Search

Abstract: The female athlete triad (FAT) is defined by the American College of Sports Medicine (ACSM) as low energy availability (low EA), functional hypothalamic amenorrhoea and osteoporosis. In low EA, lutein dysfunction first develops, followed by anovulation and, subsequently, oligomenorrhea, leading to amenorrhea. Moreover, low estradiol concentrations due to amenorrhea decrease bone mineral density (BMD). In athletes with one of the factors of FAT, the risk of a stress fracture is 2.4–4.9 times higher and may increase the risk of fracture throughout the lifespan. Low EA is the starting point of FAT, and the FAT concept emphasizes the importance of energy intake that is commensurate with exercise energy expenditure in athletes. In amenorrheic athletes who undergo gynecological examination, it is important to appropriately evaluate whether the cause is low EA and to review exercise energy expenditure and energy intake. It remains difficult even for experts to calculate available energy using the ACSM definition formula when evaluating energy deficiency. Moreover, performing early FAT screening during teenage years and cooperation between the department of obstetrics and gynecology and sports dietitians are also issues. The aim of this paper is to review the management of FAT from the viewpoint of gynecologists. [ABSTRACT FROM AUTHOR]

Objective: This paper examines the frequency with which a set of life-saving interventions or signal functions was performed to treat major obstetric complications.Methods and Results: The basic signal functions include parenteral antibiotics, anticonvulsants and oxytocics, and the procedures of manual removal of the placenta, removal of retained uterine products, and assisted vaginal delivery. Comprehensive functions include the six basic functions, cesarean delivery, and blood transfusions. Data from 1906 health facilities in 13 countries indicate that the most likely functions to be reported are oxytocics and antibiotics. The basic function least likely to be reported is assisted vaginal delivery. Many of the facilities surveyed did not have the infrastructure to perform operations or provide blood transfusions.Conclusions: These data can help governments allocate their budgets appropriately, help policy makers and planners identify systemic bottlenecks and prioritize solutions. Monitoring the performance of the functions informs us of the capacity of the health system to provide key interventions when obstetric emergencies occur. [ABSTRACT FROM AUTHOR]

Background: Several key policy documents have advocated 24-hour consultant obstetrician presence on the labour ward as a means of improving the safety of birth. However, it is unclear what published evidence exists comparing the outcomes of intrapartum care with 24-hour consultant labour ward presence and other models of consultant cover.Objectives: To collate and critically appraise evidence of the effect of continuous resident consultant obstetrician cover on the labour ward on outcomes of intrapartum care compared with other models of consultant cover.Search Strategy: Studies were included which quantitatively compared intrapartum outcomes for women and babies where continuous resident consultant obstetric cover was provided with other models of consultant cover.Selection Criteria: Quantitative studies within healthcare systems with mixed obstetric-midwifery models of care.Data Collection and Analysis: Two researchers independently screened titles and full-text publications, extracted data and assessed the quality of included studies. Meta-analysis was performed using REVIEW MANAGER 5.3.Main Results: About 1508 publications were screened resulting in two papers, three conference abstracts and one letter being included. All were single-site time-period comparison studies. The quality of studies overall was poor with significant risk of bias. The only significant finding in meta-analysis related to instrumental deliveries, which occurred more frequently when there was on-call consultant cover (unadjusted risk ratio 1.14; 95% CI 1.04-1.24).Conclusion: No reliable evidence of the effects of 24-hour resident consultant presence on the labour ward on intrapartum outcomes was identified.Tweetable Abstract: More robust research is needed to assess intrapartum outcomes with resident consultant labour ward presence. [ABSTRACT FROM AUTHOR]

ABSTRACT Objectives To evaluate differences between international fetal centers in their treatment of twin-twin transfusion syndrome ( TTTS) by fetoscopic placental laser coagulation. Methods Fetal therapy centers worldwide were sent a web-based questionnaire. Participants were identified through networks and through scientific presentations and papers. Questions included physician and center demographics, treatment criteria, operative technique and instrumentation. Laser treatment was compared between low-volume (< 20 procedures/year) and high-volume (≥ 20 procedures/year) centers. Data were analyzed using descriptive statistics. Results Of 106 fetal therapy specialists approached, 76 (72%) from 64 centers in 25 countries responded. Of these, 48% (31/64) of centers and 63% (48/76) of operators performed fewer than 20 laser procedures annually. Comparison of low- and high-volume centers showed differences in technique, gestational age limits for treatment and geography. High-volume centers more often used the Solomon technique and applied wider gestational age limits for treatment. Europe and Asia had more high-volume centers, whereas South America, the Middle East and Australia had mainly low-volume centers. Conclusion This survey revealed significant differences between fetal centers in several aspects of fetoscopic placental laser therapy for TTTS. Increasing awareness of TTTS, and of laser coagulation as its preferred treatment, will lead to an increase in centers offering this modality, especially in Asia, Africa, South America and the Middle East. Considering the rarity of TTTS and the relative complexity of the procedure, developing international guidelines for techniques, instrumentation and suggested minimum volumes per center may aid in optimizing perinatal outcome. Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd. [ABSTRACT FROM AUTHOR]

