Descent of fetal head during active pushing: secondary analysis of prospective cohort study investigating ultrasound examination before operative vaginal delivery.

OBJECTIVES: To investigate if descent of the fetal head during active pushing is associated with duration of operative vaginal delivery, mode of delivery and neonatal outcome in nulliparous women with prolonged second stage of labor. METHODS: This was a prospective cohort study of nulliparous women with prolonged second stage of labor, conducted between November 2013 and July 2016 in five European countries. Fetal head descent was measured using transperineal ultrasound. Head-perineum distance (HPD) was measured between contractions and on maximum contraction during active pushing, and the difference between these values (ΔHPD) was calculated. The main outcome was duration of operative vaginal delivery, estimated using survival analysis to calculate hazard ratios (HRs) for vaginal delivery, with values > 1 indicating a shorter duration. HR was adjusted for prepregnancy body mass index, maternal age, induction of labor, augmentation with oxytocin and use of epidural analgesia. Pregnancies were grouped according to ΔHPD quartile, and delivery mode and neonatal outcome were compared between groups. RESULTS: The study population comprised 204 women. Duration of vacuum extraction was shorter with increasing ΔHPD. Estimated mean duration was 10.0, 9.0, 8.8 and 7.5 min in pregnancies with ΔHPD in the first to fourth quartiles, respectively, and the adjusted HR for vaginal delivery, using increasing ΔHPD as a continuous variable, was 1.04 (95% CI, 1.01-1.08). Mean ΔHPD was 7 mm (range, -10 to 37 mm). ΔHPD was either negative or ≤ 2 mm in the lowest quartile. In this group, 7/50 (14%) pregnancies were delivered by Cesarean section, compared with 8/154 (5%) of those with ΔHPD > 2 mm (P < 0.05). There was no significant association between umbilical artery pH < 7.10 or 5-min Apgar score < 7 and ΔHPD quartile. CONCLUSION: Minimal or no fetal head descent during active pushing was associated with longer duration of operative vaginal delivery and higher frequency of Cesarean section in nulliparous women with prolonged second stage of labor. © 2019 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

Overweight in childhood and adolescence: Does it lead to airway hyperresponsiveness in adulthood?

BACKGROUND: Obesity is increasing worldwide among children and adolescents, and has been associated with an increased incidence of asthma. However, the mechanisms underlying this association are incompletely understood. OBJECTIVE: In this cohort study we aimed to investigate whether being overweight in childhood and adolescence is associated with an increased risk of airway hyperresponsiveness (AHR), a hallmark of asthma, in early adulthood. METHODS: Of 527 subjects from a random population sample of children and adolescents (7-17 years) examined at baseline, a total of 184 subjects completed the follow-up visit 20 years later and were included in the present analysis. Both visits included assessment of height and weight, case history and spirometry. At both visits, bronchial provocation tests were performed using either histamine (baseline) or methacholine (follow-up). In addition, fractional exhaled nitric oxide (FeNO) was measured at follow-up. RESULTS: No significant difference in the prevalence of AHR at follow-up was found between subjects who were overweight or obese at baseline visit (n = 26) (pediatric definition, body mass index ≥ 85%percentile) and normal weight subjects (n = 158) (positive bronchial provocation tests: 15.4% vs. 22.2%, respectively, p = 0.35). Likewise, follow-up FeNO levels did not differ significantly between subjects who were lean and those who were overweight or obese at baseline (geometric mean (95% confidence interval [CI]) 15.1 (13.7, 16.6) parts per billion (ppb) versus 13.0 (10.6, 15.9) ppb, p = 0.23). CONCLUSION: In children and adolescents, being obese or overweight seems not to be associated with an increased risk of AHR or increased FeNO levels in early adulthood.

Methotrexate or expectant management in women with an ectopic pregnancy or pregnancy of unknown location and low serum hCG concentrations? A randomized comparison.

