Racial differences in the etiology of abruptio placentae

Of 13,500 deliveries in a 6-year period, 326 cases of antepartum hemorrhage (2.4%) were encountered. Fifty-six (0.42%) of these patients had abruptio placentae while 130 (0.96%) had placenta previa. An inverse ratio of placenta previa and abruption placentae was observed in this study, which may be due to a racial difference--probably a result of the late onset of preeclampsia among Nigerians. A high perinatal mortality of 643/1000, influenced mainly by the high prematurity rate, was observed; cesarean section resulted in the lowest perinatal mortality (154/1000). There was one maternal death, giving a maternal mortality rate of 18/1000.     

Cesarean versus vaginal delivery in abruptio placentae associated with live fetuses

In order to test the relative effectiveness of cesarean section and vaginal delivery in mild abruptio placentae associated with live fetuses, 23 consecutive patients were delivered vaginally and 18 by cesarean section over an 18-month period at the University of Ife Hospital in Nigeria. The perinatal mortality of the vaginal delivery group (52.2%) was significantly greater than that of those delivered by cesarean section (16.7%) (P greater than 0.02; less than 0.05; chi 2 test). The 1-min Apgar score test was also significantly greater than that of those delivered by cesarean section (P greater than 0.001). These differences have been attributed to the admission-to-delivery interval, which was significantly longer in the vaginal delivery group (12 h vs. 2 h). It is concluded that cesarean section is clearly superior to vaginal delivery in the management of abruptio placentae associated with live fetuses.     

Trasylol in the management of abruptio placentae with consumption coagulopathy and uterine inertia

A study was conducted on 40 patients with abruptio placentae complicated by intrauterine death of the fetus, consumption coagulopathy and uterine inertia. All patients had severe hyperfibrinolysis (FDP > 300 microgram/ml). Following correction of shock, amniotomy was performed, intrauterine pressure catheters were placed, and oxytocin infusions were begun in all cases. The diagnosis of uterine inertia was made when the cervix failed to dilate following six hours of this treatment. After diagnosing uterine inertia, 18 patients (group B) did not. All but one patient in group A showed a marked improvement in the associated consumption coagulopathy and a rapid reawakening of uterine activity with progress to spontaneous vaginal delivery. Thirteen patients in group B did not show prepartum improvement in consumption coagulopathy or a resumption of uterine activity. These patients required cesarean section. There were two maternal deaths in group B; the overall complication rate in this group was greater than in group A.     

Perinatal mortality associated with abruptio placenta in singletons and multiples

OBJECTIVE: This study was undertaken to investigate the association among plurality (number of fetuses per pregnancy), abruptio placenta, and perinatal mortality. STUDY DESIGN: A retrospective cohort study on 15,051,872 singletons, 413,619 twins, and 22,585 triplets delivered in the United States between 1995 and 1998 was conducted. We compared the occurrence of perinatal death between pregnancies complicated by abruptio placenta and those without with the use of adjusted odds ratios. The generalized estimating equations framework was applied to adjust for intracluster correlations among multiples. RESULTS: Placental abruption occurred among 93,968 singletons (6.2 per 1000), 5051 twin (12.2 per 1000), and 353 triplet (15.6 per 1000) gestations ( P for trend<.0001). Placental abruption was associated with significant risk of mortality irrespective of the plurality subtype. Perinatal mortality was greatest among singletons (adjusted odds ratio [95% CI]=14.3[13.2-15.4]), followed by twins (4.4[3.9-4.9]) and least among triplets (3.0[2.0-4.6]) ( P for trend<.0001). CONCLUSION: As plurality increases from 1 to 3, the risk of placental abruption rises, whereas the risk of abruptio-associated perinatal mortality declines.     

Maternal vagal tone change in response to methadone is associated with neonatal abstinence syndrome severity in exposed neonates

Objective. Though methadone pharmacotherapy is the treatment of choice for opiate-dependence during pregnancy in the USA, most methadone-exposed neonates develop neonatal abstinence syndrome (NAS). NAS expression is widely variable among methadone-exposed neonates and only a subset requires pharmacotherapy. This study explores the potential predictors of NAS severity, including aspects of maternal substance use and methadone maintenance histories, concomitant exposure to other licit substances, and individual differences in intrinsic maternal or infant factors that may affect the infant's vulnerability to NAS expression.

Methods. Fifty methadone-maintained pregnant women attending a comprehensive substance abuse treatment facility, received electrocardiogram monitoring at 36 weeks of gestation at the times of trough and peak maternal methadone levels. Vagal tone, an estimate of the magnitude of an individual's respiratory sinus arrhythmia and an indicator of autonomic control, was derived.

