased perinatal morbidity and mortality.

    Title Fetal Pulse Oximetry: Duration of Desaturation and Intrapartum Outcome.
    Date July 1999
    Journal Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: To analyze labor outcomes in relation to masked fetal arterial oxyhemoglobin saturation values above or below 30%. METHODS: Consenting gravidas with uncomplicated pregnancies at or beyond 36 weeks' gestation underwent continuous fetal pulse oximetry. Pregnancy outcomes were compared between two groups: women with fetuses with at least one epoch of arterial oxyhemoglobin saturation below 30% (10 seconds or longer) and women with fetuses without such an episode. We also attempted to ascertain whether duration of saturation below 30% correlated with fetal compromise. RESULTS: We measured arterial oxyhemoglobin saturation in 129 fetuses, 69 (53%) of whom had at least one epoch of saturation below 30%. There were no statistically significant differences in labor and delivery outcomes between the high-saturation and low-saturation groups (eg, cesarean delivery: 13 versus 9%, P = .41; umbilical artery [UA] pH less than 7.20: 10 versus 9%, P > .999). However, as duration of fetal arterial oxyhemoglobin saturation below 30% increased from 10 seconds to longer than 9 consecutive minutes, the incidence of fetal compromise (considered present when at least one of the following criteria was met: cesarean delivery for nonreassuring fetal heart rate pattern, UA pH less than 7.20, admission to the special care nursery, or 5-minute Apgar score not more than 3) increased significantly (P = .002). The threshold duration of fetal arterial oxyhemoglobin saturation below 30% associated with increased fetal compromise was 2 minutes. CONCLUSION: Transient fetal arterial oxyhemoglobin saturation values below 30% are common during normal labor and did not predict fetal compromise. Fetal arterial oxyhemoglobin saturation values less than 30% for 2 minutes or longer might be associated with fetal compromise.

    Title Severe Preeclampsia and the Very Low Birth Weight Infant: is Induction of Labor Harmful?
    Date May 1999
    Journal Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: To compare the effects of labor induction with the effects of cesarean delivery without labor on neonatal outcome in pregnancies complicated by severe preeclampsia and delivery of very low birth weight infants. METHODS: This was a retrospective study of 278 singleton, live-born infants who weighed 750-1500 g and were delivered because of severe preeclampsia between 1988 and 1997. Outcomes of infants delivered by cesarean without labor were compared with those of infants exposed to labor induction. Statistical analysis was performed using Student t test, Mann-Whitney U test, chi2 analysis, and Fisher exact test, where appropriate. Multiple logistic regression analysis was used to adjust for outcomes of interest. RESULTS: One hundred forty-five (52%) of the 278 women with severe preeclampsia who delivered infants weighing between 750 and 1500 g had labor induced and 133 (48%) delivered by cesarean without labor. Vaginal delivery was accomplished by 50 (34%) women in the induced group. Apgar scores of 3 or less at 5 minutes were more likely in the induced-labor group (6 versus 2%, P = .04), but other neonatal outcomes, including respiratory distress syndrome, grade 3 or 4 intraventricular hemorrhage, sepsis, seizures, and neonatal death, were similar in the two groups. Adjustment for birth weight and gestational age did not affect those results. Analysis of data from the induced-labor group did not reveal an effect by route of delivery on neonatal outcome. CONCLUSION: Induction of labor in cases of severe preeclampsia is not harmful to very low birth weight infants.

    Title Pitfalls in Ultrasonic Cervical Length Measurement for Predicting Preterm Birth.
    Date May 1999
    Journal Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: To describe the anatomic and technical difficulties encountered with transvaginal ultrasound imaging of the cervix in a consecutive series of women at risk for preterm delivery. METHODS: Three groups of women had cervical ultrasound examinations: those with histories of preterm birth, those with incompetent cervices, and those admitted for preterm labor that did not progress. Standardized ultrasound examinations of the cervix involved measuring the length of the endocervical canal, funneling length, and internal os dilation with and without fundal pressure. RESULTS: Sixty consecutive women had transvaginal ultrasound examinations for assessment of the cervix. Forty-six had histories of preterm birth, five had incompetent cervices, and nine had arrested preterm labor. Six types of problems arose, which can be divided into anatomic or technical considerations, with an overall frequency of 27% (95% confidence interval 16%, 40%). Anatomic pitfalls that hampered identification of the internal os included an undeveloped lower uterine segment (n = 5), a focal myometrial contraction (n = 1), rapid and spontaneous cervical change (n = 1), and an endocervical polyp (n = 1). Technical pitfalls included incorrect interpretation of internal os dilation because of vaginal probe orientation (n = 7) and artificial lengthening of the endocervical canal because of distortion of the cervix by the transducer (n = 1). CONCLUSION: We caution those who perform cervical length examinations to be wary of falsely reassuring findings due to potential anatomic and technical pitfalls.

