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Obstetricians
Selected AbstractsIdentification and management of women with inherited bleeding disorders: a survey of obstetricians and gynaecologists in the United KingdomHAEMOPHILIA, Issue 4 2006C. CHI Summary., A mail survey of members and fellows of Royal College of Obstetricians and Gynaecologists was carried out to determine current practices of obstetricians and gynaecologists in the United Kingdom in the management of women with inherited bleeding disorders. In total, 3929 questionnaires were sent, 707 returned and analysis was limited to 545 valid questionnaires. In the past 5 years, 91% have managed women with inherited bleeding disorders. The majority (83%) considered inherited bleeding disorders to be under diagnosed in obstetrics and gynaecology. More than 80% considered the prevalence of von Willebrand's disease (VWD) to be <0.2% in the general population and <1% in women with menorrhagia and no gynaecological pathology, although the reported prevalence is 1% and 5,25% respectively. Twelve percent of the respondents would arrange testing for VWD when reviewing an 18-year-old with menorrhagia and no pelvic pathology, while only 2% would do the same for a 35-year-old with the same presentation. Twenty-one percent thought elective caesarean section is indicated in all fetuses known to be at risk of being affected by haemophilia. Eighty-four percent considered vacuum extraction unsafe in these cases, but 76% would consider the use of low forceps. In conclusion, obstetricians and gynaecologists underestimate inherited bleeding disorders as an underlying cause for menorrhagia. Increased awareness and management guidelines are essential in minimizing haemorrhagic complications and improving quality of care of these women. [source] Fetal thickened nuchal soft tissues may first appear in the second trimester in Down syndromeJOURNAL OF CLINICAL ULTRASOUND, Issue 2 2010Etan Z. Zimmer MD Abstract Purpose. To describe a series of cases of late-onset fetal nuchal translucency in Down syndrome. Method. In our practice area, most pregnant women usually undergo 3 different sonographic examinations: a fetal nuchal translucency examination in the 1st trimester and 2 detailed surveys of all fetal organs in the early 2nd trimester and in midpregnancy. Result. During the study period (2003,2008), we detected 11 fetuses with new appearance of severe thickened nuchal soft tissues (,6 mm) at 14,16 weeks' gestation after a normal nuchal screening in the 1st trimester. All of these fetuses had trisomy 21. Associated structural anomalies were observed in 10/11 of the cases. In addition, there were 12 fetuses with new appearance of thickened nuchal soft tissues (<4 mm); all these fetuses had a normal karyotype and were normal at delivery. Conclusion. Obstetricians should be aware that a nuchal abnormality may first appear only at 14,16 weeks' gestation. Fetal karyotyping is advocated in these cases because of the high probability of Down syndrome. © 2009 Wiley Periodicals, Inc. J Clin Ultrasound, 2010 [source] The 2008 National Institute of Child Health and Human Development Workshop Report on Electronic Fetal Monitoring: Update on Definitions, Interpretation, and Research GuidelinesJOURNAL OF OBSTETRIC, GYNECOLOGIC & NEONATAL NURSING, Issue 5 2008George A. Macones MD ABSTRACT In April 2008, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the American College of Obstetricians and Gynecologists, and the Society for Maternal-Fetal Medicine partnered to sponsor a 2-day workshop to revisit nomenclature, interpretation, and research recommendations for intrapartum electronic fetal heart rate monitoring. Participants included obstetric experts and representatives from relevant stakeholder groups and organizations. This article provides a summary of the discussions at the workshop. This includes a discussion of terminology and nomenclature for the description of fetal heart tracings and uterine contractions for use in clinical practice and research. A three-tier system for fetal heart rate tracing interpretation is also described. Lastly, prioritized topics for future research are provided. [source] Complications and myoma recurrence after laparoscopic uterine artery occlusion for symptomatic myomasJOURNAL OF OBSTETRICS AND GYNAECOLOGY RESEARCH (ELECTRONIC), Issue 1 2006Zdenek Holub Abstract Aim:, To determine the frequency and severity of complications and the recurrence of fibroids as a result of laparoscopic occlusion of the uterine artery (LOUA) in women with symptomatic fibroids. Methods:, One hundred and fourteen women with symptomatic fibroids were treated using ultrasonically activated shears, clips or electrosurgery. A retrospective evaluation of the complications and recurrence rate was carried out. For each patient, the analysis took place at least 3 months after the procedure was performed. Each complication was categorized using the complication classifications developed by the Czech Society of Gynecologic Endoscopy and a modified set of the classifications of the American College of Obstetricians and Gynecologists. All adverse events that occurred during the follow-up period were included, in addition to those that occurred after the 3 months minimum interval. Results:, A total of eight women (7.1%, 95% confidence intervals [CI], 3.3,14.4) experienced complications; one of these women had two complications, resulting in a total of nine adverse events. There were no intraoperative complications and no permanent injuries. Two women required supracervical hysterectomy and myomectomy, respectively, as a result of fibroid necrosis. One patient had an undiagnosed endometrial stromal sarcoma after 12 months of LOUA. The rate of fibroid recurrence was 9.0% (10 patients). The recurrence-free survival interval rate (no clinical failure, no