Delivery in lateral position. Comparative study in low risk pregnancy between lateral and dorsal position for the delivery in eutocic vaginal birth

ObjectiveFor several years in French labour wards, delivery in the lateral decubitus position (LP) has raised great interest. We wanted to assess perineal outcomes and neonatal morbidity following delivery in the lateral LP compared to the dorsal decubitus position (DP).Patients and methodsTwo teams of midwives, in a private and in a public hospital, performed a total of 6800 deliveries in the area of Tours following a training session on the techniques of delivery in the lateral decubitus position. The design was a retrospective case-control study including patients with low obstetrical risks and normal vaginal delivery. We included 645 patients who gave birth from May 1st to September 30th, 2007.ResultsWe showed a significant difference in perineum outcomes, with a lower episiotomy rate (56.7% in LP/40.7% in DP, P = 0.0001), a higher rate of intact perineum (56.7% in LP/40.7% in DP, P = 0.0001) and no differences with respect to perineal laceration. These differences were significant in primiparous (intact perineum: 46.8% in LP/20.2% in DP, P = 0.004; episiotomy: 17% en DL/44.7% en DD, P = 0.006) and secondiparous patients (episiotomy: 8.6% in LP/30.7% in DP, P = 0.0001). We showed significant differences in fetal heart abnormalities during labour in favour of the lateral decubitus position (no anomaly, P = 0.00004; separated decrease, P = 0.04; bradycardia, P = 0.0009; early decrease, P = 0.04).Discussion and conclusionThe neonatal mortality and morbidity did not differ between delivery positions. The lateral position seems to be protective for the perineum without affecting neonatal outcome. Incorporating lateral decubitus deliver into daily practice is possible in large groups of midwives after appropriate training.     

First-trimester maternal serum 25-hydroxyvitamin D3 status and pregnancy outcome

ObjectiveTo determine the pregnancy outcome as a function of the first-trimester serum 25-hydroxyvitamin D₃ [25(OH)D] status and to compare the 25(OH)D levels in the first and third trimesters.MethodsPregnant women (n = 466) tested for serum 25(OH)D levels during the first trimester were followed up until the end of pregnancy, and the obstetric and neonatal outcomes were compared in reference to the baseline 25(OH)D status. The third-trimester 25(OH)D levels were additionally measured in a subset of women (n = 148).ResultsThe obstetric and neonatal outcomes did not vary as a function of the first-trimester 25(OH)D status. Neither did the 25(OH)D levels vary as a function of pregnancy outcomes. Overall, the 25(OH)D levels significantly decreased from the first to the third trimester. The first- and third-trimester 25(OH)D levels of samples initially taken during autumn/winter were significantly lower than those that were initially taken during spring/summer. Interestingly, the decrease in 25(OH)D levels during the third trimester was independent of the season of sampling.ConclusionThe pregnancy outcome was independent of the first-trimester 25(OH)D status. Overall, the 25(OH)D levels significantly decreased in the third trimester. More research in this area is warranted.     

Outcome of obstetric fistula repair after 10-day versus 14-day Foley catheterization

ObjectiveTo compare outcome between 10-day and 14-day bladder drainage after obstetric fistula repair.MethodsIn a randomized prospective study at Hamlin Fistula Center, Bahir Dar, Ethiopia, patients presenting with obstetric vesicovaginal fistula between 2007 and 2010 were randomized to undergo 10-day (group 1) or 14-day (group 2) postoperative catheterization. Fistulas were categorized via Goh classification. The inclusion criteria were any type of vesicovaginal fistula except circumferential or recurrent.ResultsIn total, 189 women were enrolled: 107 in group 1, and 82 in group 2. The groups were similar in age, parity, duration of labor, and time from injury to surgical repair. There was no significant difference in fistula stage according to the Goh classification (urethral length, P = 0.3; fistula size, P = 0.9; and vaginal scarring, P = 0.3). There were 3 fistula breakdowns in group 1, and 6 in group 2. The difference in cure was not significant (P = 0.15, confidence interval –0.009 to 0.1). There was no significant difference in non-fistula-related incontinence or urinary retention after repair.ConclusionThe outcome of postoperative catheterization for 10 days was not inferior to that for 14 days. A similar treatment outcome with a shorter duration of catheterization will have a significant impact on reducing infection and cost.     

