RESUMEN
BACKGROUND: The purpose of this study was to compare the reliability and reproducibility of the traditional qualitative method of assessing uterine cervical stiffness with those of a quantitative method using a novel device based on the aspiration technique. METHODS: Five silicone models of the uterine cervix were created and used to simulate different cervical stiffnesses throughout gestation. The stiffness of the five cervix models was assessed both by digital palpation (firm, medium and soft) and with the Pregnolia System. Five self-trained participants conducted the device-based assessment, whereas 63 obstetricians and midwives, trained in digital palpation, conducted the cervical palpation. RESULTS: The results of the two methods were analyzed in terms of inter-and intra-observer variability. For digital palpation, there was no common agreement on the assessment of the stiffness, except for the softest cervix. When assessing the same cervix model for a second time, 76% of the obstetricians and midwives disagreed with their previous assessment. In contrast, the maximum standard deviation for the device-based stiffness assessment for intra- and inter-observer variability was 3% and 3.4%, respectively. CONCLUSIONS: This study has shown that a device based on the aspiration technique provides obstetricians and midwives with a method for objectively and repeatably assess uterine cervical stiffness, which can eliminate the need to rely solely on a subjective interpretation, as is the case with digital palpation.
Asunto(s)
Maduración Cervical/fisiología , Cuello del Útero/fisiología , Palpación/métodos , Succión/instrumentación , Femenino , Humanos , Modelos Anatómicos , Variaciones Dependientes del Observador , Embarazo , Reproducibilidad de los ResultadosRESUMEN
PURPOSE: To identify risk factors for emergency caesarean section in women attempting a vaginal breech delivery at term. METHODS: Data from 1092 breech deliveries performed between 1998 and 2013 at a Swiss cantonal hospital were extracted from an electronic database. Of the 866 women with a singleton, full term pregnancy, 464 planned a vaginal breech delivery. Fifty-seven percent (265/464) were successful in delivering vaginally. Multivariate regression analyses of risk factors were performed, and neonatal and maternal complications were compared. RESULTS: Risk factors for failed vaginal delivery were peridural anaesthesia (OR 2.05; 95 % CI 1.09-3.84; p = 0.025), nulliparity (OR 2.82; 95 % CI 1.87-4.25; p < 0.001), high birth weight (OR 1.17; 95 % CI 1.04-1.30; p = 0.006) and induction of labour (OR 1.56; 95 % CI 1.003-2.44; p = 0.048). Maternal age, height and weight; gestational age; or newborn length and head circumference were not associated with an unplanned caesarean section. The rate of successful vaginal delivery in the low risk sub-group (multiparous women without induction of labour) was 58-83 %, depending on birth weight category. The likelihood of success for the high risk sub-group (nulliparous women with induction of labour) fell below a third at neonatal birth weights >3250 g. Complication rates were low in the cohort. CONCLUSIONS: Use of peridural anaesthesia, nulliparity, high birth weight and induction of labour were risk factors for unsuccessful vaginal breech delivery requiring an unplanned caesarean section. Awareness of these risk factors is useful when counselling women who are considering a vaginal breech delivery.
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Presentación de Nalgas/cirugía , Cesárea/métodos , Adulto , Procedimientos Quirúrgicos Electivos/estadística & datos numéricos , Urgencias Médicas/epidemiología , Femenino , Humanos , Recién Nacido , Embarazo , Factores de RiesgoRESUMEN
OBJECTIVE: The objective of this study was to determine for the first time the reliability and the diagnostic power of high-resolution microarray testing in routine prenatal diagnostics. METHODS: We applied high-resolution chromosomal microarray testing in 464 cytogenetically normal prenatal samples with any indication for invasive testing. RESULTS: High-resolution testing revealed a diagnostic yield of 6.9% and 1.6% in cases of fetal ultrasound anomalies and cases of advanced maternal age (AMA), respectively, which is similar to previous studies using low-resolution microarrays. In three (0.6%) additional cases with an indication of AMA, an aberration in susceptibility risk loci was detected. Moreover, one case (0.2%) showed an X-linked aberration in a female fetus, a finding relevant for future family planning. We found the rate of cases, in which the parents had to be tested for interpretation of unreported copy number variants (3.7%), and the rate of remaining variants of unknown significance (0.4%) acceptably low. Of note, these findings did not cause termination of pregnancy after expert genetic counseling. The 0.4% rate of confined placental mosaicism was similar to that observed by conventional karyotyping and notably involved a case of placental microdeletion. CONCLUSION: High-resolution prenatal microarray testing is a reliable technique that increases diagnostic yield by at least 17.3% when compared with conventional karyotyping, without an increase in the frequency of variants of uncertain significance.
