Direct current cardioversion in pregnancy: a multicentre study.

OBJECTIVE: Direct current cardioversion (DCCV) in pregnancy is rarely required and typically only documented in single case reports or case series. A recent UK confidential enquiry reported on several maternal deaths where appropriate DCCV appeared to have been withheld. DESIGN: Retrospective cohort study. SETTING: Seventeen UK and Ireland specialist maternity centres. SAMPLE: Twenty-seven pregnant women requiring DCCV in pregnancy. MAIN OUTCOME MEASURES: Maternal and fetal outcomes following DCCV. RESULTS: Twenty-seven women had a total of 29 DCCVs in pregnancy. Of these, 19 (70%) initial presentations were to Emergency Departments and eight (30%) to maternity settings. There were no maternal deaths. Seventeen of the women (63%) had a prior history of heart disease. Median gestation at DCCV was 28 weeks, median gestation at delivery was 35 weeks, with a live birth in all cases. The abnormal heart rhythms documented at the first cardioversion were atrial fibrillation in 12/27 (44%) cases, atrial flutter in 8/27 (30%), supraventricular tachycardia in 5/27 (19%) and atrial tachycardia in 2/27 (7%). Fetal monitoring was undertaken following DCCV on 14/29 (48%) occasions (10 of 19 (53%) at ≥26 weeks) and on 2/29 (7%) occasions, urgent delivery was required post DCCV. CONCLUSIONS: Direct current cardioversion in pregnancy is rarely required but should be undertaken when clinically indicated according to standard algorithms to optimise maternal wellbeing. Once the woman is stable post DCCV, gestation-relevant fetal monitoring should be undertaken. Maternity units should develop multidisciplinary processes to ensure pregnant women receive the same standard of care as their non-pregnant counterparts.

Blunt thoracic trauma--an analysis of 264 patients in Rawalpindi, Pakistan.

OBJECTIVE: To analyse the outcome in terms of morbidity and mortality in blunt thoracic trauma patients in tertiary care hospitals, Rawalpindi. METHODS: The prospective study was conducted from March 2008 to February 2012 in surgical wards of public and private sector hospitals in Rawalpindi. A total of 221 patients were included from the Combined Military Hospital during 2008-10, and 43 patients from the Heart's International during 2011-12. The patients reported to emergency department within 48 hours of trauma. All patients were subjected to detailed history and respiratory system examination to ascertain fracture of ribs, flail segment and haemopneumothorax. The diagnosis of chest wall injuries, parenchymal pulmonary injuries and pleural involvement were made on the basis of chest radiographs and computed tomography scan of the chest. The lung contusion was assessed by the number of lobes involved. SPSS 19 was used for statistical analysis. RESULTS: Of the 264 patients in the study, 211 (80%) were males and 54 (20%) females. The overall mean age was 44.8 +/- 17.1 years. Over all morbidity was 222 (84.2%); morbidity (minor) was 128 (48.5%), and morbidity (major) was 94 (35.7%). Mortality was 26 (9.8%) and 16 (6%) cases had normal outcome. CONCLUSION: Early identification and aggressive management of blunt thoracic trauma is essential to reducing significant rates of morbidity and mortality.

Challenges of prenatal diagnosis in obese pregnant women.

Obesity rates are increasing world-wide with most of the increase in women of the reproductive age group. While recognised as an important contributor to non-communicable diseases, pregnant women with obesity are particularly at risk of not only maternal and pregnant complications but also have an increased risk of congenital malformations. Furthermore, pregnant obese women are more likely to be older and therefore at a greater risk of aneuploidy. Prenatal diagnosis in these women especially those who are morbidly obese is challenging due not only to their weight but the implications of the increase adiposity on biochemical markers of aneuploidy. In this review we discuss the current challenges in providing prenatal diagnosis for these women including those related to the ergonomics of ultrasound and those inherent in them because of their obesity. Appropriate counselling for these women should include the lower sensitivity of the tests, the difficulties in performing some of the procedures (imaging and invasive testing) as well as the increased risk of structural abnormalities related to their obesity.

Oxytocin versus no treatment or delayed treatment for slow progress in the first stage of spontaneous labour.