    Title Atherosis Revisited: Current Concepts on the Pathophysiology of Implantation Site Disorders.
    Date April 1999
    Journal Obstetrical & Gynecological Survey
    Excerpt

    There are two distinct histological manifestations of impaired placental implantation in humans--incomplete trophoblastic vascular invasion and atherosis. Both have been described to occur in pregnancies affected by a variety of disorders such as preeclampsia, fetal growth restriction, systemic lupus erythematosus, and diabetes. Our purpose was to integrate recent developments in the understanding of implantation site disorders into a pathophysiological scenario that interrelates these placentation disorders and associated pregnancy complications. Sources were identified from a MEDLINE search of English-language articles published from 1966 to 1997. Additional sources were identified from references cited in relevant reports. We selected articles relating to the following topics: atherosis, implantation site disorders, trophoblastic invasion, preeclampsia, fetal growth restriction, implantation site development, atherosclerosis, and endothelial activation-damage. A contemporary version of normal placentation, including vascular adaptation, was reviewed with comments on normal trophoblastic differentiation and vascular invasion. Specific abnormalities of the implantation site, including atherosis and incomplete trophoblastic invasion, were discussed in the context of placental site hypoperfusion and the association with pregnancy complications. It was concluded that atherosis and incomplete trophoblastic invasion may be both a consequence and a cause of placental site hypoperfusion resulting in the development of preeclampsia and a variety of other pregnancy disorders.

    Title Birth Weight in Relation to Morbidity and Mortality Among Newborn Infants.
    Date April 1999
    Journal The New England Journal of Medicine
    Excerpt

    BACKGROUND: At any given gestational age, infants with low birth weight have relatively high morbidity and mortality. It is not known, however, whether there is a threshold weight below which morbidity and mortality are significantly greater, or whether that threshold varies with gestational age. METHODS: We analyzed the neonatal outcomes of death, five-minute Apgar score, umbilical-artery blood pH, and morbidity due to prematurity for all singleton infants delivered at Parkland Hospital, Dallas, between January 1, 1988, and August 31, 1996. A distribution of birth weights according to week of gestation at birth was created. Infants in the 26th through 75th percentiles for weight served as the reference group. Data on preterm infants (those born at 24 to 36 weeks of gestation) were analyzed separately from data on infants delivered at term (37 or more weeks of gestation). RESULTS: A total of 122,754 women and adolescents delivered singleton live infants without malformations between 24 and 43 weeks of gestation. Among the 12,317 preterm infants who were analyzed, there was no specific birth-weight percentile at which morbidity and mortality increased. Among 82,361 infants who were born at term and whose birth weights were at or below the 75th percentile, however, the rate of neonatal death increased from 0.03 percent in the reference group (26th through 75th percentile for weight) to 0.3 percent for those with birth weights at or below the 3rd percentile (P<0.001). The incidence of five-minute Apgar scores of 3 or less and umbilical-artery blood pH values of 7.0 or less was approximately doubled for infants at or below the 3rd birth-weight percentile (P=0.003 and P<0.001, respectively). The incidence of intubation at birth, seizures during the first day of life, and sepsis was also significantly increased among term infants with birth weights at or below the 3rd percentile. These differences persisted after adjustment for the mother's race and parity and the infant's sex. CONCLUSIONS: Mortality and morbidity are increased among infants born at term whose birth weights are at or below the 3rd percentile for their gestational age.

    Title Clinical Outcome of Mild Fetal Ventriculomegaly.
    Date September 1998
    Journal American Journal of Obstetrics and Gynecology
    Title Lack of Effect of Walking on Labor and Delivery.
    Date July 1998
    Journal The New England Journal of Medicine
    Excerpt