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Aberraciones Cromosómicas , Análisis por Micromatrices/métodos , Diagnóstico Prenatal/métodos , Adulto , Células Cultivadas , Cromosomas Humanos , Estudios de Cohortes , Femenino , Humanos , Cariotipificación/métodos , Edad Materna , Valor Predictivo de las Pruebas , Embarazo , Reproducibilidad de los ResultadosRESUMEN
CONTEXT: We and others have previously shown that standardized psychosocial stress significantly increases salivary alpha-amylase (sAA), but it remains unclear whether sAA reflects autonomic nervous system activation. OBJECTIVE: The aim of this study was to assess cardiovascular effects and sAA and catecholamine secretion after iv injection of yohimbine. DESIGN AND SETTING: We conducted a randomized double-blind placebo-controlled study at an academic research unit. PARTICIPANTS: Thirteen healthy males (aged 20-28 yr) were examined. INTERVENTION: Participants received iv injection of yohimbine (0.4 microg/kg) or placebo (0.9% NaCl). MAIN OUTCOME MEASURES: Eight saliva and blood samples were taken before and after injection for the assessment of salivary flow rate and sAA and catecholamine concentrations. In addition, blood pressure, mood, and anxiety were assessed repeatedly. RESULTS: Yohimbine induced increases of sAA activity and output in comparison to placebo (P = 0.034). Blood pressure (P < 0.001), salivary flow rate (P = 0.007), and catecholamines (P < 0.001) were also significantly increased. No significant correlations between alpha-amylase parameters and catecholamines were observed. CONCLUSIONS: The results indicate that yohimbine administration activates not only autonomic parameters but also sAA via adrenergic mechanisms, suggesting that sAA might be an indirect indicator of the central sympathetic system.
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Saliva/efectos de los fármacos , Saliva/enzimología , Yohimbina/farmacología , alfa-Amilasas/análisis , Antagonistas Adrenérgicos alfa/farmacología , Adulto , Afecto/efectos de los fármacos , Ansiedad/enzimología , Presión Sanguínea/efectos de los fármacos , Método Doble Ciego , Epinefrina/sangre , Humanos , Masculino , Placebos , Estrés Psicológico/enzimologíaRESUMEN
This review considers six main situations in which pathologists are expected to report and interpret placental messages for obstetricians, neonatologists and, indirectly, parents: (1) abortion is the body's corrective response to the embryonic defect suggested by malformed chorionic villi; (2) infection causing chorionic villous inflammation is specific and haematogenous; pathogen identification is mandatory, in contrast to chorioamnionitis caused by increased local immunosuppression allowing indiscriminate bacterial entry; (3) prematurity and (4) intrauterine growth restriction are often associated with pregnancy-specific disease (pre-eclampsia) or pre-existing maternal conditions (systemic lupus); parental studies may improve outcome in subsequent pregnancies; (5) intrauterine death near term is often due to placental dysmaturity featuring a severely reduced number of syncytiocapillary membranes; it accounts for the death in utero of 3 in 1000 pregnancies; detection helps to minimise recurrence in subsequent pregnancies; (6) twins are best confirmed as monozygous by the absence of chorionic tissue in the dividing membranes; most monochorionic twins have vascular connections whose detailed analysis is requested only if there are inter-twin differences in growth and colour. From a formal point of view, many more bits of pathology than discussed in this review can be found in placentas and, with the advances in ultrasonography, might even be seen prior to birth. The extent of such a disturbance might ultimately affect fetal growth, which is amenable to prenatal detection offering the chances for an appropriate management. In contrast, dysmaturity is a great challenge as no predictive tests are as yet available.
