Denial of pain relief during labor to parturients in southeast Nigeria

Objective

To evaluate the experiences of parturients with regard to pain relief during labor in Enugu, Nigeria.

Methods

Women attending the prenatal clinics of 3 maternity care centers were interviewed via pre-tested interviewer-administered questionnaires between August 2010 and January 2011. Both open and closed questions were asked to evaluate the opinions and experiences of the respondents with regard to labor analgesia in previous pregnancies.

Results

Overall, 34.1% of respondents were aware of their right to labor pain relief. Only 33.5% of maternal requests for labor pain relief were granted. Women who did not request labor analgesia indicated ignorance and fear of labor caregivers as their major reasons.

Conclusion

Most women in southeast Nigeria are unaware of their right to pain relief in labor. Ignorance and fear of unfavorable reactions from labor caregivers are hindering women from requesting labor analgesia. There is a need to address the issue of refusal of maternal requests for labor pain relief because it constitutes a violation of the fundamental right of the parturient and an unnecessary breach of medical ethics.     

Cost-effectiveness of misoprostol and prenatal iron supplementation as maternal mortality interventions in home births in rural India

Objective

To determine the cost-effectiveness of prenatal iron supplementation and misoprostol use as interventions to prevent maternal mortality in home births in rural India.

Methods

A cost-effectiveness analysis depicted three hypothetical cohorts of 10 000 pregnant women delivering at home in rural India: one with no intervention, one receiving standard prenatal iron supplements, and 1 receiving 600 µg of misoprostol in the third stage of labor.

Results

Misoprostol used to prevent postpartum hemorrhage resulted in a 38% (95% CI, 5%-73%) decrease in maternal deaths, while prenatal iron supplementation resulted in a 5% (95% CI, 0%-47%) decrease. Misoprostol cost a median US $1401 (IQR US $1008-$1848) prenatal iron supplementation cost a median US $2241 (IQR No Lives Saved-$3882) per life saved compared with the standard care outcome.

Conclusion

Misoprostol is a cost-effective maternal mortality intervention for home births. Iron supplementation may be worthwhile to improve women's health, but it is uncertain whether it can prevent mortality after hemorrhage.     

Impact of ALSO training on the management of prolonged labor and neonatal care at Kagera Regional Hospital, Tanzania

Objective

To evaluate the management of prolonged labor and neonatal care before and after Advanced Life Support in Obstetrics (ALSO) training.

Methods

Staff involved in childbirth at Kagera Regional Hospital, Tanzania, attended a 2-day ALSO provider course. In this prospective intervention study conducted between July and November 2008, the management and outcomes of 558 deliveries before and 550 after the training were observed.

Results

There was no significant difference in the rate of cesarean deliveries owing to prolonged labor, and vacuum delivery was not practiced after the intervention. During prolonged labor, action was delayed for more than 3 hours in half of the cases. The stillbirth rate, Apgar scores, and frequency of neonatal resuscitation did not change significantly. After the intervention, there was a significant increase in newborns given to their mothers within 10 minutes, from 5.6% to 71.5% (RR 12.71; 95% CI, 9.04-17.88). There was a significant decrease from 6 to 0 neonatal deaths before discharge among those born with an Apgar score after 1 minute of 4 or more (P = 0.03).

Conclusion

ALSO training had no effect on the management of prolonged labor. Early contact between newborn and mother was more frequently practiced after ALSO training and the immediate neonatal mortality decreased.     

Analgesia and anesthesia for assisted reproductive technologies

Background

Oocyte retrieval for in vitro fertilization (IVF) is one of the most common minor surgical procedures.

Objectives

To give an update on anesthesia practices used currently in the United States and Europe in assisted reproductive technology, and discuss the safety or the potential risks for oocyte and embryo quality.

Search strategy

Electronic search of MEDLINE for literature published between 1972 and 2008.

Selection criteria

Relevant studies on the types of anesthesia used for oocyte retrieval and the impact on oocyte and embryo quality.

