Is documentation of TOLAC counseling a good measure of quality of care?

Objective: The objective of this study is to determine whether chart documentation of patient counseling on trial of labor after cesarean (TOLAC) during prenatal care is associated with patient knowledge of risks and benefits of TOLAC and repeat cesarean delivery (RCD).

Study design: Prenatal patients eligible for TOLAC completed a questionnaire that assessed their knowledge of basic maternal and neonatal risks and benefits of TOLAC versus planned repeat cesarean delivery. Patient electronic medical records were reviewed for documentation of TOLAC counseling. Women were included at both early and late time points in pregnancy to include those who both had and had not undergone counseling.

Results: Patients with documented completed TOLAC counseling did not perform better on the knowledge survey. Patients who had documentation of counseling on specific subjects such as TOLAC success rates, risk of uterine rupture, and downstream health risks of cesarean section were no more likely to answer questions on these topics correctly than patients without counseling. However, patients with documented completed counseling generally felt that they were well informed.

Conclusion: Chart documentation of TOLAC counseling was not correlated with patient knowledge. Patients may not be gaining the knowledge from counseling that providers believe is important for informed decision making.     

Improvement of accuracy of clinical reports—the case of IVF cycle rank

Purpose

Accurate clinical reports of In Vitro Fertilization Cycle Rank (IVF-CR) are important because of their predictive value of treatment success—clinical pregnancy. Our district currently provides more than a hundred IVF pick-up cycles per month. The study objective was to evaluate and improve the accuracy of IVF units’ reports of IVF-CR.

Methods

Reports of IVF-CR from local IVF units were correlated with administrative data. Couples who were having IVF treatments during the 3-month study period were included in the study. Data were collected before and after an intervention program.

Results

During the study period accurate IVF-CR reporting rate improved from 27% (29 out of 108) to 83% (91 out of 110).

Conclusions

Accuracy of clinical reports of IVF-CR from local units significantly improved after the intervention. It is recommended that national regulatory bodies should issue compulsory guidelines for the recording and reporting of IVF-CR.     

Prenatal ultrasonographic diagnosis of vein of Galen aneurysms – report of two cases

Aneurysms of the vein of Galen (AVG) represent less than 1% of all intracranial arteriovenous malformations. Two cases of prenatal diagnosis made by color Doppler ultrasonography at 32 weeks of gestation are reported. Both cases presented with antenatal mild cardiomegaly and both developed severe cardiac failure in the neonatal period. Embolization was unsuccessful and both infants died. These cases highlight the need for a careful evaluation of the time and mode of delivery; embolization must be performed after a fully informed decision.     

Order of twins--random choice of natural selection?

OBJECTIVE: Testing of hypothesis that the order of twins is random. DESIGN: Confrontation of birthweight and incidence of stillbirth between twins. MATERIALS AND METHODS: The group of 829 twin deliveries was investigated. Probability of distribution was assessed according to Bernoullie's trials schema. RESULTS: The first twin was usually heavier then the second one (p = 0.05), especially at term. Order of twin delivery was influenced by a birthweight difference > 250 g. In cases of single twin intrauterine death, the alive, term baby was delivered as the first one statistically more common (p = 0.029), despite of smaller number of cases. Discussion suggests that differences between twins are rather reasons of observed order than results. CONCLUSION: Hypothesis of natural selection of stronger baby for the first delivery was presented.     

Pathological characteristics of a series of rare chronic histiocytic intervillositis of the placenta

Chronic histiocytic intervillositis of the placenta (CHI) is a rare and poorly understood pathology which may occur in all trimesters. The most conspicuous feature is a histiocytic infiltration of the intervillous space without involvement of the villous parenchyma. In this report on CHI, we re-evaluate a series of four cases and focus on histological, immunohistological and fluorescence in situ hybridisation-derived findings, fetal status and clinical data for previously unrecognised CHI-associated features. Our approach revealed that assisted reproduction-induced pregnancy had been performed in 2 of 4 CHI cases, but other factors and comorbidities are likely to contribute to CHI.     