The diagnostic criteria of polycystic ovary syndrome incorporate hyperandrogenism, polycystic ovaries, anovulation and irregular menstrual bleeding and the syndrome is a recognized reason behind infertility. The biguanide metformin has encouraging effects on several metabolic aspects of the syndrome, including insulin sensitivity, plasma glucose concentration and lipid profile. Moreover, metformin improves the ovarian function in women diagnosed with polycystic ovary syndrome. Hence, metformin is considered an agent for ovulation induction among these patients. However, even higher ovulation frequencies have been observed when metformin has been adjuvant to clomifene therapy. Metformin-induced ovulation presumably brings about resumption of regular menstrual cycles and improved conception rates. Polycystic ovary syndrome patients are presumably more likely than healthy women to suffer from pregnancy-related problems like early pregnancy loss, gestational diabetes mellitus and hypertensive states in pregnancy. Recent data suggest sparing effects of continued metformin therapy throughout pregnancy on early pregnancy loss and gestational diabetes mellitus, but its impact on hypertensive complications to pregnancy appears less evident. Instead, metformin might even induce pre-eclampsia or exert no effect on blood pressure. Conclusion. So far, evidence for safety of continued therapy throughout gestation is insufficient, and existing papers are limited in design and might mask for fetal toxic outcomes due to metformin therapy. Prior to a recommendation of sustained metformin therapy throughout pregnancy, randomized placebo-controlled double-blinded clinical trials are awaited with interest, so that present assumptions on efficiency can be clarified, in order to assure efficient and safe management of pregnant polycystic ovary syndrome patients. [ABSTRACT FROM AUTHOR]

Objective: This paper argues for an additional indicator for measuring progress of the Millennium Development Goal for maternal health-the availability of emergency obstetric care.Methods: MDG monitoring will be based on two indicators: the maternal mortality ratio and the proportion of births attended by skilled personnel. Strengths and weaknesses of a third indicator are discussedResults: The availability of EmOC measures the capacity of the health system to respond to direct obstetric complications. Benefits to using this additional indicator are its usefulness in determining an adequate distribution of services and showing management at all levels what life-saving interventions are not being provided, and stimulate thought as to why. It can reflect programmatic changes over a relatively short period of time and data requirements are not onerous.Conclusion: A measure of strength of the health system is important since many interventions depend on the health system for their implementation. [ABSTRACT FROM AUTHOR]

Preterm birth (PTB; defined as delivery before 37 weeks of pregnancy) is the leading cause of morbidity and mortality in infants and children aged <5 years, conferring potentially devastating short‐ and long‐term complications. Despite extensive research in the field, there is currently a paucity of medications available for PTB prevention and treatment. Over the past few decades, inflammation in gestational tissues has emerged at the forefront of PTB pathophysiology. Even in the absence of infection, inflammation alone can prematurely activate the main components of parturition resulting in uterine contractions, cervical ripening and dilatation, membrane rupture, and subsequent PTB. Mechanistic studies have identified critical elements of the complex inflammatory molecular pathways involved in PTB. Here, we discuss therapeutic options that target such key mediators with an aim to prevent, postpone, or treat PTB. We provide an overview of more traditional therapies that are currently used or being tested in humans, and we highlight recent advances in preclinical studies introducing novel approaches with therapeutic potential. We conclude that urgent collaborative action is required to address the unmet need of developing effective strategies to tackle the challenge of PTB and its complications. [ABSTRACT FROM AUTHOR]

Abstract: Obstetric fistula is a complication of childbirth that often follows obstructed labor and is almost exclusive to low-resource countries. The original Global Burden of Disease Study (GBD 1990 Study) reported an incidence of 8.68 per 100000 and a prevalence of 51.35 per 100 000 for women aged 15–44years in low-resource regions. The most cited global prevalence estimate is 2 million women. Although the global burden of obstetric fistula remains unclear, the number of women suffering from the condition is increasing, while surgical treatment remains limited. There are few experienced fistula surgeons and past surgical training approaches have been inconsistent. The Global Competency-Based Fistula Surgery Training Manual developed by FIGO and partners contains a set curriculum and, to ensure its implementation, a global strategy and training program have been developed. This paper describes key elements of the training program and its implementation. The anticipated impact of the training program is a reduction in global morbidity caused by obstetric fistula. [Copyright &y& Elsevier]

Aim: Tranexamic acid (TXA) has been used to treat peripartum hemorrhage, while preoperative use of TXA in cesarean section (CS) remains controversial. To assess the effectiveness and safety of prophylactic application of TXA, a meta‐analysis was performed. Methods: Electronic databases (MEDLINE [PubMed], Cochrane central register of controlled trials and Embase) were searched up to November 2018. The relevant data and quality of included trail were analyzed by RevMan 5.3. The study was registered at PROSPERO (CRD42018111165). Results: Twenty‐one randomized controlled trials with a total of 3852 patients were included. Only one research reported thromboembolic events. Compared with control groups, the intra‐operative blood loss (mean difference [MD] −155.23 mL, 95% confidence interval [CI] −195.64 − 114.81; P<0.01), postoperative blood loss (MD −26.67 mL, 95% CI −32.98 to −20.36; P<0.01), total blood loss (MD −184.88 mL, 95% CI −218.83 to −150.94; P<0.01), transfusion requirements (relative risk [RR] 0.29, 95% CI 0.18−0.49, P<0.01), massive hemorrhage (RR 0.39, 95% CI 0.30 to 0.51; P<0.01) and additional uterotonic agents use (RR 0.40, 95% CI 0.30−0.55, P<0.01) were markedly reduced in TXA‐treated patients. Besides, TXA yielded a significant reduction in hemoglobin drop (MD −0.80 g/dL, 95% CI −1.07 to −0.53; P<0.01) and hematocrit drop (MD −2.05, 95% CI −3.09 to −1.01; P<0.01) compared with control groups. Conclusion: Prophylactic application of TXA can decrease perioperative blood loss and transfusion requirements in patients undergoing CS. More high‐quality researches are needed to determine optimal dose of the drug. [ABSTRACT FROM AUTHOR]