Data collection and analysis

Relevant studies were reviewed by the authors and the ones of significant scientific merit, based on methodology, were included.

Main results

Types of anesthesia that may be used for transvaginal follicular aspiration and oocyte retrieval include: general anesthesia, neuraxial anesthesia, conscious sedation, injection of local anesthetic agents into the cervix or the vaginal wall, or any combination of the above. Conscious sedation is most commonly used in IVF because it is relatively safe and does not require the presence of an anesthesiologist when opioids or benzodiazepines are used. Propofol is the preferred anesthetic agent, but should be used by specially trained personnel.

Conclusion

Conscious sedation is the most popular method of anesthesia used in IVF. Presently, a combination of propofol, fentanyl, and midazolam is used frequently. It is easy to administer in cooperative and motivated patients and is safe in healthy individuals; it has a relatively low risk for adverse effects on oocyte and embryo quality and pregnancy rates.     

Absence of activating somatic mutations of PI3KCA and AKT1 genes in South Indian women with endometriosis

Objective

To investigate whether the PI3KCA and AKT1 gene influences the risk of developing endometriosis in South Indian women.

Study design

Mutations in exon 9 and 20 of PI3KCA gene and E17K mutation in exon 4 of AKT1 gene were tested for association in a case-control study between eutopic and ectopic endometrium tissue from 30 endometriosis cases and eutopic endometrium tissue from 30 controls. The genotype frequencies of these mutations were compared using polymerase chain reaction and direct sequencing analysis of tissue DNA.

Results

The analysis did not reveal any activating somatic mutations in either PI3KCA or AKT1 gene in the cases.

Conclusion

In the present study we could not observe any mutation in PI3KCA and AKT1 gene, indicating that these mutations are rarely associated with endometriosis in South Indian women.     

Oral misoprostol versus intracervical prostaglandin E2 gel for active management of premature rupture of membranes at term

Objective

To compare the efficacy and safety of oral misoprostol with intracervical prostaglandin E2 (PGE2) gel for the active management of premature rupture of membranes (PROM) at term.

Methods

Women with pregnancies between 37 and 42 weeks presenting with PROM at term and a Bishop score of 5 or less were randomly assigned to receive either a 4-hourly oral dose of 50 µg of misoprostol up to a maximum of 3 doses or 2 applications of intracervical PGE2 gel at a 6-hour interval. Oxytocin was given if labor had not started after 12 hours.

Results

Twenty women in the misoprostol group (n = 31) delivered within 12 hours compared with 5 in the PGE2 group (n = 30) (P < 0.001). The induction-to-delivery interval in the misoprostol group was shorter than in the PGE2 gel group (615 min vs 1070 min; P < 0.001). The mode of delivery was comparable between the 2 groups (P = 0.821). Abnormalities in uterine contractions and neonatal outcomes were also comparable. The requirement for oxytocin was lower and patient satisfaction was better in the misoprostol group.

Conclusion

Oral misoprostol is a safe and efficacious alternative to intracervical PGE2 gel in the active management of PROM at term.     

A study of 579 pregnant women with premature rupture of membranes at term

Objective

To determine the best management for women with premature rupture of membranes at term.

Method

In 2008, 579 women admitted to Peking University First Hospital for premature rupture of membranes (PROM) at term were allocated to one of 3 groups. Group 1 (n = 292) consisted of those whose labor began spontaneously within 12 hours of PROM; group 2 (n = 234), of those whose labor did not begin within 12 hours of PROM and were induced with oxytocin; and group 3 (n = 53), of those who accepted a cesarean delivery immediately after PROM was diagnosed. The χ² test was used to compare the rates of intrauterine and neonatal infection in these 3 groups.

Results

Compared with the intrauterine and neonatal infection rates for group 1 (3.4% and 13.7%) and group 3 (1.9% and 3.8%), the corresponding rates were higher for group 2 (10.7% and 21.8%) (P < 0.05). In group 2, 76.5% of the women began labor within 24 hours of induction and 92.7% of these within 12 hours.

