Application of 3-dimensional ultrasonography to imaging the fetal anal canal.

OBJECTIVE: Ultrasonography has been applied previously to the assessment of the fetal anal canal. We aimed to examine the potential of 3-dimensional ultrasonography (3DUS) in the evaluation of the fetal anal canal and to obtain normal fetal anal canal measurements. METHODS: Patients were recruited from an unselected population of gravidas with known gestational age (by dates or first-trimester ultrasonography) and without known fetal anomalies presenting for fetal evaluation in the ultrasound units of 2 tertiary care centers between 16 and 39 gestational weeks. In addition to the ordered scan, 3DUS imaging of the fetal anal canal was performed. Transverse and sagittal views and volumes were obtained. Measurements of the fetal anal canal anteroposterior diameter, lateral diameter, and length were performed in transverse and sagittal planes, respectively, and scatterplots of these dimensions were created. Measurements were performed and repeated on raw data sets by 2 independent observers, and the results were analyzed to estimate interobserver and intraobserver reliability. RESULTS: A total of 186 patients were examined for this study at 16 to 39 weeks' gestation (mean, 27.4 weeks). The anteroposterior diameter of the fetal anal canal in this study group ranged from 4 to 21 mm (mean, 11.2 mm; SD, +/-3.5 mm), whereas the lateral diameter ranged from 7 to 18 mm (mean, 9.1 mm; SD, +/-3.0 mm). The length of the fetal anal canal in this study group ranged from 3 to 24 mm (mean, 14.3 mm; SD, +/-3.8 mm). CONCLUSIONS: Ultrasonographic assessment of the fetal anal canal with 3DUS is feasible. Scatterplots were created for internal anal sphincter width and length measurements from 16 to 39 weeks' gestation. Larger studies are necessary to establish nomograms of these measurements and their application to the evaluation of pathologic cases. We speculate that 3DUS assessment of the fetal anal canal may improve detection rates of disorders involving this system.

Mifepristone followed by high-dose oxytocin drip for second-trimester abortion: a randomized, double-blind, placebo-controlled, pilot study.

OBJECTIVE: To study the effect of mifepristone for priming and induction of second-trimester abortion in conjunction with a high-concentration oxytocin drip. STUDY DESIGN: Prospective, randomized, placebo-controlled, pilot study. Thirty patients with 14-25 weeks' gestational age abortion received either 600 mg of mifepristone or placebo in 3 identical capsules followed, 48 hours later, by a high-concentration oxytocin drip (HCOD). RESULTS: The mifepristone group showed significantly higher success rates as compared to the placebo group (92.3% vs. 52.9%, p<0.05). The time interval to abortion (from beginning of HCOD) was also significantly shorter in the mifepristone group as compared to the placebo group (11.3 +/- 6.0 hours vs. 17.6 +/- 6.5 hours, p <0.05). Probability of success as calculated by the Kaplan-Meier method was found to be highly significant (log rank test p = 0.001). CONCLUSION: Our results suggest that mifepristone is very effective for priming and induction of second-trimester abortion and shortens significantly the time interval to evacuation following HCOD.

Prognostic parameters for successful external cephalic version.

OBJECTIVE: To improve patient consultation before external cephalic version (ECV) attempt at term by defining prognostic parameters for the success of the procedure. METHODS: This was a prospective observational study set in a university teaching hospital. We prospectively collected demographic and obstetric data from 603 ECV attempts at our center for the period between January 1997 and June 2005. Analysis was performed by stepwise logistic regression of the demographic and obstetric parameters. The main outcome measure was success of ECV attempt. RESULTS: Success rates were 72.3% and 46.1% for multiparas and nulliparas, respectively. Prognostic parameters associated with successful ECV were amniotic fluid index > 7 cm, multiparity, non-frank breech, non-anterior placental location, and body mass index < 25. CONCLUSION: Prognostic parameters, particularly amniotic fluid index and multiparity, can help physicians in counseling parturients before deciding on ECV.

Endometrial carcinoma first presenting as paraneoplastic cerebellar degeneration.

BACKGROUND: Paraneoplastic degeneration (PCD) is an immune-mediated disorder affecting the cerebellum, characterized by subacute onset of cerebellar dysfunction progressing to severe disability, and is associated with an underlying malignancy. Ovarian carcinoma and breast carcinoma are commonly implicated. CASE: We report a rare case PCD in an elderly woman, later diagnosed with endometrial carcinoma. CONCLUSION: PCD is an unusual and rare manifestation of gynecological malignancies, including endometrial carcinoma, and a high degree of suspicion is required in these cases in order to make the correct diagnosis.

Physician versus paramedic in the setting of ground forces operations: are they interchangeable?

BACKGROUND: The setting of military ground force operations can be demanding and requires a matched medical assistance plan. A major consideration is the type of medical caregiver that is assigned to the mission. We studied the similarities, differences, advantages, and disadvantages of physicians versus paramedics in this scenario. METHODS: We interviewed 20 ground force physicians, highly experienced in this setting. We summarized their responses and formulated quantitative decision-making tables regarding two sorts of missions: a long-duration mission, far from friendly definitive care, and a short-duration mission, close to friendly hospitals. RESULTS: The major areas in which physicians and paramedics differ, pertinent to a ground force operation are: formal education, on-job training, knowledge base, ability to treat a wide variety of medical conditions, ability to perform manual lifesaving procedures, social and moral impact, availability, physical fitness, combat skills, and cost. Of a maximum score of 100 points, for a long-term mission a physician scores 77.7 points while a paramedic scores 63.6 points. The scores for a short-term mission are 72.7 and 67.9, respectively. DISCUSSION: Physicians and paramedics are distinct groups of medical caregivers and this is also true for the setting of ground force operations. They are not interchangeable. Our data show that a physician has a relative advantage over a paramedic, especially in long-term missions, far from friendly facilities. CONCLUSION: A physician is the first choice for all kinds of military ground force missions while a paramedic can be a reasonable substitute for missions of short duration, close to definitive care.