Comparative study of the outcome of induction of labor using 25 µg and 50 µg of vaginal misoprostol

Objective: To compare the safety and effectiveness of vaginal misoprostol 25 μg with those of 50 μg in induction of labor. Method: One hundred and sixty eligible women of low parity with indications for induction of labor at term were enrolled for the study. The subjects were randomized into two groups of vaginal misoprostol 25 µg and 50 µg dose regimens. Maternal characteristics, labor and newborn outcome were compared. Results: The total duration of labor was significantly shorter in the 50 µg group (8.24?±?1.5?h) than 25 µg group (9.09?±?2.7?h), p = 0.02. Oxytocin augmentation was significantly higher in the 25 µg group (18.75%) than in the 50 µg group (7.5%), p = 0.04. The indications for caesarean section were significantly different, (p = 0.02) between the two groups although the incidence was similar. The intrapartum adverse effects like fetal distress, meconium stained liquor, and tachysystole were significantly higher in the 50 µg group, p = 0.003. Similarly, the postpartum adverse effects such as cervical and vaginal tears were significantly higher in 50 µg group, p = 0.01. Conclusion: The two dose regimens were both effective in induction of labor, but 50 µg dose regimen resulted in significantly shorter duration of labor but with higher rate of labor complications than the 25 µg dose regimen.     

Radiation damage to the uterus — Review of the effects of treatment of childhood cancer

At the present time approximately 1 in 1000 young people aged between 16 and 35 years will have been cured of cancer in childhood and some of the treatment regimens used will have predictable effects on their future fertility prospects. In young women who have been exposed to radiotherapy below the diaphragm, the reproductive problems include the risk of ovarian failure and significantly impaired development of the uterus. The magnitude of the risk is related to the radiation field, total dose and fractionation schedule. Premature labour and low birth weight infants have been reported after flank abdominal radiotherapy. Female long-term survivors treated with total body irradiation and marrow transplantation are also at risk of ovarian follicular depletion and impaired uterine growth and blood flow, and of early pregnancy loss and premature labour if pregnancy is achieved. Despite standard oestrogen replacement, the uterus of these young girls is often reduced to 40% of normal adult size. Uterine volume correlates with the age at which radiation was received. Regrettably, it is likely that radiation damage to the uterine musculature and vasculature adversely affects prospects for pregnancy in these women. It has been demonstrated that, in women treated with total body irradiation, sex steroid replacement in physiological doses significantly increases uterine volume and endometrial thickness, as well as re-establishing uterine blood flow. However, it is not known whether standard regimens of oestrogen replacement therapy are sufficient to facilitate uterine growth in adolescent women treated with total body irradiation in childhood. Even if the uterus is able to respond to exogenous sex steroid stimulation, and appropriate assisted reproductive technologies are available, a successful pregnancy outcome is by no means ensured. The uterine factor remains a concern and women who are survivors of childhood cancer and their carers must recognize that these pregnancies will be at high risk.     

Administration of 400 μg of misoprostol to augment routine active management of the third stage of labor

Objective

To assess the effectiveness and safety of the administration of misoprostol, an orally active prostaglandin, in addition to routine uterotonic therapy as part of the active management of the third stage of labor.

Methods

The present study was a hospital-based, decentralized, multi-center, randomized, placebo-controlled, double-blind trial. We enrolled 1103 women (out of a target sample size of 1180) at 4 hospitals in South Africa, Uganda, and Nigeria. Participants received a sublingual dose of 400 μg of misoprostol or a placebo, in addition to standard active management of the third stage of labor, after vaginal birth.

Results

The baseline characteristics of the participants were comparable. The difference in the primary outcome of blood loss of 500 mL or more within 1 hour of randomization was not significant between the 2 groups (misoprostol 22/546 [4.0%] versus placebo 35/553 [6.3%]; relative risk, 0.64; 95% confidence interval, 0.38-1.07). Shivering and pyrexia occurred more frequently in the misoprostol group. No maternal deaths occurred.