Introduction: Providing safe, high‐quality admitted‐patient care for people with intellectual disabilities (IDs) requires consideration for their special needs particularly in relation to communication and consent. To make allowance for these special requirements, it would be helpful for hospitals to know how often they are likely to arise. This study set out to identify the amount and patterns of use of acute, non‐psychiatric hospital admitted‐patient care in England by people with ID. Patterns are considered in relation to clinical specialties, modes of admission (emergency or planned) and life stages (children and young people, working age and older adults). In each case, patterns for people with ID are compared with patterns for those without. Methods: Descriptive observational study using a major general practitioner (GP) research database (Clinical Practice Research Datalink GOLD) linked to routine national statistical records of admitted‐patient care. Results: Overall people identified by their GP as having ID had higher rates of admitted‐patient care episodes and longer durations of stay than those without. Differences varied considerably between clinical specialties with rates more elevated in medical and paediatric than surgical specialties. Admitted‐patient care rates for women with ID in obstetrics and gynaecology were lower than for other women, while rates for admitted‐patient dental care were much higher for both men and women with ID. In an average English health administrative area with a local population of 250 000 people, at any time, there are likely to be approximately 670 people receiving acute admitted‐patient care. Approximately six of these are likely to have been identified by their GP as having ID. At 0.9% of hospital in‐patients, this is just under twice the proportion in the population. Conclusion and implications: Our figures are likely to be an underestimate as GP identification of people with ID is known to be far from complete. However, they indicate that the number of people with ID in acute hospital settings is likely to be substantially more than a recent survey of English health services indicated they were aware of. The study is intended to help guide expectations for acute hospitals seeking to audit the completeness of their identification of people with ID and to indicate their likely distribution between clinical specialties. [ABSTRACT FROM AUTHOR]

Background: There is a substantial body of research evaluating ways to prevent and manage miscarriage, but all studies do not report on the same outcomes.Objective: To review systematically, outcomes reported in existing miscarriage trials.Search Strategy: MEDLINE, Embase, CINAHL, and Cochrane were searched from inception until January 2017.Selection Criteria: Randomised controlled trials (RCTs) reporting prevention or management of miscarriage. Miscarriage was defined as a pregnancy loss in the first trimester.Data Collection and Analysis: Data about the study characteristics, primary, and secondary outcomes were extracted.Main Results: We retrieved 1553 titles and abstracts, from which 208 RCTs were included. For prevention of miscarriage, the most commonly reported primary outcome was live birth and the top four reported outcomes were pregnancy loss/stillbirth (n = 112), gestation of birth (n = 68), birth dimensions (n = 65), and live birth (n = 49). For these four outcomes, 58 specific measures were used for evaluation. For management of miscarriage, the most commonly reported primary outcome was efficacy of treatment. The top four reported outcomes were bleeding (n = 186), efficacy of miscarriage treatment (n = 105), infection (n = 97), and quality of life (n = 90). For these outcomes, 130 specific measures were used for evaluation.Conclusions: Our review found considerable variation in the reporting of primary and secondary outcomes along with the measures used to assess them. There is a need for standardised patient-centred clinical outcomes through the development of a core outcome set; the work from this systematic review will form the foundation of the core outcome set for miscarriage.Tweetable Abstract: There is disparity in the reporting of outcomes and the measures used to assess them in miscarriage trials. [ABSTRACT FROM AUTHOR]

Objective: The World Maternal Antifibrinolytic (WOMAN) Trial was the first in the UK to use the option of waiver of informed consent at the time of an obstetric emergency. This qualitative study aimed to investigate participants' views of the acceptability of the recruitment methods used.Design: Qualitative study using in-depth interviews with women who did and did not give consent at the time of their recruitment to the WOMAN Trial.Setting: Highest UK recruitment site for the WOMAN Trial (129/569). Interviews were conducted in participants' homes.Population: About 40 of the 129 women who were recruited to the WOMAN Trial at one UK site were invited to take part, 15 women were interviewed.Methods: Qualitative, interview study.Main Outcome Measures: Facilitators and barriers to successful recruitment during obstetric emergencies. Guidance for future researchers.Results: Findings revealed that what is important is not so much the consent process used or a signature on a form, but the way in which consent is obtained. Clinicians who successfully negotiate consent to research during childbirth emergencies engage in a 'humane choreography' of words and actions. This emphasises the importance of prompt decision-making and treatment, while respecting the woman's personal situation and experience.Conclusions: Our findings do not support a single pathway to consent in the context of an obstetric emergency. Women understand that consent to research in an emergency is complex. Clinicians' skills in considering the clinical, ethical, and emotional aspects within the context of the clinical emergency can hamper or promote women's satisfaction.Tweetable Abstract: Study reports on women's views of consent to research in an obstetric emergency.Plain Language Summary: Why and how was the study carried out? We undertook this study to find out what women thought about being included in a research study called the WOMAN Trial at the time they were being treated for heavy bleeding after giving birth. Some women had been asked if they wanted to be a part of the research at the time they were bleeding. Others were asked later, after they had recovered. We conducted interviews with 15 women who had been involved and asked what they thought about the way they had been asked, their preferences and ideas for improvements in future similar studies What were the main findings? Women understood how difficult it was for their doctors and midwives to ask them about the research study. They were pleased to have been included in the research and were mostly happy with the way they gave consent. Women's views were similar whether they were asked about the research at the time of the bleeding or after they had recovered. The most important thing was that doctors and midwives carefully thought about the situation the woman found herself in and how this might make her feel, so they could tailor their approach accordingly. What are the limitations of the work? This study only involved women from one hospital. The WOMAN Trial included women from many areas of the UK and other countries around the world. We do not know how their experiences or views may differ. What is the implication for professionals? Careful use of actions and words by birth attendants was the difference between a good or bad experience for the woman and her family. This is an important skill that could be developed as part of professional training. [ABSTRACT FROM AUTHOR]