BACKGROUND: Slow progress in the first stage of spontaneous labour is associated with an increased caesarean section rate and fetal and maternal morbidity. Oxytocin has long been advocated as a treatment for slow progress in labour but it is unclear to what extent it improves the outcomes for that labour and whether it actually reduces the caesarean section rate or maternal and fetal morbidity. This review will address the use of oxytocin and whether it improves the outcomes for women who are progressing slowly in labour compared to situations where it is not used or where its administration is delayed. OBJECTIVES: To determine if the use of oxytocin for the treatment of slow progress in the first stage of spontaneous labour is associated with a reduction in the incidence of caesarean sections, or maternal and fetal morbidity compared to situations where it is not used or where its administration is delayed. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (23 February 2013) and bibliographies of relevant papers. SELECTION CRITERIA: Randomised controlled trials which compared oxytocin with either placebo, no treatment or delayed oxytocin in the active stage of spontaneous labour in low-risk women at term. DATA COLLECTION AND ANALYSIS: Two authors independently assessed studies for inclusion, assessed risk of bias and extracted data. We sought additional information from trial authors. MAIN RESULTS: We included eight studies in the review involving a total of 1338 low-risk women in the first stage of spontaneous labour at term. Two comparisons were made; 1) the use of oxytocin versus placebo or no treatment (three trials); 2) the early use of oxytocin versus its delayed use (five trials). There were no significant differences in the rates of caesarean section or instrumental vaginal delivery in either comparison. Early use of oxytocin resulted in an increase in uterine hyperstimulation associated with fetal heart changes. However, the early use of oxytocin versus its delayed use resulted in no significant differences in a range of neonatal and maternal outcomes. Use of early oxytocin resulted in a statistically significant reduction in the mean duration in labour of approximately two hours but did not increase the normal delivery rate. There was significant heterogeneity for this analysis and we carried out a random-effects meta-analysis; however, all of the trials are strongly in the same direction so it is reasonable to conclude that this is the true effect. We also performed a random-effects meta-analysis for the four other analyses which showed substantial heterogeneity in the review. AUTHORS' CONCLUSIONS: For women making slow progress in spontaneous labour, treatment with oxytocin as compared with no treatment or delayed oxytocin treatment did not result in any discernable difference in the number of caesarean sections performed. In addition there were no detectable adverse effects for mother or baby. The use of oxytocin was associated with a reduction in the time to delivery of approximately two hours which might be important to some women. However, if the primary goal of this treatment is to reduce caesarean section rates, then doctors and midwives may have to look for alternative options.

Assessment of stress among physiotherapy students at Riphah Centre of Rehabilitation Sciences.

OBJECTIVE: To assess stress and psychological morbidity in undergraduate students of physiotherapy at Riphah Centre of Rehabilitation Sciences (RCRS). METHODS: A cross-sectional study was conducted from 2008 to 2010 at RCRS. Two hundred and thirty one students from first semester to fourth semester were included in the study. The data was collected through a semi-structured proforma and the Student Life Stress Inventory (SLSI) scale. Data was analysed by applying t-test and ANOVA with SPSS version 17. RESULTS: Two hundred and three respondents (88%) reported feeling stressed: 97(42%) students were mildly stressed, 92(40%) were moderately stressed, and 14 (6%) were severely stressed. Significant gender differences were found on the total score of stress, stressors and reactions. The findings revealed that females face more stressors especially pressures (p<0.001), physiological, emotional (p<0.01) and behavioural (p<0.05). An analysis of variance on SLSI is significant, F = 3.747 (p<.05). Mean difference indicates that prevalence of stress is higher in 4th semester RCRS students. CONCLUSION: The findings reveal the higher level of stress in undergraduate physiotherapy students. The high psychological morbidity necessitates the need for interventions like counseling and psychological support to improve the quality of life for these allied health care professionals.

Promoting healthy workplaces--health pledges initiative at North Kirklees Primary Care Trust, NHS, England.

OBJECTIVE: To evaluate the effectiveness of health promotion activities targeting physical activity, healthy eating, smoking and stress management as a part of healthy workplace initiative at North Kirklees Primary Care Trust, England. METHODS: The quasi-experimental interventional study was conducted from April 2005 to March 2006 and involved all the employees of the North Kirklees Primary Care Trust, England, who were willing to participate. Main interventions were; lunch-time walk, motivational interviews, counselling and support sessions from qualified dieticians, physical activity and smoking cessation advisors. Free occupational therapy sessions were provided at the workplace. Incentives like discounted vouchers for sports club and the gymnasium were also given. Pre- and post-intervention data was collected and analysed using SPSS version 17. RESULTS: Of the total, 57 (42%) pledged to undertake physical activity; 50 (37%) healthy eating; 20 (15%) mental and emotional well-being; and 8 (6%) to quit smoking. Statistically significant associations were found between different health promotion activities like physical activity (p = 0.004), healthy eating (p = 0.003), stress management and stop smoking (p = 0.001) at the workplace. CONCLUSION: Workplace is a potentially valuable setting for health promotional activities for primary prevention and may facilitate lifestyle modification.