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Muerte Fetal/patología , Mortalidad Infantil , Enfermedades del Recién Nacido/mortalidad , Placenta/patología , Resultado del Embarazo , Adulto , Femenino , Muerte Fetal/etiología , Humanos , Recién Nacido , EmbarazoRESUMEN
OBJECTIVE: To describe a novel, effective, and minimally invasive surgical technique for avoiding excess blood loss and hysterectomy in intractable postpartum hemorrhage. Previously described techniques-uterine artery ligation at various levels, hypogastric (internal iliac) artery ligation, uterine compression-all require an abdominal approach. METHODS: This procedure, which is quickly learned, is performable in the delivery room with minimal preparation, with or without bladder retraction. A 2-cm horizontal incision is made in the anterior cervix 1 cm beneath the estimated vaginocervical fold and the bladder reflected in the natural plane. Firm but gentle downward traction on the uterus to the contralateral side of the intended ligature maximizes cephalad and lateral access, permitting bilateral uterine artery ligation from laterally under direct vision and/or indirect transcervical palpation. RESULTS: Between November 1997 and June 2001, 13 women with intractable postpartum hemorrhage chose the vaginal route over laparotomy as a uterus-preserving procedure. Hysterectomy proved necessary in only one case (8%) because of placenta percreta. One woman has since delivered a healthy term infant by cesarean, and uterine vascularization was unimpaired. CONCLUSION: The vaginal route offers a novel, simple, effective, and minimally invasive technique for treating intractable puerperal hemorrhage by uterine artery ligation. Timely intervention avoids hysterectomy and consumption coagulopathy and preserves reproductive potential.
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Pérdida de Sangre Quirúrgica/prevención & control , Hemostasis Quirúrgica/métodos , Hemorragia Posparto/cirugía , Arterias/cirugía , Femenino , Humanos , Histerectomía , Ligadura/métodos , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Hemorragia Posparto/diagnóstico , Embarazo , Estudios Retrospectivos , Sensibilidad y Especificidad , Índice de Severidad de la Enfermedad , Resultado del Tratamiento , Útero/irrigación sanguínea , Vagina/irrigación sanguíneaRESUMEN
BACKGROUND: Although methadone maintenance is the standard treatment of opiate addiction in pregnancy, opinion as to its utility is divided. The aim of this study was to analyze polydrug abuse, pregnancy outcome and fetomaternal complications among pregnant women in a major Swiss methadone maintenance program. METHODS: Prospective data collection of all pregnant opiate addicts and their neonates from 1996 to 2001. RESULTS: Maternal complications occurred in 73% and fetal complications in 34% of the pregnancies. The average methadone dose at delivery in the 89 pregnancies was 40.9 +/- 32.7 (0-150) mg/day. Sixty-four percent of the women were co-users of cocaine and/or heroin. Birthweight was lower in polydrug abusers than in near-exclusive methadone users (p = 0.001). CONCLUSION: The high rate of maternal complications demonstrates the need for further improvement in antenatal management of opiate addiction in pregnancy. Methadone maintenance is inefficient in preventing pregnancy exposure to additional illicit drug consumption. Additional illicit heroin and/or cocaine abuse does not seem to increase the incidence of fetomaternal complications during pregnancy, but reverses the positive impact of methadone on birthweight. Heroin-assisted treatment may be a more effective method of minimizing the use of street drugs.