Conclusion

The present study did not confirm a beneficial effect of administering 400 μg of misoprostol, in addition to routine uterotonic therapy, during the third stage of labor, but was consistent with other trials showing a cumulative modest benefit. Where routine uterotonics are available for prophylactic use, any potential benefit of misoprostol might not outweigh the likelihood of adverse effects. Trial registered on clinical trials.gov: NCT 00124540.     

Is a cause of postpartum hemorrhage of using of tocolytic agents in preterm delivery?

Objective: Tocolytic agents are used to inhibit uterine contraction in preterm. The authors undertook this study to determine whether using of tocolytic agents before delivery is associated with increase postpartum hemorrhage in preterm delivered women.

Method: 296 singleton pregnancies delivered preterm from 24?+?1 to 37?+?0 weeks gestation were retrospectively reviewed. Hemoglobin (HB) and hematocrit (HCT) levels were checked before and after delivery to access postpartum blood loss. Multivariate logistic regression analysis was performed to determine whether delivery within the half-lives of tocolytic agents was associated with decreased HB and HCT levels.

Results: After adjusting for maternal age, parity, gestational age at delivery, birth weight, delivery method, and induction of labor, postpartum HB and HCT levels of those delivered within half-lives of tocolytic agents were found to be significantly diminished (HB: OR 3.306, 1.308–8.356 95% CI, p?=?0.011; HCT: OR 2.692, 1.077–6.726 95% CI, p?=?0.034). In addition, blood transfusion rates were elevated for deliveries made within the half-lives of tocolytic agents, (p?=?0.006).

Conclusions: Delivery within half-lives of tocolytic agents was found to be associated with low HB and HCT levels after delivery and higher blood transfusion rates in preterm delivered women.     

Prediction of successful trial of labor after cesarean – the benefit of prior vaginal delivery

Objective: To determine predictive factors for vaginal birth after cesarean section (VBAC).

Methods: A retrospective cohort study of all women with singleton pregnancies and a prior single low transverse cesarean section (CS) who attempted vaginal delivery in a tertiary hospital (2010–2014). Pregnancy outcome of women with VBAC was compared to those who failed vaginal delivery. Sub-analysis for women with no prior vaginal deliveries was performed. Pregnancies with non-cephalic presentation, estimated fetal weight?>4000 g and any contraindications for vaginal delivery were excluded.

Results: Of the 40 714 deliveries, 1767 women met inclusion criteria. Among them 1563 (88.5%) had a VBAC and 204 (11.5%) failed. There was no significant difference between the groups regarding maternal age, comorbidities and pregnancy complications. Predictors for VBAC were (odds ratio, 95% confidence interval) interval from prior CS (1.13, 1.04–1.22, p=0.004), previous VBAC (2.77, 1.60–4.78, p?<?0.001), prior vaginal delivery prior to the CS (3.05, 1.73–5.39, p?<?0.001) and induction of labor (0.62, 0.40–0.97, p?=?0.03). For women with no prior vaginal birth, only birthweight was associated with VBAC (0.99, 0.99–1.00, p?=?0.02).

Conclusion: While different variables may influence the rate of VBAC, the predictive ability of VBAC for women with no previous vaginal deliveries remains poor.     

