Faculty Bibliography

OBJECTIVE: To report the obstetrical results following vaginal radical trachelectomy (VRT), a fertility-preserving surgery in the treatment of early-stage cervical cancer. METHODS: Retrospective review of our first 72 patients treated by a laparoscopic pelvic lymphadenectomy followed by a VRT from October 1991 to October 2003 with regards to their reproductive function. RESULTS: Patients' median age was 32 years old (21-42) and 53 (74%) were nulligravida. A total of 50 pregnancies occurred in 31 women. The majority (66%) had only one pregnancy, 19% had 2 pregnancies and 16% had 3 pregnancies or more. The rate of first trimester miscarriage was 16%, the rate of second trimester miscarriage was (4%) and 2 women (4%) elected to have pregnancy termination. A total of 36 pregnancies (72%) reached the third trimester. Of those, 3 (8%) ended prematurely at <32 weeks gestation, 5 (14%) delivered between 32 and 36 weeks and 28 (78%) delivered at term (>37 weeks). One newborn died of neonatal sepsis from E. coli infection and one died from cardiac malformation (trisomy-18). Seven patients (10%) had infertility problems: 3 from ovulatory causes of which 2 successfully conceived with IVF, one from endometriosis and low sperm count and 3 from probable cervical cause of which one conceived with IUI. One patient had a twin pregnancy following IVF and elected to have embryo reduction and subsequently delivered at 37 weeks. CONCLUSION: Based on our experience, the obstetrical results following VRT for early-stage cervical cancer are very encouraging. The majority of women can anticipate to conceive spontaneously and deliver near term.

OBJECTIVE: To assess the use of the Friedman labor curve as a predictor of operative delivery in macrosomic pregnancies. STUDY DESIGN: Medical records of 1141 patients who had delivered babies > or =4000 gm (group 1) were reviewed and were compared with the results of the next mother who delivered a neonate with birth weight <4000 gm (group 2). The variables studied were progress of labor as denoted on the Friedman curve, oxytocin use, and need for operative delivery. RESULTS: In the 1141 patients with neonatal birth weights > or =4000 gm, there was a trend toward a longer second stage, arrest disorder, and operative delivery but this did not reach statistical significance. CONCLUSION: Abnormalities in the Friedman curve were not useful as a predictor for operative delivery in pregnancies complicated by fetal macrosomia. There were no statistically significant differences between the two groups in terms of the variables studied

Maternal drug use during pregnancy may result in neonatal withdrawal. This statement presents current information about the clinical presentation, differential diagnosis, therapeutic options, and outcome for the offspring associated with intrauterine drug exposure.

This statement provides current recommendations about the use of emergency drugs for acute pediatric problems that require pharmacologic intervention. At each clinical setting, physicians and other providers should evaluate drug, equipment, and training needs. The information provided here is not all-inclusive and is not intended to be appropriate to every health care setting. When possible, dosage recommendations are consistent with those in standard references, such as the Advanced Pediatric Life Support (APLS) and Pediatric Advanced Life Support (PALS) textbooks.(1-3) Additional guidance is available in the manual Emergency Medical Services for Children: The Role of the Primary Cave Provider, published by the American Academy of Pediatrics, as well as in the PALS and APLS textbooks.

PROBLEM: To assess the usefulness of amniotic fluid (AF) granulocyte colony-stimulating factor levels (G-CSF) in chorioamnionitis (CAM) to predict neonatal sepsis. METHOD OF STUDY: AF samples were obtained from term and preterm patients with (Group I) and without (Group II) CAM and were assayed for G-CSF levels. Patients with other infections were excluded. All AF samples were also tested for gram stain and cultures. The sensitivity, specificity, and predictive values of these parameters for diagnosing neonatal sepsis were assessed. RESULTS: Positive AF cultures were the best predictors of neonatal sepsis in CAM, with a sensitivity of 67% and a positive predictive value (PPV) of 80%. Elevated AF G-CSF levels (> 1,000 pg/ml) were poor predictors of neonatal sepsis with a sensitivity of 29% and PPV of 39%. CONCLUSION: Even though AF G-CSF levels were markedly elevated in patients with CAM, they were poor predictors of subsequent neonatal sepsis

PROBLEM: To assess the usefulness of amniotic fluid (AF) granulocyte colony stimulating factor (G-CSF) levels as a rapid marker for diagnosing chorioamnionitis. METHOD OF STUDY: AF levels were obtained from term and preterm patients with and without chorioamnionitis (CAM). Patients with urinary tract, respiratory tract, and other infections were excluded. Results obtained from the AF G-CSF assays were compared with those from other parameters used for diagnosing CAM: maternal fever, leukocytosis, tachycardia, fetal tachycardia, AF glucose levels, white blood cell count, Gram stain, and aerobic and anaerobic cultures. The sensitivity, specificity, and predictive values were calculated. RESULTS: In the uninfected AF samples, G-CSF levels were present but low, ranging from 400 to 1600 pg/ml. Levels in the infected samples, however, were markedly increased, ranging from 1600 to 14,000 pg/ml; P < 0.05. When a cutoff of 2000 pg/ml was used as a clear marker for CAM, the sensitivity was 67%, the specificity was 100%, and the positive and negative predictive values were 100% and 86%, respectively. The comparison of the other AF G-CSF laboratory parameters also revealed high sensitivity, specificity, and predictive values for detecting CAM. CONCLUSION: (i) AF G-CSF levels are elevated in CAM. (ii) An AF G-CSF level > 2000 pg/ ml is a strong positive predictor of CAM. (iii) Elevated AF G-CSF levels appear to be more reliable in predicting CAM than any other single test currently used in clinical practice