recurrence) at 23.6 months (median) follow-up was 88.3% (CI 84.9,93.5). Conclusion:, The rate of complications and fibroid recurrence was low in patients undergoing LOUA. [source] Lipid peroxidation and vitamin E status in gestational diabetes mellitusJOURNAL OF OBSTETRICS AND GYNAECOLOGY RESEARCH (ELECTRONIC), Issue 5 2003Debjyoti Santra Abstract Aim: To investigate any correlation between plasma levels of lipid peroxides, antioxidant nutrient (,-tocopherol) and oxidized high-density lipoprotein (HDL) in patients with gestational diabetes and those with a normal pregnancy and the incidence of pre-eclampsia. Methods: Sixty pregnant women attending an antenatal clinic were recruited for the study and were divided into two groups. Thirty women with gestational diabetes mellitus were recruited in the study group. The glucose-tolerance-test criteria, using 100 g of glucose taken orally, as laid down by the American College of Obstetricians and Gynecologists (1994) for diagnosis of gestational diabetes mellitus was used. Thirty gestation-matched pregnant women with normal glucose tolerance test results were recruited as controls. A 10 mL venous blood sample was collected from each subject at the time of recruitment and thereafter at 4 week intervals until the time of delivery. Samples were analyzed for malondialdehyde thiobarbituric acid reactive, oxidized HDL-cholesterol and ,,tocopherol. The incidence of pre-eclampsia and its correlation with antioxidant and lipid peroxide levels were compared in both the groups. Results: Ten subjects out of 30 in the study group and three subjects out of 30 in the control group developed pre-eclampsia. The incidence of preterm labor in both the groups was same (16.66%). The mean lipid peroxide level was lower in the study group at recruitment and later the levels kept falling, whereas levels of ,,tocopherol and oxidized-HDL were higher in the study group and kept on rising at follow up. Conclusion: Gestational diabetes is not associated with increased levels of lipid peroxides and decreased levels of ,-tocopherol. [source] Screening Strategies for Group B Streptococcus in the Third Trimester of PregnancyJOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS, Issue 12 2002APRN-BC, FAANP, Lorna Schumann PhD Purpose To identify the best screening protocol to prevent neonatal group B streptococcal (GBS) sepsis through literature review. Data Sources Selected research articles, texts, and Internet sources. Conclusions Centers for Disease Control and Prevention (CDC), American Academy of Pediatrics (AAP), American College of Obstetricians and Gynecologists (ACOG), and American College of Nurse Midwives (ACNM) have issued guidelines describing methods to identify pregnant women at risk of intrapartum transmission of GBS to their babies. Studies have been conducted to discover the superiority of one prevention method over the other but no consensus has been reached. Implications for Practice Before widely used prevention methods, approximately 8,000 babies each year became infected with GBS; of those, 400 died and many survivors suffered life-long sequelae. Adoption of an appropriate protocol can prevent transmission of GBS from a colonized mother to her infant. Clinicians should implement either universal culture-based or risk factor-based screening guidelines for prenatal diagnosis and intrapartum prophylaxis of GBS disease. [source] Obesity and Pregnancy: Implications and Management Strategies for ProvidersMOUNT SINAI JOURNAL OF MEDICINE: A JOURNAL OF PERSONALIZED AND TRANSLATIONAL MEDICINE, Issue 6 2009Taraneh Shirazian MD Abstract Obesity in pregnancy (pregravid body mass ,30) has been linked to several adverse pregnancy outcomes, including spontaneous abortion, preeclampsia, gestational diabetes, fetal macrosomia, cesarean delivery, and wound complications post,cesarean section. Intrapartum and postpartum management of obese gravidas requires multidisciplinary consultations between obstetricians, anesthesiologists, nurses, and pediatricians in order to improve the pregnancy outcomes of the mother and neonate. The American College of Obstetricians and Gynecologists currently supports risk-reducing strategies for obese pregnant patients, including limiting weight gain to 15 lb (standardized by the Institute of Medicine). Interventions to reduce gestational weight gain may be important modifiable risk factors for maternal and fetal perinatal complications. Interventions have targeted modifications of diet and exercise with educational methods such as radio broadcasts, pamphlets, and counseling. Interventions have also focused on motivational methods, such as individual and group classes, and have been implemented both before conception and immediately after birth. Effective interventions appear to be individualized in approach, but there is a lack of data to support any specific model. Prospective interventional studies are needed to demonstrate the benefits of weight limitation on pregnancy outcomes. Mt Sinai J Med 76:539-545, 2009. © 2009 Mount Sinai School of Medicine [source] Commentary: The federal ,Prenatally and Postnatally Diagnosed Conditions Awareness Act'PRENATAL DIAGNOSIS, Issue 9 2009Philip R. Reilly Abstract The recently enacted federal law, the ,Prenatally and Postnatally Diagnosed Conditions Awareness Act' (United States Public Law 110,374) seeks to improve opportunities for parents and pregnant women to anticipate and understand the likely life course of children born with Down syndrome and other (unspecified) conditions. The law is in part a response to the continued growth of prenatal screening and testing. For example, the American College of Obstetricians and Gynecologists' Practice Bulletin 77 recommends that ,Screening and invasive diagnostic testing for aneuploidies be available to all women who present for prenatal care before 