Results. NAS expression was unrelated to maternal substance abuse history, methadone maintenance history, or psychotropic medication exposure. Male infants displayed more profound NAS symptoms and received more pharmacotherapy to treat NAS (all p < 0.05). NAS expression was related to maternal vagal reactivity; both suppression and activation of maternal vagal tone in response to methadone administration were positively and significantly associated with NAS symptomatology (F (2,44) = 4.15, p < 0.05) and treatment (F (2,44) = 3.39, p < 0.05). Infants of vagal non-responder mothers showed substantially lower NAS expression.

Conclusions. NAS severity is associated with maternal vagal tone change in response to methadone administration.     

学龄期脑性瘫痪儿童髋关节发育与髋周肌肉状况的相关性分析

目的探讨学龄期脑性瘫痪(简称脑瘫)儿童髋关节发育与髋周肌肉状况的关系。方法 2015年4月至6月在广州康复实验学校进行康复训练的脑瘫患儿56例,其中痉挛型41例,不随意运动型9例,共济失调型4例,混合型2例;双瘫37例,四肢瘫16例,偏瘫3例。对全部患儿进行髋关节X线片检查,评定股骨头外移百分比(MP值),并且评定髋关节屈曲、内收、内旋肌肌张力、髋关节伸展、外展、外旋肌肌力。结果 56例脑瘫患儿中髋关节发育基本正常21例(37.50%),半脱位32例(57.140%),全脱位3例(5.36%)。Spearman相关分析显示,MP值与髋关节屈曲、内收、内旋肌肌张力呈正相关(P0.05),与髋关节伸展、外展、外旋肌肌力测试结果均呈负相关(P0.05)。结论学龄期脑瘫儿童髋关节发育与髋周肌肉状况相关。     

Twin pregnancy in patients with a uterine anomaly

Abstract

Objective: In singleton pregnancies, a uterine anomaly is a known risk factor for preterm birth and fetal growth restriction. Data on outcomes of twin pregnancies with uterine anomalies is limited to case reports. The objective of this study was to compare outcomes in twin pregnancies based on the presence or not of a uterine anomaly.

Methods: This was a retrospective cohort of twin pregnancies managed by a single maternal-fetal medicine practice from 2005 to 2012. Patients with monoamniotic twins and twin-twin transfusion syndrome were excluded. Pregnancy outcomes were compared between patients with and without a uterine anomaly. Nonparametric tests (Fisher’s exact test, Mann–Whitney U) were used for analysis. A p value of ≤0.05 was considered significant.

Results: Five hundred and fifty-six twin pregnancies were included, 17 (3.1%) of whom had a known uterine anomaly (nine septate uterus, three bicornuate, three arcuate, one unicornuate and one didelphys). Patients with a uterine anomaly had significantly worse outcomes, including cerclage, preterm birth and lower median birth weights. Birth weight less than the 10th or 5th percentile for gestational age was not more common in patients with a uterine anomaly, nor was there an increase in birth weight discordancy.

Conclusion: In patients with twin pregnancies, the presence of a uterine anomaly is associated with an increased risk of cerclage, preterm birth and lower birth weights, but not fetal growth restriction.     

Prognostic determinants in patients with uterine and ovarian clear carcinoma

Objective

The purpose of this study is to analyze and compare the demographics, treatment, recurrence, and survival rates in patients with uterine clear cell carcinoma (UCCC) and ovarian clear cell carcinoma (OCCC).

Methods

A retrospective review of the Cancer Registry database was performed. All patients with UCCC and OCCC who underwent surgical staging at the two participating institutions, between January, 1995 and December, 2007, were identified. Categorical variables were evaluated by Chi square test. Survival estimates were plotted utilizing the Kaplan-Meier method.

Results

Analysis of 41 women with UCCC and 121 with OCCC was performed. In patients with OCCC, 48.4% had localized disease, 18.9% had regional spread, 31.1% had distant metastasis, and in 1.6% spread is unknown; compared to UCCC, 41.5% had localized disease, 12.2% regional spread, and 46.3% distant metastasis (p = 0.2). The median progression free survival was 31.4 months in women with UCCC, compared to 145 months in patients with OCCC (p = 0.04). UCCC women had a median overall survival of 39.5 months, compared to 155.8 months in patients with OCCC (p = 0.002). In the multivariate Cox regression model, age > 55 years old, tumor extension, optimal cytoreduction, and platinum-based chemotherapy were identified as independent predictors of overall survival. UCCC vs. OCCC was not associated with decreased overall survival in multivariate analysis.

Conclusion

OCCC and UCCC have the same rate of localized disease, regional spread and distant metastasis. After controlling for age, tumor extension, optimal cytoreduction, and platinum based chemotherapy, UCCC was not associated with decreased overall survival compared to OCCC.     