STUDY QUESTION: What is the treatment success rate of systemic methotrexate (MTX) compared with expectant management in women with an ectopic pregnancy or a pregnancy of unknown location (PUL) with low and plateauing serum hCG concentrations? SUMMARY ANSWER: In women with an ectopic pregnancy or a PUL and low and plateauing serum hCG concentrations, expectant management is an alternative to medical treatment with single-dose systemic MTX. WHAT IS KNOWN AND WHAT THIS PAPER ADDS: MTX is often used in asymptomatic women with an ectopic pregnancy or a PUL with low and plateauing serum hCG concentrations. These pregnancies may be self-limiting and watchful waiting is suggested as an alternative, but evidence from RCTs is lacking. The results of this RCT show that expectant management is an alternative to treatment with systemic MTX in a single-dose regimen in these women. STUDY DESIGN, SIZE, DURATION: A multicentre RCT women were assigned to systemic MTX (single dose) treatment or expectant management, using a web-based randomization program, block randomization with stratification for hospital and serum hCG concentration (<1000 versus 1000-2000 IU/l). The primary outcome measure was an uneventful decline of serum hCG to an undetectable level (<2 IU/l) by the initial intervention strategy. Secondary outcome measures included additional treatment, side effects and serum hCG clearance time. PARTICIPANTS, SETTING, METHODS: From April 2007 to January 2012, we performed a multicentre study in The Netherlands. All haemodynamically stable women >18 years old with both an ectopic pregnancy visible on transvaginal sonography and a plateauing serum hCG concentration <1500 IU/l or with a PUL and a plateauing serum hCG concentration <2000 IU/l were eligible for the trial. MAIN RESULTS: We included 73 women of whom 41 were allocated to single-dose MTX and 32 to expectant management. There was no difference in primary treatment success rate of single-dose MTX versus expectant management, 31/41 (76%) and 19/32 (59%), respectively [relative risk (RR) 1.3 95% confidence interval (CI) 0.9-1.8]. In nine women (22%), additional MTX injections were needed, compared with nine women (28%) in whom systemic MTX was administered after initial expectant management (RR 0.8; 95% CI 0.4-1.7). One woman (2%) from the MTX group underwent surgery compared with four women (13%) in the expectant management group (RR 0.2; 95% CI 0.02-1.7), all after experiencing abdominal pain within the first week of follow-up. In the MTX group, nine women reported side effects versus none in the expectant management group. No serious adverse events were reported. Single-dose systemic MTX does not have a larger treatment effect compared with expectant management in women with an ectopic pregnancy or a PUL and low and plateauing serum hCG concentrations. WIDER IMPLICATIONS OF THE FINDINGS: Sixty percent of women after expectant management had an uneventful clinical course with steadily declining serum hCG levels without any intervention, which means that MTX, a potentially harmful drug, can be withheld in these women. BIAS, LIMITATION AND GENERALISABILITY: A limitation of this RCT is that it was an open (not placebo controlled) trial. Nevertheless, introduction of bias was probably limited by the strict criteria to be fulfilled for treatment with MTX. STUDY FUNDING: This trial is supported by a grant of the Netherlands Organization for Health Research and Development (ZonMw Clinical fellow grant 90700154). TRIAL REGISTRATION: ISRCTN 48210491.

Chronic mucus hypersecretion: prevalence and risk factors in younger individuals.

SETTING: Chronic mucus hypersecretion (CMH) is a common condition in patients with chronic respiratory diseases. Little is known about the incidence, prevalence and determinants of CMH in younger individuals. OBJECTIVE: To determine prevalence, incidence and risk factors for CMH in a young general population. DESIGN: A cohort of Danish twins (aged 12-41 years) was prospectively examined using questionnaires in 1994 (n = 29 180) and in 2002 (n = 21 130). Prevalence and incidence of CMH were determined, and risk factors for the condition were assessed using logistic regression. RESULTS: Lifetime prevalence of CMH was 8.6% in females and 6.9% in males in 1994, and the cumulative incidence among females and males was respectively 10.7% and 8.7% during the study period. Smoking and asthma were risk factors for CMH, with a dose-response effect of tobacco consumption, and smoking habits also predicting incidence of CMH. CONCLUSION: Among the young, CMH is a condition related to asthma and smoking, with a dose-response relationship with tobacco consumption and a relation between smoking habits and incidence. Female susceptibility to development of CMH was observed, as well as signs of greater susceptibility related to young age.

