Increased rates of chorioamnionitis with extra-amniotic saline infusion method of labor induction.

OBJECTIVE: Extra-amniotic saline infusion has been shown to be equal to or more efficacious than misoprostol, laminaria, dinoprostone, and prostaglandin estradiol for cervical ripening and labor induction. Because of the introduction of a foreign body into the uterus, extra-amniotic saline infusion may potentially cause increased rates of chorioamnionitis. This study examines the risk of chorioamnionitis with extra-amniotic saline infusion compared with other methods of induction and spontaneous labor. METHODS: A retrospective analysis was performed based on deliveries at Bellevue Hospital Center, a tertiary-care facility, from August 2000 to December 2002. Three groups were identified: extra-amniotic saline infusion, other methods of induction, and spontaneous labor. Differences in chorioamnionitis rates were analyzed by using analysis of variance and multivariable logistic regression as appropriate. RESULTS: There were 625 charts evaluated: 171 extra-amniotic saline infusion, 190 other, and 264 with spontaneous labor. The rates of chorioamnionitis were 26.9%, 17.9%, and 13.3%, respectively. After adjusting for confounding variables, such as instrumentation, length of rupture, and number of exams, subjects who were induced with extra-amniotic saline infusion were significantly more likely to develop chorioamnionitis (relative risk = 2.2; 95% confidence interval 1.4, 4.0; P =.006). CONCLUSION: Extra-amniotic saline infusion may be associated with a greater risk of chorioamnionitis when compared with other methods of labor induction. Given the increased risk of chorioamnionitis associated with extra-amniotic saline infusion, its use should be in the context of a careful assessment of the risks and benefits of various methods of labor induction. LEVEL OF EVIDENCE: II-2

An ethnic predilection for fetal echogenic intracardiac focus identified during targeted midtrimester ultrasound examination: A retrospective review.

BACKGROUND: Echogenic intracardiac focus (EIF) has been identified as a common ultrasound finding in association with fetal aneuploidy. Little is known about the association of this soft marker aneuploidy in various ethnic groups. Although it is commonly thought Asians in general have a higher incidence of EIF, it is unknown whether this also applies to Japanese as a subpopulation. The purpose of this study is to determine the antenatal incidence and postnatal significance of EIF observed during sonography in Japanese patients. METHODS: A cohort of Japanese patients who underwent ultrasound screening from 1997 to 1999 in the ultrasound unit at the New York University School of Medicine was identified. Variables included age, gestational age, serum markers, and the presence or absence of aneuploidy. Patients with first degree paternal or maternal Japanese ancestry were included for analysis. Examinations were performed between 14 and 24 weeks gestation. The prevalence of EIF was calculated. The control group was based on previously published data in the U.S (7.3% prevalence). RESULTS: A total of 154 subjects were identified, 148 were available for final analysis. Twenty-two fetuses had an EIF, 19 (86.4%) left-sided, 3 (13.6%) right-sided. Seventeen patients had other sonographic markers associated with aneuploidy. The mean maternal age at diagnosis was 30.7 +/- 3.9 years and the mean gestational age was 19.8 +/- 1.6 weeks. The prevalence of EIF was 14.8%. Compared to published population prevalence, there was a statistically significant difference (p < 0.005). No abnormal karyotypes were found. CONCLUSION: Asians of Japanese origin may have a higher prevalence of echogenic intracardiac foci, thus affecting the positive predictive value of this sonographic marker for aneuploidy.

Use of fluorescence imaging technology to identify peritoneal endometriosis: a case report of new technology.

Indocyanine green has long been used to determine the vascularity of various anatomic structures. Endometriosis is a disease that features neovascularization as a part of its pathologic process. Presented is a case of detecting endometriosis with indocyanine green using the fluorescence imaging technology built into the daVinci Si surgical platform.

Successful treatment of refractory pudendal neuralgia with pulsed radiofrequency.

Pudendal neuralgia (PN) involves severe, sharp pain along the course of the pudendal nerve, often aggravated with sitting. Current therapies include medication management, nerve blocks, decompression surgery, and neuromodulation. The ideal management for PN has not been determined. We present a case of a female with 1.5 years of sharp, burning pain of the left gluteal and perineal regions. She could not sit for longer than 10 to 15 minutes. Sacroiliac joint, epidural, and piriformis injections did not improve her pain. She had tried physical therapy, occupational therapy, massage, and acupuncture but the pain persisted. Medication treatment with oxycodone-acetaminophen, extended release morphine sulfate, amitriptyline, and gabapentin provided only minor relief and she had failed other multianalgesic therapy. She had been unable to work at her desk job for over a year. She had a positive response to 2 diagnostic pudendal nerve blocks with lidocaine that provided pain relief for several hours. This patient elected to undergo pulsed radiofrequency (PRF) of the left pudendal nerve in hopes of achieving a longer duration and improved pain relief. PRF was carried out at a frequency of 2 Hz and a pulse width of 20 milliseconds for a duration of 120 seconds at 42 degrees Celsius. After the procedure she reported tolerating sitting for 4 to 5 hours. Her multianalgesic therapy was successfully weaned. At 5 months follow-up she felt motivated to return to work. One and a half years after the procedure the patient is only taking oxycodone-acetaminophen for pain relief and still has good sitting tolerance. There were no procedure-related complications. To our knowledge PRF for the treatment of PN has not been reported elsewhere in the literature. PRF is a relatively new procedure and is felt to be safer than continuous radiofrequency. Current literature suggests that PRF delivers an electromagnetic field, which modifies neuro-cellular function with minimal cellular destruction. We conclude that PRF of the pudendal nerve offers promise as a potential treatment of PN that is refractory to conservative therapy.

Extra-amniotic saline infusion increases cesarean risk versus other induction methods and spontaneous labor.

Extra-amniotic saline infusion (EASI) via a Foley catheter has been thought to be comparable in efficacy to other induction and cervical ripening methods. This study examines the risk of cesarean delivery associated with EASI compared with spontaneous labor and other methods of cervical ripening. A retrospective cohort study based upon deliveries at Bellevue Hospital Center from August 2000 to December 2002 was conducted. Three groups were identified: EASI, other methods of induction such as prostaglandins and oxytocin administration, and spontaneous labor. Pairwise comparisons were performed using analysis of variance and multivariate logistic regression analysis to control for confounding variables. There were 625 charts evaluated: including 171 with EASI, 190 with other induction methods, and 264 with spontaneous labor. The rates of cesarean section were 33.9%, 17.9%, and 7.2%, respectively. When compared with spontaneous labor, there was a higher risk of cesarean delivery for subjects induced with other methods (adjusted odds ratio [OR], 2.4; 95% confidence interval [CI], 1.3 to 4.5; P < 0.001), and for those induced with EASI (adjusted OR, 5.5; 95% CI, 3.1 to 9.9; P < 0.001). When EASI was compared with other methods of induction, the risk of cesarean delivery was still increased (adjusted OR, 2.3; 95% CI, 1.4 to 3.8; P = 0.001). EASI is associated with an increased risk of cesarean delivery compared with spontaneous labor and other methods of cervical ripening.