Background: Obstetric hemorrhage (OH) and access to peripartum blood transfusion remains a global health challenge. The rates of peripartum transfusion in South Africa exceed those in high-income countries despite comparable rates of OH. We sought to evaluate factors associated with peripartum transfusion.Study Design and Methods: A case-control study was conducted at four large South African hospitals. Transfused peripartum women (cases) and nontransfused controls were stratum matched 1:2 by hospital and delivery date. Data on obstetric, transfusion, and human immunodeficiency virus (HIV) history were abstracted from medical records. Blood was obtained for laboratory evaluation. We calculated unadjusted and adjusted odds ratios (ORs) for transfusion using logistic regression.Results: A total of 1200 transfused cases and 2434 controls were evaluated. Antepartum hemorrhage (OR, 197.95; 95% confidence interval [CI], 104.27-375.78), hemorrhage with vaginal delivery (OR, 136.46; 95% CI, 75.87-245.18), prenatal anemia (OR, 22.76; 95% CI, 12.34-41.93 for prenatal hemoglobin level < 7 g/dL), and failed access to prenatal care (OR, 6.71; 95% CI, 4.32-10.42) were the major risk factors for transfusion. Platelet (PLT) count (ORs, 4.10, 2.66, and 1.77 for ≤50 × 109 , 51 × 109 -100 × 109 , and 101 × 109 -150 × 109 cells/L, respectively), HIV infection (OR, 1.29; 95% CI, 1.02-1.62), and admitting hospital (twofold variation) were also associated with transfusion. Mode of delivery, race, age category, gravidity, parity, gestational age, and birthweight were not independently associated with transfusion.Conclusion: Major risk factors of peripartum transfusion in South Africa, namely, prenatal anemia and access to prenatal care, may be amenable to intervention. HIV infection and moderately low PLT count are novel risk factors that merit further investigation. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the safety and efficacy of ultrasound-guided high-intensity focused ultrasound (USgHIFU) for treating abdominal wall endometrioses (AWE).Design: A retrospective study.Setting: Department of Obstetrics and Gynaecology in China.Population: Patients with abdominal wall endometriosis.Methods: From August 2010 to April 2014, 32 patients with AWE were treated with USgHIFU in our hospital. USgHIFU treatment was performed with the Model JC-200 High Intensity Focused Ultrasound Tumor Therapeutic System. The symptom relief and the adverse effects were evaluated after USgHIFU ablation.Main Outcome Measures: USgHIFU as a new treatment option for patients with AWE.Results: Contrast-enhanced ultrasound showed that all lesions were successfully ablated with USgHIFU. The follow-up results showed that the average volume of AWE lesions at 6 months after USgHIFU was significantly smaller than that before treatment (2.80 ± 0.12 versus 1.33 ± 0.31 cm3 ). The pain scores at 6 months after treatment were significantly lower than those before treatment (6.80 ± 2.64 versus 1.80 ± 0.3). The non-perfused volume (indicative of successful ablation) was measured in all patients immediately after treatment, ranging from 0.9 to 2.1 cm3 (median: 1.6 cm3 ), and the fractional ablation ranged from 87% to 100% (median: 94%). Local oedema was observed in these patients, lasting for 1-3 days only. No severe complications occurred during the follow-up period.Conclusions: Based on our study, USgHIFU ablation is a safe and effective method for treating AWE.Tweetable Abstract: As a non-invasive treatment technique, HIFU could be used to treat abdominal wall endometriosis. [ABSTRACT FROM AUTHOR]

Objective: To describe the incidence of mechanical prosthetic heart valves (MPHV) in pregnancy in the UK; rates of maternal and fetal complications in this group of women, and whether these vary with the anticoagulation used during pregnancy.Design: Prospective descriptive population-based study.Setting: All consultant-led maternity units in the UK.Population: All women with an MPHV who were pregnant between 1 February 2013 and 31 January 2015.Methods: Collection and analysis of anonymous data relating to pregnancy management and outcome, using the UKOSS notification and data collection system.Main Outcome Measures: Maternal death, serious maternal morbidity, poor fetal outcome.Results: Data were obtained for 58 women giving an estimated incidence of 3.7 (95% CI 2.7-4.7) per 100 000 maternities. There were five maternal deaths (9%); a further 24 (41%) suffered serious maternal morbidity. There was a poor fetal outcome from 26 (47%) pregnancies. Only 16 (28%) women had a good maternal and good fetal outcome. Low-molecular-weight heparin (LMWH) was used throughout pregnancy by 71% of women. Of these, 83% required rapid dose escalation in the first trimester. Monitoring regimens lacked consistency.Conclusions: This study has estimated the incidence of MPHV in pregnant women in the UK. It includes the largest cohort managed with LMWH throughout pregnancy reported to date. It demonstrates a high rate of maternal death, and serious maternal and fetal morbidity. Women with MPHVs, and their clinicians need to appreciate the significant maternal and fetal risks involved in pregnancy. Care should be concentrated in specialist centres.Tweetable Abstract: High rates of poor maternal and fetal outcomes in pregnant women with mechanical prosthetic heart valves. [ABSTRACT FROM AUTHOR]

Background: There is little consensus regarding the hypothesised link between obstetric consultant presence and maternal and neonatal outcomes.Objectives: To pool existing data on the impact of consultant presence on the outcomes of women who have given birth in UK National Health Service (NHS) maternity units.Search Strategy: Twelve databases, grey literature, and reference lists were searched.Selection Criteria: Studies conducted in UK NHS maternity units comparing outcomes during lesser consultant presence versus increased consultant presence that reported mode of delivery and adverse maternal or neonatal outcomes.Data Collection and Analysis: Studies were divided into three groups by type of comparison: (1) hours of rostered consultant presence during the weekend versus hours of rostered consultant presence during the week; (2) hours per week of rostered consultant presence pre-increase versus hours per week of rostered consultant presence post-increase; and (3) no rostered consultant presence versus rostered consultant presence. A random-effects meta-analysis was performed.Main Results: Fifteen studies fulfilled the inclusion criteria, presenting data from 125 856 births. Overall, there was no significant difference between lesser and increased consultant presence for any outcome. When data were stratified by comparison type, the likelihood of emergency caesarean section was significantly lower (odds ratio, OR 0.91; 95% confidence interval, 95% CI 0.86-0.96) and the likelihood of non-instrumental vaginal delivery was significantly higher (OR 1.07; 95% CI 1.02-1.12) when the rostered hours of consultant presence per week were increased.Conclusions: Increased consultant presence has some effect on mode of delivery, but no evidence for a benefit for adverse outcomes was found.Tweetable Abstract: Increasing hours of NHS obstetric consultant presence may increase chance of non-instrumental vaginal delivery. [ABSTRACT FROM AUTHOR]