Conclusion

In women at term, induction should be performed immediately after PROM is diagnosed, as it is likely to fail when labor does not begin within 12 hours of oxytocin administration.     

Is acupuncture in addition to conventional medicine effective as pain treatment for endometriosis?: A randomised controlled cross-over trial

Objective

The aim of the study was to examine whether acupuncture is an effective additional pain treatment for endometriosis.

Study design

One hundred and one women aged 20-40 years participated and were randomised into two groups, each receiving two units of 10 acupuncture treatments, twice a week over a period of five weeks. Group 1 (n = 47) received verum-acupuncture during the first series, and group 2 (n = 54) received non-specific acupuncture. After the first unit of 10 treatments, an observation period of at least two menstruation cycles was set, followed by a second unit, according to a cross-over design. Prior to the study (during a two-week run-in period) the patients’ actual pain intensity was surveyed. Throughout the study period, participants were asked to keep a ‘pain protocol’, in which they defined and recorded their pain according to the 10-point visual analogue scale (VAS).

Results

Eighty-three out of a total of 101 patients finished the study. Group 1 showed a significant reduction of pain intensity after the first 10 treatments. In comparison, group 2 showed significant pain relief only after the cross-over.

Conclusion

Acupuncture treatment on specific acupuncture points appears to be an effective pain treatment for endometriosis, but this has to be confirmed in further study.     

Comprehensibility of patient consent forms for radiation therapy of cervical cancer

Objective

The construct of Health Literacy (HL) deals with patients' capacity to understand their health-related instructions, consent forms, and other documents. A significant challenge of providing healthcare to patients with low HL is the complex nature of the disease process, and of requisite treatments. In radiation oncology specifically, the delivery of ionizing radiation is difficult enough to describe; describing radiation toxicity in terms of the underlying physics and biology is daunting. A multimodal analysis of a small sample of patient consent forms was undertaken in order to address this issue more closely, and identify the extent to which such literature contributes to the challenges faced by patients with low HL.

Methods

Members of national cooperative group panels dealing with gynecologic cancer were asked to submit copies of consent forms provided to patients with stage II cervical cancer. Four such forms were submitted and reviewed by a single person with expertise in linguistics using standard tools.

Results

Three of the four consents scored within the lower portion of the “adequate“ range. One consent was not suitable. Consent readability ranged from grades 12.18 to 16.13; this means that they required at least a high school education to interpret, and in two cases required post-graduate coursework.

Conclusion

There is significant room for improvement in consent form design and structure. When considering cultural and socioeconomic appropriateness of patient consent forms, input of staff with expertise in linguistics should be sought.     

The revolving door: hospital readmissions of gynecologic oncology patients

Objective

Rehospitalization within 30 days of discharge was identified by the Obama Administration as a target for reducing health care spending. We examined readmissions to our gynecologic oncology service to determine: 1) rates of readmission, 2) indication for readmissions, 3) whether the admission was planned, and 4) costs.

Methods

IRB approval was obtained for this 5-year retrospective review (2004-2008). Gynecologic oncology patients were included if they were readmitted within 30 days of discharge at a single academic hospital. Abstracted data included: demographics, dates of hospitalizations, cancer history, indication for admission, and cost. A series of admissions was any number of admissions that occurred within 30 days of discharge. An index admission was the first admission in a series.

Results

In the study period, 2455 unique patients were admitted to Gynecologic Oncology. 324 unique patients (13.2%) were readmitted within 30 days, with 37 experiencing > 1 series of admission. 87.3% were readmitted to Gynecologic Oncology. Within a series of admissions, patients were admitted on average 1.5 times following the index admission, up to 9 admissions. The median cost of index admission was $9820; for readmissions, $8059. The total cost of readmissions over 5 years was $6,421,733. Unplanned readmissions accounted for the majority of this cost.

Conclusions

Hospital readmissions affect the cost of care, but also the quality of care delivered to our patients. When extrapolated across institutions and across the country, unplanned readmissions are a costly expenditure to patients and the health system, deserving of attention.     