High-dose epirubicin in patients with advanced or recurrent uterine sarcoma

Twenty patients with advanced or recurrent uterine sarcoma who had not received prior chemotherapy, were treated with epirubicin 120 mg m⁻² intravenously every 3 weeks. Four patients (20%) achieved complete response (pathologically confirmed in three cases) and three (15%) achieved partial response. The overall response rate was 35% (95% CI: 15–59). no response was observed for pelvic lesions in previously irradiated areas. Three patients (15%) exhibited stable disease, while 10 (50%) had progressive disease. The median number of courses was six in responders and two in non-responders. The median survival was 48 months (range 19–50+ months) in responders and 6 months (range 2–18 months) in non-responders. Adverse effects consisted primarily of myelosuppression, nausea and vomiting. No patients experienced life-threatening toxicity. High-dose epirubicin appears to be active in patients with advanced or recurrent uterine sarcoma.     

Misoprostol for uterine evacuation in patients with early pregnancy failures

OBJECTIVE: The purpose of this study was to evaluate the effectiveness of misoprostol that is administered intravaginally for uterine evacuation in patients with early pregnancy failures. STUDY DESIGN: From March 2001 through March 2003, we treated 41 patients who had early pregnancy failures with vaginal misoprostol, 800 microg. A second course of misoprostol was administered if uterine evacuation did not occur in 24 hours. Patients who had no response to misoprostol underwent a surgical curettage. Our principal outcome measures were the percentage of patients who had successful evacuation of the products of conception and the frequency of adverse drug effects. RESULTS: Twenty-six patients had successful uterine evacuation with a single course of misoprostol; 6 patients required a second course. The overall success rate was 78% (95% CI, 63, 88). No patient experienced a serious adverse drug effect. CONCLUSION: Intravaginal misoprostol is a safe, effective alternative to surgical curettage for the treatment of early pregnancy failure.     

Direct gamete uterine transfer in patients with tubal absence or occlusion

Purpose: Our aim was to examine the potential of the uterine cavity to affect fertilization and early embryo development. Design: A prospective IRB-approved protocol for patients fulfilling study eligibility criteria was used. Methods: Patients studied included those with primary or secondary infertility, aged less than 38 years, with no history of severe male-factor infertility, and with hysterosalpingogram-and laparoscopic-confirmed bilateral proximal tubal occlusion. Superovulation induction was accomplished with a combination of GnRH agonist and menotropins, with serum hormonal and sonographic monitoring. Within 24 hr prior to, and again at the time of, ovulatory hCG administration, progesterone (P4) was given. Sonographic-guided transvaginal retrieval was performed 35 hr after hCG. Between four and six oocytes were returned to the uterine cavity, admixed with sperm, immediately following retrieval. Luteal support consisted of daily P4 administration. Results: Of the 20 patients recruited for the study, all completed the retrieval and transfer procedure. A total of four clinical pregnancies was achieved, with one early first-trimester loss, one late first-trimester loss (Trisomy 14), and two healthy term infants delivered. IVF of surplus oocytes demonstrated a 82.5% fertilization rate and 66.7% cleavage following cryopreservation. Conclusions: Human fertilization can be achieved through direct uterine transfer of gametes. Furthermore, administration of P4 prior to the ovulatory dose of hCG is compatible with in vitro or in vivo fertilization and implantation.     

CA 125 in serum and tumor from patients with uterine sarcoma

Serial serum samples of 33 patients with primary sarcoma of the uterus were analyzed for CA 125 and frozen tissue sections of tumor from 23 patients were tested for this antigen. Before treatment, 12 of 30 evaluable patients showed serum CA 125 levels> 16 Uml⁻¹ (40%). There was no relationship between serum CA 125 level and the histologic subtype. Patients with serum CA 125> 16 Uml⁻¹ showed extrauterine tumor sites in 67% of the cases versus 33% in patients with normal CA 125 determinations ( P = 0.026). In (FIGO) stages I and II, elevated serum CA 125 levels prior to surgery were associated with a poor prognosis ( P = 0.043). Patients with recurrent or progressive disease demonstrated serum CA 125 levels> 16 Uml⁻¹ in 14 of the 20 cases (70%). Sarcoma cells were completely negative for CA 125, whereas positivity was observed in the epithelial component of mixed Müllerian tumors. The source of the elevated serum CA 125 levels in patients with uterine sarcoma may be stimulated mesothelial cells.     

The value of re-exploration in patients with inadvertently morcellated uterine sarcoma

Objective

To describe the role of immediate re-exploration in patients with inadvertently morcellated uterine leiomyosarcoma (ULMS) and smooth muscle tumors of uncertain malignant potential (STUMP).