Objective: To describe the incidence, risks, management and outcomes of cardiac arrest in pregnancy in the UK population, with specific focus on the use of perimortem caesarean section (PMCS).Design: A prospective, descriptive study using the UK Obstetric Surveillance System (UKOSS).Setting: All UK hospitals with maternity units.Population: All women who received basic life support in pregnancy in the UK between 1 July 2011 and 30 June 2014 (n = 66).Methods: Prospective case identification through UKOSS monthly mailing.Main Outcome Measures: Cardiac arrest in pregnancy, PMCS, maternal death.Results: There were 66 cardiac arrests in pregnancy, resulting in an incidence of 2.78 per 100 000 maternities (1:36 000; 95% CI 2.2-3.6). In all, 28 women died (case fatality rate 42%); 16 women arrested solely as a consequence of obstetric anaesthesia, 12 of whom were obese. Basic and advanced life support were rapidly delivered. Those who died were more likely to have collapsed at home. Perimortem caesarean section was performed in 49 women, 11 in the emergency department. The time from collapse to PMCS was significantly shorter in women who survived (median interval 3 versus 12 minutes, P = 0.001). Forty-six of 58 babies were born alive; 32 babies to surviving mothers and 14 to women who died.Conclusion: Cardiac arrest is rare in the pregnant UK population, however, nearly a quarter of cases are precipitated by obstetric anaesthesia, suggesting an opportunity to reduce the incidence further. Maternal survival rates of 58% were achieved with timely resuscitation, including PMCS, delay in which was associated with maternal death. Inpatient arrests were associated with higher survival rates than arrests that occurred outside the hospital setting.Tweetable Abstract: 25% of cardiac arrest in pregnancy is caused by anaesthesia. Rapid perimortem section improves survival. [ABSTRACT FROM AUTHOR]

Background: Previous studies have shown that more than 20% of laboratories would have recommended inaccurate doses of Rh immune globulin (RhIG) in hypothetical cases. Efforts have been made in educating laboratories in correct dosing calculations; however, obstetricians are most often responsible for ordering RhIG. The objective of this study was to assess knowledge of RhIG indications and dosing among obstetrics and gynecology (OB/GYN) physicians in the United States.Study Design and Methods: An anonymous 17- question online survey was distributed to all OB/GYN resident and attending physicians affiliated with US residency training programs.Results: A total of 165 surveys were collected, with 139 fully completed. Ninety-two percent of respondents correctly recognized the need for RhIG in D- patients with negative antibody screens. In a scenario of a fetomaternal hemorrhage (FMH) of 45 mL, only 22% of respondents correctly chose the appropriate RhIG dosage. Of those who were correct, 10% had correctly identified 30 mL as the amount of fetal whole blood covered by one dose of RhIG, while 48% incorrectly identified 15 mL (n = 31). A total of 49.3% of respondents reported residency as the most recent formal training on RhIG dosing and 35% reported never (n = 140).Conclusions: Our study found that OB/GYN physicians are knowledgeable regarding indications for RhIG immunoprophylaxis but were insufficient at calculating dosages in cases of FMH. More standardized education and training among OB/GYN physicians may decrease the risk of maternal alloimmunization, in part because RhIG dosage recommendations from laboratories are not standard practice. [ABSTRACT FROM AUTHOR]

Objective To evaluate the effectiveness of 200 mg of daily vaginal natural progesterone to prevent preterm birth in women with preterm labour. Design Multicentre, randomised, double-blind, placebo-controlled trial. Setting Twenty-nine centres in Switzerland and Argentina. Population A total of 385 women with preterm labour (240/7 to 336/7 weeks of gestation) treated with acute tocolysis. Methods Participants were randomly allocated to either 200 mg daily of self-administered vaginal progesterone or placebo within 48 hours of starting acute tocolysis. Main outcome measures Primary outcome was delivery before 37 weeks of gestation. Secondary outcomes were delivery before 32 and 34 weeks, adverse effects, duration of tocolysis, re-admissions for preterm labour, length of hospital stay, and neonatal morbidity and mortality. The study was ended prematurely based on results of the intermediate analysis. Results Preterm birth occurred in 42.5% of women in the progesterone group versus 35.5% in the placebo group (relative risk [ RR] 1.2; 95% confidence interval [95% CI] 0.93-1.5). Delivery at <32 and <34 weeks did not differ between the two groups (12.9 versus 9.7%; [ RR 1.3; 95% CI 0.7-2.5] and 19.7 versus 12.9% [ RR 1.5; 95% CI 0.9-2.4], respectively). The duration of tocolysis, hospitalisation, and recurrence of preterm labour were comparable between groups. Neonatal morbidity occurred in 44 (22.8%) cases on progesterone versus 35 (18.8%) cases on placebo ( RR: 1.2; 95% CI 0.82-1.8), whereas there were 4 (2%) neonatal deaths in each study group. Conclusion There is no evidence that the daily administration of 200 mg vaginal progesterone decreases preterm birth or improves neonatal outcome in women with preterm labour. [ABSTRACT FROM AUTHOR]