Pregnancy after Caesarean section: fewer or later?

BACKGROUND: It is unclear whether having a Caesarean section results in fewer subsequent pregnancies with longer intervals between pregnancies, an effect which may impact on the reproductive performance of a population. Our aim was to determine the implications of a Caesarean section on the subsequent fecundity and interpregnancy interval. METHODS: This is a cohort study. The obstetric follow-up of primiparous women who delivered by a Caesarean section of a singleton infant in breech presentation is compared with the follow-up of women who delivered vaginally of a singleton infant after a physiological, uncomplicated pregnancy. RESULTS: A total of 279 women delivered a singleton infant in breech presentation at term. From these women, 165 (59.1%) had a Caesarean section. In this group, 131 (79.4%) women had a subsequent pregnancy. In the reference group of 268 women who delivered vaginally, 208 (77.6%) became pregnant again. The median interval between birth of the first child and the beginning of the next pregnancy was 20 months for the Caesarean section group and 18 months for the reference group. No significant difference in interpregnancy interval between the different groups was found. CONCLUSIONS: Women who delivered by Caesarean section at term in their first pregnancy do not have fewer second pregnancies compared with women who delivered vaginally. The interpregnancy interval between first and second pregnancy was not prolonged.

A 3-year longitudinal study of asthma quality of life in undiagnosed and diagnosed asthma patients.

SETTING: Juniper's Asthma Quality of Life Questionnaire with standardised activities (AQLQ(S)) is commonly used to evaluate the effect of interventions in pharmaceutical trials, but rarely, if ever, used clinically in long-term follow-up of undiagnosed or diagnosed asthma patients. DESIGN: The AQLQ(S) was administered to 493 asthma patients who were randomised to treatment in primary or specialist care over a 3-year period. RESULTS: Of the 493 patients, 249 had not been diagnosed before screening and 244 had a doctor's diagnosis of asthma. At entry, known patients had a lower total AQLQ(S) score (median 6.03, 95%CI 3.9-7.0) than undiagnosed patients (median 6.54, 95%CI 4.8-7.0, P < 0.001). Treatment with inhaled corticosteroids induced lower scores (median 5.7, 95%CI 3.5-7.0) than no treatment (median 6.5, 95%CI 4.8-7.0, P < 0.01). Half of the patients (n = 260) were randomly invited to participate in a follow-up survey in a specialist setting. In the first 3 months of follow-up, a decrease in AQLQ(S) score among the undiagnosed patients (median -0.24, 95%CI -1.6-0.9, P = 0.02) was observed. After 3 years, the score improved significantly (by >0.5 points) in 45% of the undiagnosed patients (n = 107) compared to 26% of the known patients (n = 116, P < 0.05). CONCLUSION: The initial total AQLQ(S) score was higher in undiagnosed asthma patients. After diagnosis the AQLQ(S) initially decreased but then increased, followed by an overall improvement that exceeded that of the known asthma patients.

Peripartal cardiomyopathy.

A case of peripartal cardiomyopathy diagnosed post partum by preoperative routine examination for a sterilization operation is discussed. Data from the literature show that 50% of the patients suffering from peripartal cardiomyopathy recover nearly completely; the other patients with distinct symptoms of cardial insufficiency die almost without exception from the disease. Current concepts of diagnosis and treatment are reviewed.

Observations on intra-uterine resting-phase pressure in at term pregnancy in different body positions.

Investigations were conducted into the influence of body position on intra-uterine resting phase pressure in women in labour. A micro pressure sensor was placed in the uterus and rectum of 14 women immediately after artificial rupture of the fetal membranes. A significant increase in the intra-uterine resting-phase pressure was experienced when the body position was changed from supine to sitting and also from supine to standing. The intrarectal pressure, a parameter of the intra-abdominal pressure, also showed this significant increase by the same magnitude. The increased resing-phase pressure in the uterus, when the women are in a standing or sitting position, is therefore the result of extra-uterine factors.