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Recien Nacido Prematuro , Metadona/uso terapéutico , Trastornos Relacionados con Opioides/tratamiento farmacológico , Complicaciones del Embarazo/tratamiento farmacológico , Resultado del Embarazo , Adulto , Peso al Nacer , Trastornos Relacionados con Cocaína/diagnóstico , Trastornos Relacionados con Cocaína/tratamiento farmacológico , Estudios de Cohortes , Relación Dosis-Respuesta a Droga , Esquema de Medicación , Femenino , Muerte Fetal , Desarrollo Fetal/fisiología , Estudios de Seguimiento , Dependencia de Heroína/diagnóstico , Dependencia de Heroína/tratamiento farmacológico , Humanos , Recién Nacido , Modelos Lineales , Servicios de Salud Materna , Trastornos Relacionados con Opioides/diagnóstico , Atención Perinatal/métodos , Embarazo , Complicaciones del Embarazo/diagnóstico , Probabilidad , Estudios Prospectivos , Sistema de Registros , Medición de Riesgo , Estadísticas no Paramétricas , Suiza , Resultado del TratamientoRESUMEN
AIMS: To document, and explain, the pulmonary paradox whereby despite relative lung immaturity, preterm infants exposed to amniotic infection (AI) have better postnatal pulmonary function than those exposed to preeclampsia (PE). METHODS: Lung maturation was characterized in 65 preterm perinatal deaths [AI (n=40) and PE (n=25)] and postnatal respiratory function in 100 preterm survivors [AI (n=50) and PE (n=50)]. RESULTS: At autopsy, lung architecture was in advance of gestational age in 5% of AI infants versus 40% of PE infants (P<0.001). In survivors, the groups were similar in age and Apgar scores. At birth, 40% of the AI group required continuous positive airway pressure or mechanical ventilation versus 24% of the PE group (NS). However, 24 hours later, only 1 AI infant had deteriorated compared to 40% of PE infants (P<0.05). CONCLUSIONS: Accelerated morphologic lung maturation in preterm PE infants does not translate into improved postnatal respiratory function. Most likely, this is due to a relative lack of surfactant, ascribable to low stimulant cytokine and high TNF-alpha levels. An intrauterine history supplemented by an antenatal cytokine profile could identify an increased exogeneous surfactant need in preterm infants exposed to PE.
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Amnios , Madurez de los Órganos Fetales , Recien Nacido Prematuro , Infecciones , Pulmón/embriología , Complicaciones Infecciosas del Embarazo , Enfermedad Crónica , Femenino , Edad Gestacional , Humanos , Mortalidad Infantil , Recién Nacido , Pulmón/patología , Pulmón/fisiopatología , Enfermedades Pulmonares/epidemiología , Oxígeno/administración & dosificación , Preeclampsia/fisiopatología , Embarazo , Respiración ArtificialRESUMEN
BACKGROUND: Maternal cocaine abuse in pregnancy is associated with complications such as intrauterine growth retardation, abruptio placentae, and preterm delivery. CASE: We report what is, to our knowledge, the first published observation of fetal bilateral renal agenesis associated with a vascular disruption syndrome comprising upper limb reduction defect and a single umbilical artery following maternal cocaine abuse in early pregnancy. CONCLUSIONS: This constellation in a fetus aborted at 18 weeks extends the spectrum of complications possibly associated with cocaine abuse in pregnancy.
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Anomalías Múltiples/inducido químicamente , Anomalías Múltiples/diagnóstico , Trastornos Relacionados con Cocaína , Cocaína/toxicidad , Ectromelia/inducido químicamente , Riñón/anomalías , Exposición Materna , Arterias Umbilicales/anomalías , Adulto , Anomalías Congénitas , Femenino , Feto/efectos de los fármacos , Humanos , Masculino , Intercambio Materno-Fetal , EmbarazoRESUMEN
AIMS: To measure maternal serum interleukins (IL) in pregnancy, delivery and early puerperium, and to identify their potential determinants. METHODS: Prospective longitudinal measures of serum IL-1 beta, IL-6 and IL-8 in 38 healthy pregnant women at antenatal visits, through labor and delivery, with clinical correlates (infection, vaginal hemorrhage and anemia) recorded by questionnaire. RESULTS: Pregnancy IL levels remained consistently low. IL-1 beta increased shortly before delivery, then returned to pregnant levels, except where blood loss exceeded 500 ml. IL-6 and IL-8 rose at labor onset and exceeded pregnancy levels through postpartum day three. Postpartum IL-6 was higher after non-elective cesarean section than after spontaneous delivery (P < 0.0001), and where blood loss exceeded 500 ml. IL-6 and IL-8 were higher with systemic infection during delivery (P < 0.0001) and on postpartum day one (P < 0.05); IL-8 was higher in anemia (delivery: P < 0.005; postpartum day 1: P < 0.05). Differences due to delivery mode and systemic infection remained significant after correction for other conditions. CONCLUSIONS: Labor-dependent inflammation increases all IL levels at delivery. Further studies with larger sample sizes are required to establish reference values differentiating physiology from pathology as an aid to peripartum management.