Intraoperative mapping of anal and perineal anatomy using an electrostimulator

Objective

To present a new technique to identify perineal and anal sphincter anatomy using an electrostimulator in order to facilitate anatomical repair.

Methods

A neglected perineal tear was repaired using the technique described.

Results

The patient's St Mark's incontinence score improved from 22 out of 24 to 6 out of 24.

Conclusions

This technique may be practical and useful for intraoperative mapping of distorted perineal and anal anatomy to assist surgical repair.     

Adolescent pregnancy in Upper Egypt

Objective

To determine the reasons for adolescent pregnancy in Upper Egypt and to evaluate maternal, fetal, and neonatal outcomes.

Methods

All primigravidae under 30 years of age who attended the labor/delivery ward at Sohag University Hospital, Sohag, Egypt, between December 31, 2005, and December 31, 2009, were invited to participate. Participants were allocated to the study group (up to 19 years of age at first pregnancy) or the control group (20-30 years of age at first pregnancy). Maternal, obstetric, fetal, and neonatal complications were compared between the groups, and adolescent participants completed a questionnaire to identify the reasons for pregnancy.

Results

In total, 58.2% had married seeking motherhood. Rates of ectopic pregnancy, pre-eclampsia, eclampsia, premature rupture of membranes, preterm labor, and cesarean were significantly higher among adolescents younger than 15 years of age; the risk then decreased steadily with age and became comparable to the control group after 16 years of age.

Conclusion

Adolescent pregnancy increases the risk of ectopic pregnancy, pre-eclampsia, eclampsia, premature rupture of membranes, preterm labor, and cesarean among mothers up to 16 years of age. After 16 years of age, pregnancy is not associated with increased risk of obstetric or neonatal complications.     

Impact of a structured, hands-on, surgical skills training program for midwives performing perineal repair

Objective

To evaluate the effect of structured hands-on training for midwives performing perineal repair.

Methods

The training was performed using models and ox tongues. A total of 719 midwives completed an anonymous questionnaire prior to and immediately after training. Out of 300 participants, 151 completed a follow-up questionnaire 4 months later. Participants rated their knowledge and skills in the domains of instrument handling, knot tying, and subcuticular perineal repair.

Results

Compared with the situation before receiving the training, there was a significant increase in the use of the recommended evidence-based technique for perineal repair 4 months after training (28% vs 100%; P < 0.001), and in the mean scores for knowledge and skills in all the domains (P < 0.001). Participants believed that their patients were happier with the new technique.

Conclusions

Structured hands-on training is an effective way of improving the skills of midwives performing perineal repair and leads to modification of clinical practice.     

Pain relief in outpatient hysteroscopy: a survey of current UK clinical practice

Background

Outpatient hysteroscopy is increasingly being used as a cost-effective alternative to in-patient hysteroscopy under general anaesthesia. Like other outpatient gynaecological procedures, however, it has the potential to cause pain severe enough for the procedure to be abandoned. There are no national guidelines on pain relief for outpatient hysteroscopy.

Methods

A postal survey of UK gynaecologists was carried out to evaluate current clinical practice regarding methods of pain relief used during office hysteroscopy. A total of 250 questionnaires were sent out and 115 responses received.

Results

Outpatient hysteroscopy was offered by 76.5% of respondents. Respondents reported a wide variation in the use of routine and rescue analgesia, and also in the nature of the analgesia used. One-quarter of those offering outpatient hysteroscopy used no form of analgesia.

Conclusion

The results showed that whilst there is no consensus on the type of analgesia provided, rescue analgesia is commonly being used, particularly in the form of intracervical blocks.     

Influence of epidural dexamethasone on maternal temperature and serum cytokine concentration after labor epidural analgesia

Objective

To evaluate the effects of epidural dexamethasone on maternal temperature and serum cytokine levels after labor epidural analgesia.