20 weeks of gestation regardless of maternal age.' Emerging technologies anticipate an era in which the scope of prenatal screening and testing will be much larger than it is today. Inevitably, more women will find themselves facing the hard question of whether to continue or end a pregnancy in which a fetus has been found to have a significant abnormality. While the new federal law is not likely to have a major impact on obstetric practice, it may be a harbinger of renewed wide-scale public debate concerning the ethics of prenatal screening. Copyright © 2009 John Wiley & Sons, Ltd. [source] A study investigating obstetricians' and gynaecologists' management of women requesting an intrauterine deviceAUSTRALIAN AND NEW ZEALAND JOURNAL OF OBSTETRICS AND GYNAECOLOGY, Issue 2 2010Kirsten I. BLACK Background:, Intrauterine methods including the copper intrauterine device (Cu-IUD) and the levonorgestrel intrauterine system (LNG-IUS) provide highly effective long-term reversible contraception. The reasons for relative low use of these methods in Australia compared to many European countries are not clear, but may in part relate to provider reluctance because of outdated knowledge about their safety and efficacy. Aims:, The aim of this study was to survey Australian Fellows of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists about their knowledge of the risks, benefits and mechanisms of action of intrauterine methods. Methods:, In 2008, we undertook a cross-sectional survey of all Australian Fellows not registered as a subspecialist. The survey was mailed to 1050 practitioners and 701 were returned, comprising a response rate of 67%. Results:, Knowledge about the LNG-IUS was significantly better than for the Cu-IUD in terms of correct understanding about mechanism of action (89.3% vs. 30%; P < 0.001) and efficacy (63.2% vs. 33.5%; P < 0.001). According to the WHO, both methods are considered suitable for use in nulliparous women, yet only 39.1% of providers believed the Cu-IUD suitable compared to 69.4% for the LNG-IUS (P < 0.001). When responses were analysed according to time from graduation, many aspects of knowledge about these devices showed a linear trend, with greater accuracy in recent graduates (<10 years) compared with graduates of more than 30 years. Conclusion:, Both methods are highly effective, non-user dependent and reversible and deserve greater understanding and consideration for use by Australian practitioners and women. [source] An Australian and New Zealand survey of practice of the use of oxytocin at elective caesarean sectionAUSTRALIAN AND NEW ZEALAND JOURNAL OF OBSTETRICS AND GYNAECOLOGY, Issue 1 2010Joanne C. MOCKLER Background:, The use of oxytocin to prevent postpartum haemorrhage at elective caesarean section is largely based on evidence derived from vaginal births. Overseas studies indicate wide variation in practice with regard to specific doses of oxytocin administered at caesarean section. No such surveys have been undertaken in Australia or New Zealand. Aims:, To survey and report Australian and New Zealand practice regarding oxytocin administration at elective caesarean section. Methods:, A structured questionnaire was posted to Fellows of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists resident in Australia and New Zealand. Results:, One thousand five hundred and forty-seven questionnaires were distributed, of which 890 (58%) were returned. Of these, 700 Fellows, 600 from Australia and 100 from New Zealand, currently practiced obstetrics. Almost all Fellows, 686 (98%), reported that they administered an oxytocin bolus at elective caesarean section, most commonly 10 IU (n = 460) or 5 IU (n = 220). The choice of bolus dose was related to country, duration and type (private or public) of practice. A majority of Fellows, 683 (98%), used an additional oxytocin infusion, either routinely or selectively. A total of 68 different regimens were reported. The single most common regimen was 40 IU oxytocin in 1000 mL administered over four hours, used by 255 Fellows (37%). Conclusions:, There are wide variations in the usage of oxytocin at elective caesarean section in Australia and New Zealand, most likely due to a lack of high level evidence to guide practice. Appropriately designed clinical trials are needed to provide evidence to support future practice. [source] Opinion: Integration of diagnostic and management perspectives for placenta accretaAUSTRALIAN AND NEW ZEALAND JOURNAL OF OBSTETRICS AND GYNAECOLOGY, Issue 6 2009Alec W. WELSH The 2007 New South Wales/Queensland Royal Australian and New Zealand College of Obstetricians and Gynaecologists Annual Scientific Meeting convened a panel to discuss multidisciplinary perspectives on the management of placenta accreta, percreta or increta. While it was anticipated that this panel would stimulate discussion, the cohesion between the approaches was underestimated. This document represents an integration of the perspectives of the invited speakers at this presentation, with backgrounds in maternal,fetal medicine, gynaecological oncology, radiology and general obstetrics and gynaecology. [source] Detection and management of decreased fetal movements in Australia and New Zealand: A survey of obstetric practiceAUSTRALIAN AND NEW ZEALAND JOURNAL OF OBSTETRICS AND GYNAECOLOGY, Issue 4 2009Vicki FLENADY Background:, Decreased fetal movement (DFM) is associated with increased risk of adverse pregnancy outcome. However, there is limited research to inform practice in the detection and management of DFM. Aims:, To identify current practices and views of obstetricians in Australia and New Zealand regarding DFM. Methods:, A postal survey of Fellows and Members, and obstetric trainees of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Results:, Of the 1700 surveys distributed, 1066 (63%) were returned, of