    BACKGROUND AND METHODS: Walking during labor may reduce patients' discomfort and improve outcomes. We conducted a randomized trial of walking during active labor to determine whether it altered the duration of labor or other maternal or fetal outcomes. Women with uncomplicated pregnancies between 36 and 41 weeks' gestation and in active labor were randomly assigned either to walking or to no walking (usual care). Pedometers were used to quantify walking, and the time spent walking was recorded. RESULTS: Of the 536 women assigned to the walking group, 380 actually walked. Their mean (+/-SD) walking time was 56+/-46 minutes. There were no significant differences between the women assigned to the walking group and the 531 women assigned to the usual-care group in the duration of the first stage of labor (6.1 hours in both groups, P=0.83), the need for labor augmentation with oxytocin (23 percent vs. 26 percent, P=0.25), and the use of analgesia (84 percent vs. 86 percent, P=0.59). Similarly, the percentages of women requiring delivery by forceps (4 percent vs. 3 percent, P=0.35) and cesarean section (4 percent vs. 6 percent, P=0.25) were not significantly different. These labor and delivery outcomes were unrelated to walking in both nulliparous and parous women. The infants' outcomes were also similar in the two study groups. CONCLUSIONS: Walking neither enhanced nor impaired active labor and was not harmful to the mothers or their infants.

    Title A Randomized Placebo-controlled Evaluation of Terbutaline for External Cephalic Version.
    Date November 1997
    Journal Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: To evaluate the efficacy of subcutaneous terbutaline therapy on the success rate of external cephalic version in term gestation. METHODS: Women with singleton noncephalic gestations were assigned randomly to receive either terbutaline (0.25 mg) or placebo. Physicians were blinded to the assignment. Fifteen to 30 minutes after the study drug was administered, external cephalic version was attempted. It was discontinued after three attempts, for patient discomfort, for fetal heart rate decelerations, or when successful. Patients were discharged home after the procedure and allowed to enter spontaneous labor. Primary outcomes evaluated included initial success of version, presentation in labor, and route of delivery. RESULTS: One hundred three women were enrolled in the study between January 1994 and June 1995, of whom 52 were assigned to terbutaline and 51 to placebo. External cephalic version was successful in 27 of 52 (52%) women receiving terbutaline compared with 14 of 51 (27%) of those receiving placebo (P = .019). This comparison yielded a relative risk (RR) of 1.9 (95% confidence interval [CI] 1.3, 6.5). Four of the 27 (15%) successful versions in the terbutaline group and three of the 14 (21%) successful versions in the placebo group spontaneously reverted to breech presentation. Ultimately, in labor there were 24 (46%) cephalic presentations in the terbutaline group and 13 (25%) in the placebo group (P = .048, RR 1.84, 95% CI 1.1, 5.8). Cesarean delivery rates were 11 of 41 (27%) for women with successful versions and 58 of 62 (94%) among those with failed versions (P < .001). CONCLUSION: Terbutaline (0.25 mg) administered subcutaneously before an attempted version in women at term with noncephalic presentations significantly increased the initial success rate of version and the rate of cephalic presentations in labor while decreasing the rate of cesarean delivery.

    Title The Developmental Outcome of Children with Antenatal Mild Isolated Ventriculomegaly.
    Date July 1997
    Journal Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: To evaluate standardized developmental test performance of infants and children who as fetuses had mild isolated cerebral ventriculomegaly diagnosed by ultrasound. METHODS: Ultrasound records from 1990 to 1996 were searched for cases of mild isolated ventriculomegaly, and standardized developmental testing of the children was offered to their parents. Each consented child was matched to a normal antepartum subject with respect to sex, race, indication for ultrasound, and gestational age (+/- 2 weeks) at the time of ultrasound. Tests of cognitive, motor, and adaptive behavior were then administered by examiners blinded to the subjects' case or comparison status. RESULTS: Twenty-two cases and an equal number of matched comparison subjects completed the testing. The ventriculomegaly and comparison groups were similar with respect to parental age, maternal education, and household income. The ventriculomegaly subjects scored significantly lower than the comparison group on both the Bayley Scales of Infant Development: mental development index (88.95 versus 99.68, P = .017) and psychomotor development index (95.99 versus 103.95, P = .039). Eight of the 22 ventriculomegaly children were classified as developmentally delayed on the mental developmental index compared with one of 22 children in the comparison group (P = .021). Adaptive behavior skills, as measured by the Vineland Behavior Scales (99.64 versus 102.68), were not significantly different between the groups (P = .571). CONCLUSION: Mild isolated ventriculomegaly detected on antepartum sonographic examination is associated with a significant risk for developmental delay. Insofar as these children were judged to be completely normal at birth, our findings represent an important application of antepartum sonography for identifying infants who could be targeted for early childhood intervention.