Methods

Sixty healthy term nulliparas in spontaneous labor were randomized to receive epidural analgesia alone using bupivacaine 0.125% and fentanyl 1 μg/mL (group I) or epidural analgesia combined with dexamethasone 0.2 mg/mL (group II) (n = 30 per group). Maternal tympanic temperature was measured before epidural analgesia and hourly thereafter until delivery. Maternal and cord venous blood were sampled for analysis of interleukin-6 (IL-6), tumor necrosis factor-α, and interleukin-10 levels.

Results

There was no difference in the incidence of intrapartum fever (38 °C or more) between the 2 groups (3/30 versus 1/30, P = 0.612). The mean maternal temperature increased with time in group I, with the elevation reaching statistical significance at 4 hours post analgesia and at delivery compared with baseline (P = 0.012 and P = 0.043, respectively). A similar trend was observed with maternal serum IL-6 levels in group I. In group II, maternal temperature and IL-6 levels did not differ from baseline at any time point during labor.

Conclusion

Epidural dexamethasone alleviates maternal temperature elevation after epidural analgesia. This effect can be attributed to the decrease in IL-6 levels.     

Manometric evaluation of anal sphincter function after vaginal and cesarean delivery

Objective

To compare anal sphincter function following spontaneous vaginal delivery and cesarean delivery, and assess the association of perineal length and sphincter injury with each delivery mode.

Method

Perineal length was measured and anal manometric measurements were performed in 120 primigravidas before and after delivery.

Results

Mean values for maximum anal resting and squeeze pressures were significantly lower after delivery irrespective of the mode of delivery, but there was a positive correlation between postpartum maximum anal resting pressure and perineal length (r = 0.24, P < 0.01).

Conclusion

Anal sphincter function was disturbed after both vaginal and cesarean delivery, a finding weakened by the fact that almost half of the cesareans were performed for cephalopelvic disproportion identified during labor.     

Brain metastases from epithelial ovarian carcinoma: evaluation of prognosis and managements - a Taiwanese Gynecologic Oncology Group (TGOG) study

Objective

To evaluate the characteristics and outcome of patients with brain metastases from epithelial ovarian carcinoma.

Methods

The clinical and pathologic characteristics, treatment and outcome of patients with brain metastases from epithelial ovarian carcinoma were analyzed from eight medical centers in Taiwan under the TGOG (Taiwanese Gynecologic Oncology Group).

Results

A total of 64 patients were recruited in this study. The incidence of brain metastases from epithelial ovarian carcinoma seemed to be increasing in recent years. The median survival from the diagnosis of brain metastases was 8 months (range: 0-72). Prior cancer relapse before the diagnosis of brain metastases, number of brain metastases and multimodal treatment were related to the duration of survival.

Conclusions

The prognosis for patients with brain metastases from epithelial ovarian carcinoma is generally poor. However, clinicians should keep alert to the neurological complaints of ovarian cancer patients and the patients might benefit from aggressive multimodal treatments.     

Flujo sanguíneo de las arterias renales fetales en preeclámpticas graves y embarazadas normotensas sanas

Objective

To compare the blood flow in fetal renal arteries in severe preeclamptic and healthy normotensive pregnant women.

Method

The sample consisted of 30 women with severe preeclampsia (group A) and 30 healthy normotensive pregnant women (group B) with single pregnancies of more than 30 weeks. The pulsatility and resistance indexes of the uterine, umbilical, fetal middle cerebral and fetal renal arteries were measured.

Results

There were no significant differences in maternal age, gestational age or newborn weight (p = ns). Pulsatility and resistance index values in the uterine and umbilical arteries were significantly higher and both measurements for the fetal middle cerebral artery were significantly lower in group A than in group B (p = 0.0001). Pulsatility and resistance index values in the fetal renal artery were significantly higher in group A than in group B (p = 0.0001). The fetal renal artery pulsatility index was significantly correlated with the pulsatility index of the uterine artery (p = 0.011) and the fetal middle cerebral artery (p < 0.007). The fetal renal artery resistance index was correlated with the resistance index of the three vessels (p < 0.05).

Conclusion

Women with severe preeclampsia show blood flow alterations in the fetal renal arteries compared with healthy normotensive pregnant women.