Is the Time of administration of misoprostol of value? The uterotonic effect of misoprostol given pre- and post-operative after elective cesarean section

ObjectiveThe aim of the current study was to compare blood loss in pre- and post-operatively rectally administered 600 μg of misoprostol in elective cesarean delivery, in order to determine the optimal time for drug administration (CS).Study designA 30-month prospective, single-blind, randomized, clinical trial was done in the Qena University Hospital, Egypt, from January 2010 to October, 2012.MethodsIntervention consisted of pre and post-operative rectally administered misoprostol. At baseline, there were no significant differences in the demographic and obstetric variable between groups. Primary outcome measures were differences in intra-operative and postoperative blood loss between groups. Secondary outcomes measures were hemoglobin levels pre and operative (24 h after CS) and the need for additional uterotonic drugs.ResultsA total of 300 subjects were enrolled (pre-operative administrated rectally misoprostol n = 150, post-operative administrated rectally misoprostol n = 150). Subjects receiving pre-operative misoprostol achieved significantly lower blood loss compared to those receiving post-operative misoprostol (620 ± 291 ml vs. 898 ± 321 ml, p < 0.05), respectively. The need for additional uterotonic was significantly higher in subjects receiving post-operative misoprostol compared to those receiving pre-operative misoprostol (53.3% vs. 30%, p, 0.05), respectively.ConclusionPre-operative rectally administrated misoprostol appears to be more effective than post-operative rectally administrated misoprostol in reducing blood loss, and in decreasing the need for other uterotonic drugs in cesarean section delivery.     

Qualitative Interpretive Metasynthesis of Parents’ Experiences of Perinatal Loss

ObjectiveTo identify and synthesize common, experiential themes from qualitative studies of parents who experienced perinatal loss.Data SourcesWe searched PubMed, CINAHL, and PsycINFO for qualitative articles about parents’ experiences of perinatal loss.Study SelectionWe included research on parents’ experiences of perinatal loss published in English in the last 10 years. We excluded articles on the perspectives or experiences of health care professionals or persons other than the biological parent who experienced the perinatal loss, systematic reviews, outcome studies, and gray literature.Data ExtractionWe used a priori inclusion and exclusion criteria and identified five articles in which perinatal loss was described from the parents’ perspectives. We extracted thematic findings and supporting quotes from each article and documented them in a table for subsequent synthesis.Data SynthesisWe used a qualitative metasynthesis and interpretive model to synthesize findings from the included studies. Findings were synthesized into one overarching theme, The Paradox of Perinatal Loss, and four subthemes: Complex Emotional Responses, Prenatal Bonding–Acknowledging Personhood, Interactions With Health Care Professionals, and Traversing the Social Sphere.ConclusionOur findings indicate that perinatal loss is often a transformative event during which parents experience multiple losses and intense, complex emotions. Interactions with health care professionals greatly affected the pregnancy experience, which places professionals in a unique position to positively influence parents’ overall experiences. Therefore, it is important to develop protocols related to perinatal loss and ensure that staff are adequately trained and equipped to care for parents during this experience. Findings from this synthesis may also inform the future development of theory related to bereavement surrounding perinatal loss.     

Implantation of Artificial Penile Nodules—A Review of Literature

IntroductionThe implantation of penile nodules under the foreskin is unusual in Western society. This practice is known in Slavic and Asian cultures and occasionally appears in the western world. We review the historical and medical evidence found in world literature to this date.AimWe discuss case reports and other literature on penile nodules and evaluate their medical significance.Main Outcome MeasuresLiterature search for MEDLINE publications and additional references from non-Medline indexed publications concerning the implantation of foreign bodies under the foreskin.MethodsLiterature search for MEDLINE-indexed papers followed by a manual bibliographic review of cross-references. We extended the search to non-MEDLINE references using an Internet-based search engine. More information was retrieved by contacting different experts. A statistical analysis was applied to the data collected.ResultsThere seems to be a predominance of penile bead implantation in Asian countries. The average age of a patient was 25.47 years. The average number of beads implanted was 2.71. There is a higher risk of becoming a sexually transmitted disease.ConclusionsThe prevalence of complications seems to be low. The incidence and severity of early or delayed complications are unknown but are probably underreported. Complications associated with this procedure should be known, especially partner complications. These nodules will possibly be encountered more often in western countries. Fischer N, Hauser S, Brede O, Fisang C, and Müller S. Implantation of artificial penile nodules—A review of literature.