these, 805 (76% of responders) were currently practising and included in the analysis. The majority considered that asking women about fetal movement should be a part of routine care. Sixty per cent reported maternal perception of DFM for 12 h was sufficient evidence of DFM and 77% DFM for 24 h. KICK charts were used routinely by 39%, increasing to 66% following an episode of DFM. Alarm limits varied, the most commonly reported was < 10 movements in 12 h (74%). Only 6% agreed with the internationally recommended definition of < 10 movements in two hours. Interventions for DFM varied, while 81% would routinely undertake a cardiotocograph, 20% would routinely perform ultrasound and 20% more frequent antenatal visits. Conclusions:, While monitoring fetal movement is an important part of antenatal care in Australia and New Zealand, variation in obstetric practice for DFM is evident. Large-scale randomised controlled trials are required to identify optimal screening and management options. In the interim, high quality clinical practice guidelines using the best available advice are needed to enhance consistency in practice including advice provided to women. [source] Participant evaluation of the RANZCOG Fetal Surveillance Education ProgramAUSTRALIAN AND NEW ZEALAND JOURNAL OF OBSTETRICS AND GYNAECOLOGY, Issue 3 2009Annie KROUSHEV After a ,needs assessment', in 2004 the Royal Australian and New Zealand College of Obstetricians and Gynaecologists developed and introduced the Fetal Surveillance Education Program (FSEP) to provide high quality education to all clinicians caring for labouring women in Australia and New Zealand. A formal evaluation of the program was planned from the inception of FSEP. We report here the participant feedback from the first 4439 participants in 2004,2006. Overall, FSEP was considered a high quality resource, rated equally well by midwives and obstetricians. This is the first large-scale evaluation to be reported for any fetal surveillance education program. [source] Gynaecologists blaze the trail in primary studies and systematic reviews of diagnostic test accuracyAUSTRALIAN AND NEW ZEALAND JOURNAL OF OBSTETRICS AND GYNAECOLOGY, Issue 1 2009Neil Philip JOHNSON As the Cochrane Collaboration is poised to begin publishing systematic reviews of diagnostic test accuracy studies in addition to its traditional systematic reviews of treatment effectiveness, we are likely to see a major expansion in the number of primary studies and systematic reviews of diagnostic test accuracy in the medical literature. Obstetricians and gynaecologists have played an important role in initiating this newer area of research. However, the methodology for such studies is challenging and the published literature is riddled with pitfalls. This editorial seeks to simplify the concepts involved in diagnostic test accuracy studies and systematic reviews, to reflect on the early development of this research in our specialty and to envision the future pathway for screening and diagnostic research. [source] Survey of surgical skills of RANZCOG traineesAUSTRALIAN AND NEW ZEALAND JOURNAL OF OBSTETRICS AND GYNAECOLOGY, Issue 1 2009Andreas OBERMAIR Background: In Australia, the Integrated Training Program (ITP) of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) offers training in obstetrics and gynaecology. There is anecdotal concern among trainees and Fellows that the surgical component of training is inadequate, with new specialists lacking the confidence and competence to perform many ,standard' surgical procedures. These concerns have not previously been quantified in Australia and New Zealand. Aim: To determine trainees' subjective competence and confidence with surgical procedures and trainees' satisfaction with their surgical training. Methods: All 430 active RANZCOG trainees and 108 Fellows elevated within the previous two years were invited to complete a self-administered questionnaire (65% response rate), which assessed details of procedures performed and confidence to perform them; satisfaction with the surgical training; and perceived teaching ability of the supervising consultants. Results: Those in ITP year 6 rated their confidence high (, 4 of 5) for procedures performed very frequently, but lower for other procedures. No procedure regarding the management of complications reached a confidence score of , 4. Teaching abilities were rated best for obstetric procedures, with 54% rating their consultants' teaching ability as ,excellent'; but for laparoscopic procedures and procedures dealing with complications, 21.2% and 23.4% of respondents rated their consultants' teaching ability as ,poor', respectively. Conclusions: Advanced trainees lacked confidence in a range of surgical procedures; and possible weaker areas were identified in the teaching experience of trainers. These limitations must be addressed by medical educators and training program coordinators. [source] The importance of chlamydial infections in obstetrics and gynaecology: An updateAUSTRALIAN AND NEW ZEALAND JOURNAL OF OBSTETRICS AND GYNAECOLOGY, Issue 1 2007Marian J. CURRIE Abstract Chlamydia is now the most common notifiable infectious disease in many countries, a fact that has serious ramifications for the reproductive health of women. This review highlights the epidemiology, pathophysiology, clinical features and reproductive sequelae of the infection. Current screening and management methods are outlined. Obstetricians and gynaecologists are ideally placed to play a major role in the primary prevention of this significant sexually transmitted infection. [source] Coat of arms of The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)AUSTRALIAN AND NEW ZEALAND JOURNAL OF OBSTETRICS AND GYNAECOLOGY, Issue 1 2005Rosalind WINSPEAR No abstract is available for this article. [source] Vaginal birth after Caesarean