Background: The objective of this study was to review the management of patients presenting with severe odontogenic infections and who are also pregnant. Methods: A retrospective clinical audit was conducted of all female patients admitted to the Royal Adelaide Hospital by the Oral and Maxillofacial Surgery Unit from 1999 to 2009 with severe odontogenic infections. Pregnant patients were identified and their age, medical history, previous obstetric and gynaecological history, stage of current pregnancy, presenting infection, diagnosis and management were recorded, as well as the outcome of the pregnancy. Results: A total of 346 female patients were admitted to the Royal Adelaide Hospital under the care of the Oral and Maxillofacial Surgery Unit with an admission diagnosis of severe odontogenic infection and five were pregnant. Besides surgical and anaesthetic assessment, mother and foetus were assessed by the Obstetric and Gynaecology Unit. In all, five with severe infection were successfully resolved and four proceeded to a normal delivery with a healthy child. The remaining patient had an already planned therapeutic abortion. Conclusions: Pregnant patients with severe odontogenic infections require urgent referral to a tertiary hospital with full surgical, anaesthetic and obstetric services. This allows appropriate management of the complex requirements of mother and foetus. [ABSTRACT FROM AUTHOR]

Background: The objective of this study was to systematically review the diagnostic criteria, indications, and need for treatment of ankyloglossia (tongue-tie), as well as the various treatment options for patients in different age groups. Methods: The MEDLINE databases and the Cochrane Library were searched according to well-defined criteria, resulting in 64 included articles. The evidence regarding the classifications of tongue-tie, epidemiologic data, inheritance, breastfeeding problems, impaired tongue mobility, speech disorders, malocclusion, gingival recessions, therapy, and complications due to surgery was analyzed in detail. Results: Different classifications for ankyloglossia have been proposed but not uniformly accepted. Breastfeeding problems in neonates could be associated with a tongue-tie, but not enough controlled trials have been performed to identify an ideal treatment option. In children and adults with ankyloglossia, limitations in tongue mobility are present, but the individual degree of discomfort, as well as the severity of an associated speech problem, are subjective and difficult to categorize. There is no evidence supporting the development of gingival recessions because of ankyloglossia. Frenotomy frenectomy, and frenuloplasty are the main surgical treatment options to release/remove an ankyloglossia. Because of the limited evidence available, no specific surgical method can be favored. Conclusions: The lack of an accepted definition and classification of ankyloglossia makes comparisons between studies almost impossible. Because almost no controlled prospective trials for surgical interventions in patients with tongue-ties are present in the literature, no conclusive suggestions regarding the method of choice can be made. It also remains controversial which tongue-ties need to be surgically removed and which can be left to observation. [ABSTRACT FROM AUTHOR]

Objective To test the hypothesis that iron supplement from early pregnancy would increase the risk of gestational diabetes mellitus (GDM). Design Randomised placebo-controlled trial. Setting A university teaching hospital in Hong Kong. Population One thousand one hundred sixty-four women with singleton pregnancy at less than 16 weeks of gestation with haemoglobin (Hb) level between 8 and 14 g/dl and no pre-existing diabetes or haemoglobinopathies. Methods Women were randomly allocated to receive 60 mg of iron supplement daily ( n= 565) or placebo ( n= 599). Oral glucose tolerance tests (OGTTs) were performed at 28 and 36 weeks. Women were followed up until delivery. Outcome measures The primary outcome was development of GDM at 28 weeks. The secondary outcomes were 2-hour post-OGTT glucose levels, development of GDM at 36 weeks and delivery and infant outcomes. Results There was no significant difference in the incidence of GDM in the iron supplement and placebo groups at 28 weeks (OR: 1.04, 95% confidence interval [CI]: 0.7–1.53 at 90% power) or 36 weeks. Maternal Hb and ferritin levels were higher in the iron supplement group at delivery ( P < 0.001 and P= 0.003, respectively). Elective caesarean section rate was lower in the iron supplement group (OR: 0.58, 95% CI: 0.37–0.89). Infant birthweight was heavier ( P= 0.001), and there were fewer small-for-gestational-age babies in the iron supplement group (OR: 0.46, 95% CI: 0.24–0.85). Conclusion Iron supplement from early pregnancy does not increase the risk of GDM. It may have benefits in terms of pregnancy outcomes. [ABSTRACT FROM AUTHOR]

The article studies the short- to medium-term results of transobturator mesh placement for cystocele repair using three- and four-dimensional pelvic floor ultrasound. According to the authors, cystocele recurrence was observed in six patients. They add that cystocele recurrence was observed on translabial ultrasound dorsal to the mesh in five women, associated with a marked change in mesh axis on Valsalva, implying dislodgment of the superior anchoring arms.

Objectives To report early experience with treatment of intrauterine cytomegalovirus (CMV) infection using maternal oral administration of valaciclovir (VACV). Design Observational study of fetuses infected with CMV with or without treatment with valaciclovir. Population Pregnancies with confirmed fetal CMV infection were treated with oral VACV (8 g/day). Main outcome measures Fetal viral load and drug concentration were monitored in amniotic fluid and in fetal blood. Data on the course and outcome of a group of untreated symptomatic fetuses infected with CMV are also reported. Results Therapeutic concentrations were achieved in maternal and fetal bloods. The viral load in the fetal blood (VLFB) decreased significantly after 1–12 weeks of treatment (Wilcoxon paired test P= 0.02). Twenty pregnancies including 21 fetuses were treated at 28 weeks (median, range: 22–34) for 7 weeks (median, range: 1–12). Ten infants were developing normally at between 1 and 5 years of age. Two infants (both aged 2 years) had severe isolated unilateral deafness. One neonate presented with microcephaly and severe deafness but was also diagnosed with incontinentia pigmenti. Six out of seven cases that eventually required termination of pregnancy (TOP) had evidence of in utero progression of the disease with worsening cerebral lesions. One fetus died in utero. The outcome of 14/24 (58.3%) untreated symptomatic infected fetuses was poor with either TOP, intrauterine fetal demise or severe congenital infection disease of the neonate; the remaining ten infants were healthy at follow up. Conclusion Maternal oral administration of VACV leads to therapeutic concentrations in the maternal and fetal compartments, with a decrease in VLFB. Our results suggest that in cases where TOP is declined, a randomised controlled trial to study this treatment option further is indicated. [ABSTRACT FROM AUTHOR]