Methods

All patients with ULMS/STUMP who were managed or referred to the participating institutions from January 2005 to January 2012 following minimally invasive gynecology surgery with morcellation were detected through the pathology database. The diagnosis was confirmed by gynecologic-pathologists following post-surgery pathology review.

Results

Twenty-one patients with the diagnosis of ULMS (N = 15) and STUMP (N = 6) after morcellation were identified. The median age of occurrence was 46 years (range, 25–58 years). Median follow-up duration was 27 months (range, 1.8–93.1 months). None of the 21 patients had documented evidence of extra-uterine disease at the time of original surgery. Ultimately 12 patients were immediately re-explored to complete staging. The median time to the staging surgery was 33 days (range 15–118 days). Two (28.5%) out of seven patients with presumed stage I ULMS and one (25%) out of four patients with presumed stage I STUMP had significant findings of disseminated intraperitoneal disease detected at immediate surgical re-exploration. One of the 8 patients with confined early ULMS and STUMP at the second surgery had intraperitoneal recurrence, while the remaining 7 patients have had no recurrence and remain disease free.

Conclusion

Surgical re-exploration is likely to show findings of disseminated peritoneal sarcomatosis in a significant number of patients diagnosed with ULMS after a morcellation procedure. Findings from re-exploration can contribute to the knowledge of natural history of morcellated ULMS/STUMP and allow for accurate prognostication.     

Efficacy of thermal balloon ablation in patients with abnormal uterine bleeding

OBJECTIVE: The purpose of this study was to assess changes in menstrual pattern, quality of life, and patient satisfaction after thermal balloon ablation for abnormal uterine bleeding. STUDY DESIGN: One hundred forty-one women who underwent thermal balloon ablation in our institution initially had their charts reviewed for demographics, procedure data, clinical history, and follow-up. Thereafter, a telephone interview was conducted to assess postprocedural menstrual pattern, quality of life, and patient satisfaction. Data were compared with the use of appropriate tests for categoric or continuous variables and logistic regression. RESULTS: The median follow-up time was 18 months, and a telephone interview was obtained for 119 of 141 patients. A reduction in days per cycle (9.6 vs 3.1 days, P<.0001) and in pads per day (12.8 vs 2.5 pads/d, P<.0001) and an improvement in self-reported quality of life scores (2.8 vs 9.0, P<.0001) were observed after thermal balloon ablation. Hysterectomy was required in 21 of 141 patients (15%). Assessment of the level of satisfaction showed that 96% of patients were satisfied or very satisfied with the procedure. No major complications or deaths were related to thermal balloon ablation. CONCLUSION: Thermal balloon ablation is a safe and efficient method to treat abnormal uterine bleeding. It reduces the menstrual flow, improves the quality of life, and remarkably fulfills expectations in selected patients.     

Diagnostic evaluation of Karman endometrial aspiration in patients with abnormal uterine bleeding

AIM: To assess sensitivity and specificity of Karman aspiration in the diagnosis of abnormal endometrium compared with the final diagnosis and evaluate tissue adequacy obtained by Karman aspiration. METHODS: The study group were women who presented with abnormal uterine bleeding to Songklanagarind Hospital between August 2003 and July 2004 and who underwent Karman aspiration prior to conventional curettage. The final diagnosis was defined as the most severe histopathology from either Karman aspiration or conventional curettage. Abnormal endometrium included inflammation, polyp, hyperplasia and malignant changes. RESULTS: Two hundred and twenty-six women were assessed. Endometrial aspiration showed a sensitivity of 89.6% and specificity 100.0% in diagnosis of abnormal endometrium. Abnormal endometrium was detected in 58 women. Of 11 women diagnosed with endometrial cancer, only one case was undetected by Karman aspiration due to a failure to create negative pressure in the uterus. Endometrial aspiration yielded adequate tissue in 86.7%. CONCLUSION: Karman endometrial aspiration is an accurate and easy procedure, and should be considered in the initial evaluation of abnormal uterine bleeding.     

Induction of labour in patients with prior caesarean births or uterine surgery

The current evidence favours trial of labour after one caesarean in the absence of any other contraindications, recognizing that risks with both trial of labour after caesarean (TOLAC) and elective repeat caesarean section (ERCS) birth are relatively uncommon. When the need for induction of labour (IOL) following a previous caesarean arises, shared decision-making should be based on the current available evidence. This approach, however, needs to be tailored, taking into account the individual's history, initial examination and response to the ongoing process of induction to optimize the maternal and foetal outcomes. This paper aims to review the evidence and provide guidance on decision making surrounding labour induction in a pregnancy following a prior caesarean or uterine surgery.