section: A survey of practice in Australia and New ZealandAUSTRALIAN AND NEW ZEALAND JOURNAL OF OBSTETRICS AND GYNAECOLOGY, Issue 3 2003Jodie Dodd Abstract Aims: Women with a single prior Caesarean section (CS) in a subsequent pregnancy will be offered either a planned elective repeat CS or vaginal birth after Caesarean (VBAC). Recent reports of VBAC have highlighted risks of increased morbidity, including uterine rupture, and adverse infant outcome. A survey of practice was sent to fellows and members of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists to determine current care for women in a subsequent pregnancy with a single prior CS, and to assess variations by length and type of obstetric practice. Methods: Questions asked about the safety of VBAC, induction of labour with a uterine scar, and requirements to conduct VBAC and elective repeat CS. Results: A total of 1641 surveys were distributed, with 1091 (67%) returned, 844 from practicing obstetricians (51% of college membership). Almost all respondents (96%) agreed or strongly agreed that VBAC should be presented as an option to the woman, varying from 90% where the indication for primary CS was breech, 88% for fetal distress, and 55% for failure to progress. Forty percent of respondents agreed or strongly agreed that VBAC was the safest option for the woman, and associated with fewer risks than CS. In contrast, 44% of respondents disagreed or strongly disagreed that VBAC was the safest option for the infant, and opinions varied as to whether risks of VBAC outweighed those of CS for the infant. Almost two-thirds of practitioners would offer induction of labour to a woman with a prior CS in a subsequent pregnancy, one-third indicating a willingness to use vaginal prostaglandins, and 77% syntocinon. Most respondents preferred to conduct VBAC in a level two or three hospital (86%); required the availability within 30 min of an anaesthetist (81%), a neonatologist (84%), and operating theatre (97%); recommended continuous electronic fetal heart rate monitoring (86%); intravenous access (90%); and routine group and hold (79%) during labour. For an elective repeat CS, most practitioners request routine blood for group and hold (78%), a neonatologist in theatre (77%), the use of an in-dwelling urinary catheter (96%), and the use of intraoperative antibiotics (82%). Conclusions: Most obstetricians indicated VBAC to be the safest option for the woman, but were less certain about benefits and risks for the infant. The consensus of practice is to present VBAC as an option and induce labour if needed. Vaginal birth after Caesarean is preferred in a level two or three hospital, with an anaesthetist, neonatologist and operating theatre available within 30 min. The use of continuous electronic fetal heart rate monitoring and intravenous access are recommended. In planned CS, a neonatologist in theatre is preferred, and an in-dwelling urinary catheter and intraoperative antibiotics will be used. [source] Survival and toxicity differences between 5-day and weekly cisplatin in patients with locally advanced cervical cancerCANCER, Issue 1 2007Mark H. Einstein MD Abstract BACKGROUND. Cisplatin (CDDP) administration concomitant with radiotherapy (RT) for the treatment of locally advanced cervical cancer has evolved from an inpatient 5-day every 21-day regimen to a weekly outpatient regimen. This study was designed to test for differences in progression-free survival (PFS) and toxicity between the 2 regimens. METHODS. In all, 77 consecutive patients at a single institution with stage IB2-IV cervical cancer were included in this analysis (using the International Federation of Gynecologists and Obstetricians staging system). All patients were treated with CDDP, external beam RT, and 2 9-Gy high-dose-rate brachytherapy treatments. Two cohorts were compared: 1) 5-day, patients treated from 1995 to 2001 with CDDP 20 mg/m2 × 5 days every 21 days concomitant with RT; 2) weekly, treated after May 2001 with CDDP 40 mg/m2 weekly concomitant with RT. RESULTS. In all, 50 patients were treated with the 5-day regimen and 27 patients with the weekly regimen. There were no significant demographic differences between the groups. Overall 3-year PFS, controlling for stage, was 90% and 76% for 5-day and weekly groups, respectively (P = .01). Adjusting for stage, age, and completion of treatment, the risk of treatment failure among the weekly group was 3.46 times higher than the 5-day group (P = .02). The weekly group had a 3.43 times higher risk of developing acute toxicities than the 5-day group (P = .02) in advanced-stage patients. CONCLUSIONS. Patients who received weekly CDDP have a shorter 3-year PFS. Patients with advanced-stage cervical cancer who received weekly CDDP had significantly more acute toxicities. These data should be confirmed in a multiinstitutional, randomized, controlled study. Cancer 2007. © 2006 American Cancer Society. [source] Resuscitation at the limits of viability , an Irish perspectiveACTA PAEDIATRICA, Issue 9 2009RA Khan Abstract Background:, Advances in neonatal care continue to lower the limit of viability. Decision making in this grey zone remains a challenging process. Objective:, To explore the opinions of healthcare providers on resuscitation and outcome in the less than 28-week preterm newborn. Design/Methods:, An anonymous postal questionnaire was sent to health care providers working in maternity units in the Republic of Ireland. Questions related to neonatal management of the extreme preterm infant, and estimated survival and long-term outcome. Results:, The response rate was 55% (74% obstetricians and 70% neonatologists). Less than 1% would advocate resuscitation at 22 weeks, 10% of health care providers advocate resuscitation at 23 weeks gestation, 80% of all health care providers would resuscitate at 24 weeks gestation. 