Oxytocin versus no treatment or delayed treatment for slow progress in the first stage of spontaneous labour.

BACKGROUND: Slow progress in the first stage of spontaneous labour is associated with an increased caesarean section rate and fetal and maternal morbidity. Oxytocin has long been advocated as a treatment for slow progress in labour but it is unclear to what extent it improves the outcomes for that labour and whether it actually reduces the caesarean section rate or maternal and fetal morbidity. This review will address the use of oxytocin and whether it improves the outcomes for women who are progressing slowly in labour compared to situations where it is not used or where its administration is delayed. OBJECTIVES: To determine if the use of oxytocin for the treatment of slow progress in the first stage of spontaneous labour is associated with a reduction in the incidence of caesarean sections, or maternal and fetal morbidity compared to situations where it is not used or where its administration is delayed. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 April 2011) and bibliographies of relevant papers. SELECTION CRITERIA: Randomised controlled trials which compared oxytocin with either placebo, no treatment or delayed oxytocin in the active stage of spontaneous labour in low-risk women at term. DATA COLLECTION AND ANALYSIS: Two authors independently assessed studies for inclusion, assessed risk of bias and extracted data. We sought additional information from trial authors. MAIN RESULTS: We included eight studies in the review involving a total of 1338 low-risk women in the first stage of spontaneous labour at term. Two comparisons were made; 1) the use of oxytocin versus placebo or no treatment (three trials); 2) the early use of oxytocin versus its delayed use (five trials). There were no significant differences in the rates of caesarean section or instrumental vaginal delivery in either comparison. Early use of oxytocin resulted in an increase in uterine hyperstimulation associated with fetal heart changes. However, the early use of oxytocin versus its delayed use resulted in no significant differences in a range of neonatal and maternal outcomes. Use of early oxytocin resulted in a statistically significant reduction in the mean duration in labour of approximately two hours but did not increase the normal delivery rate. There was significant heterogeneity for this analysis and we carried out a random-effects meta-analysis; however, all of the trials are strongly in the same direction so it is reasonable to conclude that this is the true effect. We also performed a random-effects meta-analysis for the four other analyses which showed substantial heterogeneity in the review. AUTHORS' CONCLUSIONS: For women making slow progress in spontaneous labour, treatment with oxytocin as compared with no treatment or delayed oxytocin treatment did not result in any discernable difference in the number of caesarean sections performed. In addition there were no detectable adverse effects for mother or baby. The use of oxytocin was associated with a reduction in the time to delivery of approximately two hours which might be important to some women. However, if the primary goal of this treatment is to reduce caesarean section rates, then doctors and midwives may have to look for alternative options.

Peripartum considerations and challenges in the management of type IV Ehlers-Danlos syndrome.

Ehlers-Danlos syndrome (EDS) is an uncommon heterogenous autosomal dominant multisystemic connective tissue disorder, which may potentially present with life-threatening emergencies. The prevalence of EDS of all subtypes is from 1 in 10 000 to 1 in 20 000. Pregnancy in women with type IV EDS poses significant challenges, necessitating the care of multidisciplinary team. Potential complications of type IV EDS include arterial dissection, arterial aneurysm, visceral rupture, excessive bleeding, tissue fragility and delayed wound healing. We present an interesting case of a pregnant woman with type IV EDS who had previous cerebrovascular complications and had a successful delivery in our tertiary centre following a collaborative approach to her care.

COVID-19 complicated by hepatic dysfunction in a 28-week pregnant woman.

The COVID-19 outbreak has spread across the globe at an alarming rate. As the pandemic escalates, experience of COVID-19 in pregnant women is accumulating. We present a case of COVID-19 pneumonia in a 28-week pregnant woman with a known low lying placenta. The patient had deranged liver function tests at presentation, along with elevated bile acids. We discuss the differential diagnosis of these findings, and the possible mechanisms of hepatic injury in COVID-19. The low lying placenta in this patient meant that we had to carefully consider the application of recommendations for thromboprophylaxis in pregnant COVID-19 patients. With supportive management, this patient improved enough to be discharged, and has gone on to deliver a healthy neonate at term.