Objective This study was designed to examine the burnout syndrome among residents in obstetrics and gynaecology in Spain, and to analyse the predisposing factors for this condition. Setting Eight Spanish University hospitals. Sample A total of 162 residents representative of all active residents in obstetrics and gynaecology in Spain with regards to age, sex and year of residency were asked to take part in this survey. Methods The Maslach Burnout Inventory was mailed to each resident of eight Spanish hospitals representative of all active residents in obstetrics and gynaecology in Spain with regards to age, sex and year of residency. Burnout was defined as a high score on the emotional exhaustion or depersonalisation subscores, according to validated standard cutoff values. The demographic and predisposing work factors were noted for each participant using a self-reported questionnaire. A binary logistic regression model was constructed from all predisposing factors as covariates for the prediction of the burnout syndrome. Results Sixty-seven percent of the 162 eligible residents returned their questionnaires within a 3-month period. Of those, 58% fulfilled the criteria for the burnout syndrome. In the multivariate analysis, marital status and workload in office practice were found to be significant predisposing factors. Single marital status increased the odds ratio for burnout by 5.2 (95% CI 1.3–21). For every extra ten patients attended in the office per week, the odds ratio for burnout increased by 1.25 (95% CI 1.0–1.5). A stratified multivariate subanalysis showed that this risk remained significant only in the group of residents without staff supervision with an odds ratio of 2.1 (95% CI 1.3–2.9). Conclusion The prevalence of the burnout syndrome during obstetrics and gynaecology residency is high. Single marital status and workload in office practice without staff supervision are significant predisposing factors. [ABSTRACT FROM AUTHOR]

Aim: To determine the effectiveness of prenatal treatment for clinical manifestations of congenital toxoplasmosis.Methods: We prospectively identified 255 live-born infants with congenital toxoplasmosis using prenatal or neonatal screening. We determined the effect of prenatal treatment on the risks of intracranial or ocular lesions in infancy, accounting for gestational age at maternal seroconversion.Results: Prenatal treatment within 4 wk of seroconversion reduced the risk of intracranial lesions compared with no treatment (odds ratio, OR 0.28; 95% CI: 0.08-0.75), but there was no significant effect when initiated after 4 wk (OR 0.76; 95% CI: 0.35-1.59; overall p-value 0.19). Compared to spiramycin alone, no treatment doubled the risk of intracranial lesions (OR 2.33; 95% CI: 1.04-5.50), but the risk did not differ with pyrimethamine-sulphonamide treatment (overall p-value 0.52). There was no consistent relationship between the type or timing of treatment and the risk of ocular lesions. Gestational age at maternal seroconversion was inversely associated with the risk of intracranial but not ocular lesions.Conclusion: Only early versus no prenatal treatment for intracranial lesions showed a statistically significant benefit. A large randomized controlled trial and/or meta-analysis of individual patient data from cohort studies is required to confirm these findings. [ABSTRACT FROM AUTHOR]

Objective: The Government of Bangladesh has implemented safe motherhood programs throughout the country supported by the United Nations Children's Fund (UNICEF) and United Nations Population Fund (UNFPA) aimed at reducing maternal morbidity and mortality. The objective of this study is to assess the effect of the interventions on the UN emergency obstetric care (EmOC) process indicators in Khulna division, Bangladesh.Methods: Of the 71 government health facilities in Khulna division, 32 were providing comprehensive and 20 were providing basic EmOC services. Another 4 facilities were providing comprehensive or basic EmOC services during the first three-quarters but became non-functional during the last quarter. EmOC data, from January to December 2002, were collected from all these 56 facilities to determine the levels of EmOC process indicators relative to the UN guidelines and compared with baseline data from 1998 to 1999.Results: There were 1.04 and 0.64 comprehensive and basic EmOC facilities respectively per 500,000 population. When compared with the baseline data, the coverage of comprehensive EmOC services was substantially increased from 0.23 to 1.04 per 500,000 population, which achieves the minimum UN standards but the coverage of basic EmOC services remained the same. The data also showed that, compared with the baseline survey, the proportion of births at the EmOC facilities increased 119% from 5.3% to 11.7% (p<0.001), met need increased 141% from 11.1% to 26.6% (p<0.001), and cesarean section as a proportion of all expected births, increased 151% from 0.5% to 1.3% (p<0.001), while the overall case fatality rate (CFR) decreased by 51% (p<0.001).Conclusion: With the exception of coverage of basic EmOC after the interventions, there was significant improvement in all the EmOC process indicators in Khulna division. However, most of the process indicators are still far from the minimum recommended UN standards.Recommendations: Efforts should continue to keep the EmOC facilities functional 24/7 while increasing the number of basic EmOC facilities, and improving utilization of services to reach the minimum UN standards. Community mobilization should be directed to understand the danger signs and utilization of services at functional facilities when necessary. Further research to identify the factors influencing utilization of EmOC services and continuous monitoring and periodical assessment of the process indicators are recommended to evaluate the overall situation from time to time. [ABSTRACT FROM AUTHOR]

Objective: To improve the quality of clinical care for women with severe pre-eclampsia.Methods: A criteria-based audit was conducted in a large government hospital in Uganda. Management practices were evaluated against standards developed by an expert panel by retrospectively evaluating 43 case files. Results of the audit were presented, and recommendations developed and implemented. A re-audit was conducted 6 months later.Results: The initial audit showed that most standards were rarely achieved. Reasons were discussed. Guidelines were produced, additional supplies were purchased following a fundraising effort, labor ward procedures were streamlined, and staffing was increased. In the re-audit there were significant improvements in diagnosis, monitoring, and treatment.Conclusion: Criteria-based audit can improve the quality of maternity care in countries with limited resources. [ABSTRACT FROM AUTHOR]