20% of all health care providers would advocate cessation of resuscitation efforts on 22,25 weeks gestation at 5 min of age. 65% of Neonatologists and 54% trainees in Paediatrics would cease resuscitation at 10 min of age. Obstetricians were more pessimistic about survival and long term outcome in newborns delivered between 23 and 27 weeks when compared with neonatologists. This difference was also observed in trainees in paediatrics and obstetrics. Conclusion:, Neonatologists, trainees in paediatrics and neonatal nurses are generally more optimistic about outcome than their counterparts in obstetrical care and this is reflected in a greater willingness to provide resuscitation efforts at the limits of viability. [source] Interdisciplinary surveillance of intraventricular haemorrhage associated conditions in infants <1000 gACTA PAEDIATRICA, Issue 6 2008Michael Obladen Abstract Aim: Intraventricular haemorrhage (IVH) causes some of the most adverse outcomes in infants with birthweight <1000 g. Incomplete antenatal steroids, acidosis, inflammation, postnatal transfer, delayed surfactant administration, hypothermia, hypotension, hypocapnia, persistent ductus arteriosus and pneumothorax are all associated with IVH. We hypothesized that prospective surveillance of these IVH-associated conditions decreases their frequency and thus the frequency of IVH. Methods: Cranial ultrasound was performed on days 1, 3, 7, 30 after birth and at discharge, and was assessed according to Papile. The incidence of IVH and IVH-associated conditions was monitored prospectively in all infants <1000 g born in our perinatal centre in 2005/2006, and obstetricians and neonatologists held monthly interdisciplinary review conferences to discuss the preventability of IVH-associated conditions (IVH surveillance). These data were compared to existing prospective data gathered during routine monitoring in 2004. Results: IVH (all grades) occurred in 29/86 extremely low birthweight (ELBW) infants during routine monitoring and in 12/89 ELBW infants during IVH surveillance (p = 0.007). IVH grades 3,4 dropped from 20% to 3.4% (p = 0.0006). There were significant differences in completeness of antenatal steroids (54% vs. 67%, p = 0.04) and timeliness in initial surfactant substitution (45% vs. 71%, p = 0.01). Most other IVH-associated conditions were reduced during IVH surveillance without reaching significance. Conclusions: IVH is not always an inevitable disaster. Obstetricians and neonatologists can reduce its incidence by joint prospective surveillance of IVH-associated conditions. [source] First-trimester sonography: Is the fetus exposed to high levels of acoustic energy?,JOURNAL OF CLINICAL ULTRASOUND, Issue 5 2007Eyal Sheiner MD Abstract Purpose. As a form of energy, diagnostic ultrasound has bioeffects on living tissues. The thermal index (TI), TIS (TI for soft tissue), TIB (TI for bone), TIC (TI for cranial bone) expresses the potential for rise in temperature at the ultrasound beam's focal point. The mechanical index (MI) indicates the potential for the ultrasound beam to induce inertial cavitation in tissues. The goal of this study was to characterize the acoustic output of clinical ultrasound instruments, as expressed by TI and MI, during routine first-trimester sonographic examinations. Methods. A prospective observational study was conducted. First-trimester patients were randomly selected from those scheduled for viability scans. An obstetrician collected data. Sonographers were blinded to the data being sought, which included gestational age, duration of the examination, and every variation in the MI and TI during each sonographic examination. Results. A total of 52 first-trimester examinations were evaluated. The mean gestational age was 8.9 ± 1.9 weeks. The mean duration of the sonographic examinations was 8.1± 1.4 minutes. During the examinations, there were 178 MI variations (mean ± SD, 0.9 ± 0.3) and 167 TI variations (mean ± SD, 0.2 ± 0.1). Conclusion. First-trimester sonographic examinations are associated with a negligible rise in TI. © 2007 Wiley Periodicals, Inc. J Clin Ultrasound, 2007 [source] Circulatory arrest in late pregnancy: caesarean section a vital decision for both mother and childACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 6 2009H. J. ZDOLSEK Circulatory arrest during pregnancy is extremely rare and there should be a well-planned strategy for its management in all hospitals. To consider the priority of the mother's life over the child's and an unwarranted pre-term delivery may lead to hesitancy and uncertainty and jeopardize both of them. In these situations, speed is a priority. Cardiopulmonary resuscitation should commence immediately. The anaesthesiologist should be well aware of the possible advantage of a caesarean section. Even if the obstetrician is responsible for the decision to perform the operation, the anaesthesiologist should strongly support the action. An ,emergency caesarean kit' with the essential surgical instruments should be immediately available in every labour ward and emergency department. [source] Determination of sensitivity and specificity of breast tumor diagnosis by primary health care providers (Behvarz) using clinical examination by obstetrician as a gold standardJOURNAL OF OBSTETRICS AND GYNAECOLOGY RESEARCH (ELECTRONIC), Issue 2 2003Tayebeh Naderi Abstract Aim:, The aim of this study was to find a practical screening strategy to detect breast tumors in those who cannot refer to specialists due to problems, such as geographic location, and economical obstacles. Methods:, Considering the mentioned aim this study was designed to compare the sensitivity and specificity of diagnosis of breast tumors made by health care providers (Behvarz) with those made by specialists. For this, the results of examinations of Behvarzes and an obstetrician