    Title A Prediction Rule for Community-acquired Pneumonia.
    Date June 1997
    Journal The New England Journal of Medicine
    Title Autosomal Dominantly Inherited Diamond-blackfan Anemia Resulting in Nonimmune Hydrops.
    Date June 1997
    Journal Obstetrics and Gynecology
    Excerpt

    BACKGROUND: Autosomal dominant inheritance of Diamond-Blackfan syndrome has been considered an uncommon occurrence. The onset of anemia is characteristically within the first year of life, with 10% of cases presenting at birth. Hydrops fetalis has been reported rarely. CASES: Two women with Diamond-Blackfan anemia had uncomplicated pregnancies without important exacerbation of their anemia. Each delivered an edematous infant affected with Diamond-Blackfan anemia, both of whom required immediate transfusions. One infant is currently 7 years old with transfusion-dependent Diamond-Blackfan anemia. The second infant died 2 days after birth; autopsy showed severe erythroid hypoplasia with absence of extramedullary hematopoiesis and placental villous edema. CONCLUSION: Diamond-Blackfan anemia may result in severe fetal anemia requiring transfusion. Among women with this disorder, a greater percentage than previously suspected are at risk for having an infant with substantial anemia in both the fetal and perinatal periods. Because the penetrance of the disorder is variable, pregnant women with a history of Diamond-Blackfan anemia should be considered at risk.

    Title The Maternal-fetal Transfer of Lamivudine in the Ex Vivo Human Placenta.
    Date March 1997
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: Our purpose was to measure the transfer of lamivudine ([-]-2'-deoxy-3'-thiacytidine) across the human placenta both alone and in the presence of zidovudine. STUDY DESIGN: Nine placentas from term, elective cesarean deliveries were analyzed with use of the ex vivo single cotyledon perfusion system. Antipyrine was used as the reference compound to measure the clearance index values of lamivudine alone and in combination with zidovudine. Lamivudine concentrations in the perfusates and tissues were quantified by high-pressure liquid chromatography. RESULTS: The clearance index of lamivudine at a maternal concentration of 1.39 micrograms/ml was 0.23 +/- 0.14. At a peak concentration of 14.68 micrograms/ml the clearance index was 0.14 +/- 0.06. These index values did not significantly change in the presence of 1 or 10 micrograms/ml of zidovudine. In a closed recirculating system the fetal lamivudine concentration increased as more lamivudine was added to the maternal perfusate. The addition of zidovudine did not influence this transfer. CONCLUSION: Lamivudine appears to cross the placenta by simple diffusion and its transfer does not appear to be altered by zidovudine.

    Title Ampicillin for Neonatal Group B Streptococcal Prophylaxis: How Rapidly Can Bactericidal Concentrations Be Achieved?
    Date December 1996
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: Our purpose was to determine how rapidly bactericidal concentrations of ampicillin against group B streptococci are achieved in amniotic fluid and cord blood after a 2 gm maternal infusion. STUDY DESIGN: Ampicillin was administered at varying time intervals between 3 and 67 minutes before elective cesarean delivery in 40 women. Samples of amniotic fluid were obtained by amniocentesis just before the uterine incision was made. Umbilical and maternal blood were obtained at the time of delivery. Ampicillin concentrations were measured by high-pressure liquid chromatography. RESULTS: The mean concentrations of ampicillin measured in maternal and umbilical cord sera all exceeded the minimum bactericidal concentrations reported for group B streptococci (0.25 to 2.0 micrograms/ml) and were achieved as soon as 5 minutes after ampicillin infusion. Similarly, bactericidal levels of ampicillin in the amniotic fluid could be detected as early as 5 minutes. However, such concentrations of ampicillin in the amniotic fluid were achieved in only 85% of the pregnancies studied. CONCLUSIONS: Bactericidal levels of ampicillin against group B streptococci can usually be achieved rapidly in both fetal blood and amniotic fluid after a standard 2 gm intravenous dose given to the mother for neonatal prophylaxis.

    Title Group and Family Treatment of Post-traumatic Stress Disorder.
    Date October 1994
    Journal The Psychiatric Clinics of North America
    Excerpt

    A central feature of PTSD is its effect on social relationships. Trauma affects groups of people, not just individuals. Family systems, neighborhoods, and even whole generations may feel the results of psychological trauma. Because of the social nature of the effects of trauma, post-trauma treatment must address an individual's relationship to others. Group and family psychotherapy are ideally suited to this and are important components of a multimodal approach to PTSD treatment. Group and family psychotherapies provide superb opportunities for social support, social reintegration, and interpersonal learning. As with any powerful technique, these methods must be carefully applied. Although not all patients are appropriate for exposure-based treatments, improved interpersonal coping skills will likely be beneficial to many PTSD patients. Patients should be carefully evaluated for treatment types and assessed for treatment response. Although group and family therapies currently provide relief and growth for PTSD patients, many considerations remain for the future. For example, how can patients be matched with various treatments for optimal results? How should acute and chronic PTSD treatments be similar and different? What is the effectiveness of group and family therapies for PTSD? What are the social and legal implications of a prolonged course of treatment for a victim whose children meanwhile are being traumatized by the parent's relatively poor parenting skills secondary to their inadequacies and disabilities? Finally, at a global level, how do we improve systems therapy technology to enable us more radically, effectively, and quickly to bring about total systems change? Because families and groups are the "cells" that compose the "vital organs" we call nations, and these nations in turn make the total body of humankind, the answers to these questions may have a significant determining effect on the future survival of us all.