Preterm premature rupture of the membranes (PPROM) is responsible for one-third of all preterm births and affects 120,000 pregnancies in the United States each year. Effective treatment relies on accurate diagnosis and is gestational age dependent. The diagnosis of PPROM is made by a combination of clinical suspicion, patient history and some simple tests. PPROM is associated with significant maternal and neonatal morbidity and mortality from infection, umbilical cord compression, placental abruption and preterm birth. Subclinical intrauterine infection has been implicated as a major aetiological factor in the pathogenesis and subsequent maternal and neonatal morbidity associated with PPROM. The frequency of positive cultures obtained by transabdominal amniocentesis at the time of presentation with PPROM in the absence of labour is 25–40%. The majority of amniotic fluid infection in the setting of PPROM does not produce the signs and symptoms traditionally used as diagnostic criteria for clinical chorioamnionitis. Any evidence of infection by amniocentesis should be considered carefully as an indication for delivery. Documentation of amniotic fluid infection in women who present with PPROM enables us to triage our therapeutic decision making rationally. In PPROM, the optimal interval for delivery occurs when the risks of immaturity are outweighed by the risks of pregnancy prolongation (infection, abruption and cord accident). Lung maturity assessment may be a useful guide when planning delivery in the 32- to 34-week interval. A gestational age approach to therapy is important and should be adjusted for each hospital's neonatal intensive care unit. Antenatal antibiotics and corticosteroid therapies have clear benefits and should be offered to all women without contraindications. During conservative management, women should be monitored closely for placental abruption, infection, labour and a non-reassuring fetal status. Women with PPROM after 32 weeks of gestation should be considered for delivery, and after 34 weeks the benefits of delivery clearly outweigh the risks. [ABSTRACT FROM AUTHOR]

Progesterone is an essential hormone in the process of reproduction. It is involved in the menstrual cycle, implantation and is essential for pregnancy maintenance. Although the pharmacokinetics and pharmacodynamics of progesterone have been well studied, and since 1935 it has been synthesised and is now available commercially, its use in the pathophysiology of pregnancy remains controversial. One of these concerns is the way in which the hormone is administered, with parenteral use proving the best way to obtain optimal plasma levels. Another concern is the paucity of randomised controlled trials and the different dosages and populations studied. As a result, the therapeutic application of progesterone in pregnancy is restricted to the prevention and treatment of threatened miscarriage, recurrent miscarriage and preterm birth. Progesterone is efficacious when continuation of pregnancy is hampered by immunological factors, luteinic and neuroendocrine deficiencies and myometrial hypercontractility. This may explain the reduction in the incidence of preterm birth in high risk pregnant women using high-dosage prophylactic progesterone. [ABSTRACT FROM AUTHOR]

Inhibiting preterm labour at extremely early gestations.Observational study. Case reports.Perinatal Centre Lund University Hospital, South Sweden.Twenty-five women (13 cases with intact membranes and 12 cases with ruptured) with threatened preterm labour and advanced cervical status before 26 completed weeks of gestation.A combination of different drugs was used. Atosiban, an oxytocin antagonist, was the first line drug and was given as an infusion for several days as required. Supportive therapy was also given to most women with subcutaneous injections of theβ-receptor agonist terbutaline (0.25 mg up to six times a day); sulindac, a prostaglandin synthetase inhibitor (200 mg one to two times a day up to a week); and broad-spectrum antibiotics (metronidazole and cefuroxime intravenously for three days and thereafter oral therapy).Prolongation of pregnancy more than 48 hours or 7 days. Neonatal survival.Prolongation of pregnancy for more than 48 hours to enable administration of corticosteroid therapy was obtained in all but three cases. Eight women were delivered after more than a week from admission. Three neonates died at birth due to obstetric complication or sepsis. The other neonates had normal pH in cord or venous blood at birth. No severe side effects were recorded and in no case did the treatment have to be discontinued due to side effects.The policy described here is not evidence based, relating only to clinical observations, and as such is of very limited value. However, it seems that with this combined approach to management, some days can be gained by achieving full effect of corticosteroid treatment and prolongation of the pregnancy, hopefully reducing time in the neonatal intensive care in these critical cases. No severe side effects were reported. [ABSTRACT FROM AUTHOR]

Women who are undelivered after 48 hours of tocolysis remain at increased risk of preterm labour, but it is not clear whether prolonged treatment is effective.To review the current evidence for the effectiveness of maintenance tocolysis.The results of published systematic reviews were summarised.Four systematic reviews and two trials published too recently for inclusion were identified. Maintenance tocolysis withβ-agonists and magnesium sulphate was ineffective in prolonging gestation or reducing any adverse fetal outcomes. One trial of maintenance tocolysis with nifedipine was underpowered to rule out an effect on prolonging gestation. One trial using the oxytocin receptor blocker, atosiban, showed that this drug used as maintenance tocolysis does prolong gestation, but the trial was too small to demonstrate any reduction in substantive fetal outcomes.There is insufficient evidence to justify the routine use of maintenance tocolysis in preterm labour. It remains plausible that prolongation of gestation might be beneficial in selected cases of very preterm labour where fetal compromise and infection have been ruled out. The only tocolytic that has been shown to prolong gestation when used as maintenance therapy is atosiban. [ABSTRACT FROM AUTHOR]

The article is a case report of a geriatric multipara with a suggested history of stress incontinence. A transobturator sling procedure was performed on the woman that resulted in unrecognised bladder injury. Details of the diagnosis, conducting of Necrotising fasciitis, antibiotics used, risk of bladder damage and the patient's recovery are discussed.