on 2000 women referring to the 17 health care centers of Kerman and Zarand cities were compared. Results:, Among the 2000 women examined by Behvarzes 170 cases were reported to have pathological signs (palpable mass) and 1830 cases were reported without any pathological sign. Among 169 cases diagnosed by physicians as having pathological signs, 162 cases had also been diagnosed by Behvarzes, and there were only seven cases diagnosed by physicians that had been missed by Behvarzes. There were eight cases diagnosed by Behvarzes as having pathological signs that were reported healthy by physicians. Conclusions:, Based on these findings, the sensitivity and specificity of diagnosis of breast tumors made by Behvarzes was 95.8% and 99.56%, respectively, compared with those made by specialists. Considering the obtained results, the screening program for breast tumors by Behvarzes can be very helpful in early diagnosis of breast tumors. [source] Free tissue transfer in pregnancy: Guidelines for perioperative managementMICROSURGERY, Issue 5 2001G. Robert Meger M.D. A successful free tissue transfer of serratus anterior muscle, to provide coverage for an open ankle defect in a pregnant patient, is described. Microvascular surgery in the presence of a viable pregnancy demands considerations unique to this situation. Although rarely possible, an attempt should be made to plan surgery to coincide with the second trimester, to lessen the risk of anesthesia to the fetus. Maternal positioning, fluid balance, and aspiration precautions need to be critically addressed. Close perioperative monitoring by an obstetrician is essential. The condition of pregnancy results in a hypercoagulable state that may lead to an increased risk of anastomotic failure. The use of anticoagulants results in increased risk of bleeding, not only for the patient but also for the fetus, as well as risk of teratogenic effects. Closely monitored heparin is considered safe in pregnancy as is low-molecular-weight dextran and low-dose aspirin. Additional considerations include the use of narcotics and sedatives for comfort postoperatively, as well as antibiotic choices, if indicated. © 2001 Wiley-Liss, Inc. Microsurgery 21:202,207 2001 [source] The effect of the obstetrician group and epidural analgesia on the risk for cesarean delivery in nulliparous womenACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 8 2000Y. Beilin Background: The effects of regional anesthesia and of the obstetrician on the risk of cesarean delivery remain controversial. The purpose of this study was to determine whether epidural analgesia or the obstetrician group is associated with an increase in the risk for cesarean delivery in nulliparous women. Methods: Data were collected for a two-year period from the medical records of all nulliparous women who had a private obstetrician who delivered >20 babies per year, and who presented with a singleton gestation in the vertex presentation for a trial of labor. Results: Data were collected for 3699 women of whom 1832 were nulliparous. Of the 1832 nulliparous women, data were analyzed for the 1278 women who met our study criteria, representing 14 separate obstetrician groups. Excluding the 50 women whose babies were delivered for fetal distress (leaving 1228 women for analysis), the epidural rate was 93%, range 81,98%, and the cesarean delivery rate was 14%, range 8,34%. Logistic regression analyses revealed that (odds ratio, 95% confidence interval) patient age (1.7, 1.2,2.4), birth weight (1.001, 1.001,1.002), induction of labor (1.9, 1.3,2.7), non-Caucasian (1.9, 1.2,2.9) and the obstetrician group, (P=0.002), were independently associated with the risk of cesarean delivery, but epidural analgesia was not (1.6, 0.7,3.6). Conclusions: The obstetrician group is independently associated with the risk of cesarean delivery in nulliparous women, but we could not demonstrate this association with epidural analgesia. We suggest that in future studies regarding epidural analgesia and cesarean delivery, the obstetrician group should be included as a variable ( ,). [source] Anonymous non-response analysis in the ABCD cohort study enabled by probabilistic record linkagePAEDIATRIC & PERINATAL EPIDEMIOLOGY, Issue 3 2009M. Tromp Summary Selective non-response is an important threat to study validity as it can lead to selection bias. The Amsterdam Born Children and their Development study (ABCD-study) is a large cohort study addressing the relationship between life style, psychological conditions, nutrition and sociodemographic background of pregnant women and their children's health. Possible selective non-response and selection bias in the ABCD-study were analysed using national perinatal registry data. ABCD-study data were linked with national perinatal registry data by probabilistic medical record linkage techniques. Differences in the prevalence of relevant risk factors (sociodemographic and care-related factors) and birth outcomes between respondents and non-respondents were tested using Pearson chi-squared tests. Selection bias (i.e. bias in the association between risk factors and specific outcomes) was analysed by regression analysis with and without adjustment for participation status. The ABCD non-respondents were significantly younger, more often non-western, and more often multiparae. Non-respondents entered antenatal care later, were more often under supervision of an obstetrician and had a spontaneous delivery more often. Non-response however, was not significantly associated with preterm birth (odds ratio 1.10; 95% CI 0.93, 1.29) or low birthweight (odds ratio 1.16; 95% CI 0.98, 1.37) after adjustment for sociodemographic risk factors. The associations found between risk factors and adverse pregnancy outcomes were similar for respondents and non-respondents. Anonymised record linkage of cohort