    Title Hospital Turf Battles: the Manager's Role.
    Date December 1991
    Journal Hospital & Health Services Administration
    Title The Risks and Benefits of Low-dose Cotrimoxazole Prophylaxis for Pneumocystis Pneumonia in Renal Transplantation.
    Date April 1989
    Journal Transplantation
    Title Disseminated Gonococcemia in Plasma Cell Myeloma.
    Date August 1976
    Journal Minnesota Medicine
    Title Effects of Paracervical Blocks on the Fetus During Labor: a Prospective Study with the Use of Direct Fetal Monitoring.
    Date January 1973
    Journal American Journal of Obstetrics and Gynecology
    Title Clinical Experiences in Ultrasonic Scanning of Obstetrical Patients.
    Date August 1972
    Journal Wisconsin Medical Journal
    Title Phagocyte Dysfunction and Inflammatory Bowel Disease.
    Date
    Journal Inflammatory Bowel Diseases
    Excerpt

    Inflammatory bowel diseases are common chronic inflammatory disorders. The majority are idiopathic and can be broadly divided into Crohn's disease and ulcerative colitis. Their cause is unknown, but most hypotheses focus on a primary role for T-cell dysfunction. Conversely, there is a collection of congenital disorders of phagocyte function that result not only in immunodeficiency but also in noninfectious inflammatory bowel disease. In all cases, the latter is strikingly reminiscent of the clinical and pathological features of Crohn's disease. This coincides with recent work demonstrating that despite previous emphasis on adaptive immune dysfunction, patients with Crohn's disease actually possess an unusually weak acute innate inflammatory response. This review consolidates the literature on inflammatory bowel disease in congenital immunodeficiencies and considers the role of phagocyte dysfunction in Crohn's disease. Concepts about pathogenesis and treatment that can be carried across these disorders are also discussed.

    Title The Neutrophil Respiratory Burst and Bacterial Digestion in Crohn's Disease.
    Date
    Journal Digestive Diseases and Sciences
    Excerpt

    BACKGROUND: Neutrophils are a key part of the innate immune defence against microbes, using the respiratory burst (RB) to optimise killing and digestion. Previous studies of the neutrophil RB in Crohn's disease (CD) have yielded conflicting results. METHODS: Superoxide production in response to phorbol-myristyl acetate (PMA) was measured in neutrophils from 100 patients with CD compared to 50 healthy controls (HCs) and 50 patients with ulcerative colitis (UC). A further 22 CD and 10 HCs were studied using f-Met-Leu-Phe (fMLP), and digestion of E. coli by neutrophils was also evaluated. RESULTS: The mean ± SEM PMA-stimulated RB (nmol O(2)/10(6) cells/min) was 10.86 ± 0.26 in HCs, 9.76 ± 0.23 in CD (P=0.02) and 10.04 ± 0.28 in UC (P=0.09 vs HC and 0.47 vs CD). No significant effect of age, gender or medication was observed. The RB in three patients with presumed CD was found to be in the range expected in patients with inherited neutrophil disorders. Stimulation with fMLP was calcium dependent and attenuated in patients on 5-ASA. Digestion of E. coli by neutrophils was not different in HC vs CD (21.6 vs 20.53%, P=0.60). CONCLUSION: The significant reduction in neutrophil RB in CD does not appear to result in defective bacterial digestion and is therefore unlikely play a major role in pathogenesis. Three patients in this cohort of patients with presumed idiopathic CD were found to have a profound defect of the neutrophil RB. A high index of suspicion for such patients is prudent, as their prognosis can be improved by altering or augmenting the conventional treatment regimens employed for CD.

    Title Failed Labor Induction: Toward an Objective Diagnosis.
    Date
    Journal Obstetrics and Gynecology
    Excerpt

    To evaluate maternal and perinatal outcomes in women undergoing labor induction with an unfavorable cervix according to duration of oxytocin administration in the latent phase of labor after ruptured membranes.


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