study data with national registry data indicated that selective non-response was present in the ABCD-study, but selection bias was acceptably low and did not influence the main study questions. [source] Posterior fossa malformation in fetuses: a report of 56 further cases and a review of the literaturePRENATAL DIAGNOSIS, Issue 6 2007F. Forzano Abstract Objective The purposes of this study were to determine the outcome of fetuses diagnosed as having a posterior fossa abnormality (PFA) and to find out if there are associated features helpful in determining the prognosis. Methods This is a retrospective study of all posterior fossa abnormalities detected prenatally in our Units within the last 10 years. Fifty six patients were selected. Outcome data was collected from the Clinical Genetics Department records and the attending obstetrician or pediatrician. Results An enlarged cisterna magna (ECM, diameter greater than 10 mm at 18,23 gw) was detected in 22 fetuses, which was isolated in 14 cases. All the patients followed-up (n = 11) with isolated ECM were normal at birth (100%). Non-isolated ECM was present in 8 cases. Further information was available in 7, 5 (71%) of whom had a poor outcome. A Dandy Walker complex abnormality (DWC) was detected in 34 patients. The majority of them had a poor prognosis, 54% if isolated and 84% if non-isolated. Conclusions Isolated ECM detected on prenatal scans has a favourable outcome, while DWC is associated with a very high chance of a poor prognosis. Copyright © 2007 John Wiley & Sons, Ltd. [source] Persistent Genital and Pelvic Pain after ChildbirthTHE JOURNAL OF SEXUAL MEDICINE, Issue 1 2009Laurel Q.P. Paterson BA ABSTRACT Introduction., Although genital pain and pelvic pain are common and well-documented problems in the early postpartum period, little is known about their course. The few published studies of such pain beyond 1 year postpartum have focused primarily on the perineum and have not assessed pain onset. Aim., To investigate the prevalence and characteristics of all types of genital and pelvic pain in the second year postpartum, and to explore risk factors for their persistence. Methods., Over a 6-month period, a questionnaire on genital/pelvic pain, sociodemographic and childbirth variables, breastfeeding, and chronic pain history was mailed to patients of the collaborating obstetrician at 12 months postpartum. Main Outcome Measures., The prevalence, characteristics, and correlates of persistent genital/pelvic pain with postpartum onset. Results., Almost half of the 114 participants (82% response rate; M = 14 months postpartum) reported a current (18%) or resolved (26%) episode of genital or pelvic pain lasting 3 or more months. Just under one in 10 (9%) mothers continued to experience pain that had begun after they last gave birth. This pain was described at various locations (e.g., vaginal opening and pelvic area), as moderate in intensity and unpleasantness, and most often as burning, cutting, or radiating. Although it was triggered by both sexual and nonsexual activities, none of the mothers affected were receiving treatment. Univariate analyses revealed that only past diagnosis with a nongenital chronic pain condition (e.g., migraine headache) was significantly correlated with (i) any history of chronic genital/pelvic pain or (ii) the persistence of pregnancy- or postpartum-onset genital or pelvic pain. Conclusions., Postpartum genital and pelvic pain persists for longer than a year for a significant percentage of mothers. Women with a history of other chronic pain appear to be particularly vulnerable to developing persistent genital or pelvic pain. Paterson LQP, Davis SNP, Khalifé S, Amsel R, and Binik YM. Persistent genital and pelvic pain after childbirth. J Sex Med 2009;6:215,221. [source] Postnatal testing for diabetes in Australian women following gestational diabetes mellitusAUSTRALIAN AND NEW ZEALAND JOURNAL OF OBSTETRICS AND GYNAECOLOGY, Issue 5 2009Melinda K. MORRISON Background:, Postnatal blood glucose testing is recommended for reclassification of glucose tolerance following a pregnancy affected by gestational diabetes mellitus (GDM); however, there are limited data on the postnatal follow-up sought by Australian women. Aims:, To describe postnatal diabetes testing patterns in Australian women following a pregnancy affected by GDM and identify factors associated with return for follow-up testing in accordance with the Australasian Diabetes in Pregnancy Society (ADIPS) guidelines. Methods:, A cross-sectional self-administered survey of 1372 women diagnosed with GDM between 2003 and 2005, sampled from the National Diabetes Services Scheme database. Results:, Postnatal diabetes testing was reported by 73.2% of survey respondents with 27.4% returning for an oral glucose test tolerance at six to eight weeks post-GDM pregnancy. Using logistic regression analysis, factors associated with appropriate postnatal testing were receiving individualised risk reduction advice (odds ratio (OR) 1.41 (1.08,1.84)) or written information (OR 1.35 (1.03,1.76)) and in two-way interactions, being under the care of an endocrinologist and not tertiary educated (OR 2.09 (1.49,2.93)) as well as seeing an obstetrician and diabetes educator during pregnancy (OR 1.72 (1.19,2.48)). Every five years increase in age reduced the likelihood of a woman returning for testing by 17%. Conclusions:, Specialist diabetes care in non-tertiary educated women, or a team approach to management with diabetes education and obstetric care may act to reinforce the need for postnatal diabetes testing in accordance with the ADIPS guidelines. Individualised follow up from a health professional and provision of written information following a GDM pregnancy may also encourage return for postnatal testing in this high-risk group. [source] | ||||||||||||||||||||||||||||