Single-shot ropivacaine wound infiltration during cesarean section for postoperative pain relief

ObjectiveTo assess the efficiency of single-shot ropivacaine wound infiltration during cesarean section for postoperative pain relief, using a prospective, randomized, double-blinded study.Patients and methodsOne hundred consecutive patients with planned cesarean section were enrolled between September 2007 and May 2008 and randomized into two groups: single-shot wound infiltration of 20 mL of ropivacaine 7.5 mg/mL (Group R; n = 56) or single-shot wound infiltration of 20 mL of saline solution (group T; n = 44). The primary goal of this study was the double-blinded evaluation of the postoperative pain after coughing and leg raise using the 100-mm visual analog scales (VAS) during the first 48 postoperative hours after cesarean delivery. The secondary goals were the occurrence of nausea and vomiting and the morphine consumption.ResultsNumerical pain rating scale for pain evaluation was significantly lower (P < 0.05) in the ropivacaine group than in the control group at M0, M20, M40, M60, H2 and H4. But, at H8, H12 and H24, no significant difference for VAS was noted between the two groups. The occurrence of nausea and vomiting and the total morphine consumption were not significantly different between the two groups during the first 48 postoperative hours.Discussion and conclusionSingle-shot ropivacaine wound infiltration during planned cesarean section is a simple and safe procedure that provides effective reduction of post-partum pain within the first 4 hours.     

Comparison of "push" and "pull" methods for impacted fetal head extraction during cesarean delivery

ObjectiveTo compare maternal and neonatal outcomes associated with the “push” and “pull” methods for impacted fetal head extraction during cesarean delivery.MethodsA prospective study was conducted at Imam Reza Hospital, Kermanshah, Iran, from April 2006 to March 2008. After failed vacuum extraction, women with obstructed labor caused by impacted fetal head were randomly assigned to deliver via the push method (n = 35) or the pull method (n = 37). The outcomes investigated included operation time, operative blood loss, incidence of extension of the uterine incision, and postpartum fever. Data were analyzed using χ² and Student t tests.ResultsMean operative time and incidence of extension of the uterine incision were significantly increased in the group that delivered via the push method (P < 0.001). There were no significant differences in the other maternal and neonatal morbidities between the groups, although there was 1 case of neonatal femoral fracture in the pull group.ConclusionAlthough the pull method may lead to some neonatal complications, it is associated with lower maternal morbidity than the push method when used for impacted fetal head extraction during cesarean delivery.     

Obstetric perinatal and maternal outcomes of monochorionic diamniotic twins following assisted reproductive techniques. Retrospective observational study

IntroductionMultiple and specifically monochorionic diamniotic (MCDA) pregnancies are related to maternal and foetal complications. The aim of this study is to evaluate obstetric and perinatal outcomes of MCDA after assisted reproductive techniques (ART).MethodsThis is a case-control study comparing 23 MCDA twin pregnancies after ART (ART-MCDA) and 75 spontaneous MCDA (sMCDA). Maternal, obstetric, foetal, and perinatal outcomes variables including maternal age, prematurity, TTTS, sIUGR, TAPS, PROM, and neonatal weight were compared.Resultsmean maternal age is higher in the ART-MCDA pregnancies, 38.0 ± .6 (OR = 1.32(1.13–1.53)). Neonates weighing between 1500 and 2500 g are more frequent in the sMCDA group and those weighing >2500 g in the ART group (OR = 0.47(0.22–0.97)). Foetuses born at between 32 and 37 weeks are more frequent in sMCDA pregnancies and those born >37 in the TRA group (OR = 0.27(0.09–0.80)). These differences are lost when we adjust the results by maternal age. There were no differences in maternal, obstetric, or foetal complications.ConclusionsART-MCDA are not associated with a higher number of maternal, obstetric or foetal complications if they are adjusted by maternal age. When they are not adjusted by maternal age, there would be better outcomes such as premature and neonatal weight in the ART group.     

Neonatal outcome following long-distance air travel for fetoscopic laser coagulation treatment of twin-to-twin transfusion syndrome

ObjectiveTo investigate the impact of undertaking long-distance air travel to a specialized medical center while pregnant in order to undergo fetoscopic laser coagulation (FLC) for twin-to-twin transfusion syndrome (TTTS).MethodsA retrospective cohort study was conducted of women with TTTS who travelled by air (n = 16) or land (n = 61) to the Centre of Perinatal Diagnosis and Microinvasive Fetal Surgery, Mainz, Germany, between January 1, 2006, and December 31, 2010. All women underwent FLC on arrival at the study center. Neonatal outcome, postoperative neonatal survival rates, and rates of adverse effects were recorded.ResultsThe postoperative survival rate for a single twin was 100.0% (n = 16) in the flight group and 98.3% in the land transportation group (n = 60). The postoperative survival rate for both twins was 81.3% in the flight group (n = 13) and 75.4% (n = 46) in the land transportation group. No differences in neonatal outcome or the rate of adverse effects were observed between the 2 groups. No flight-related pregnancy complications were recorded.ConclusionLong-distance air travel to a specialized tertiary care medical center is sufficiently safe to warrant recommendation to pregnant women with TTTS who require FLC.     

Single pregnancy outcome after blastocyst transfer: comparison with cleavage stage embryo transfers

ObjectivesIt has been clearly shown that transfer of fresh blastocysts was efficient in in vitro fertilization cycles. However, only few data have been published about pregnancy outcome and health of children born. This study including only single pregnancies compared pregnancy, delivery and neonatal outcomes after blastocyst transfers in comparison with early cleavage stage embryo transfers (Day 2).Patients and methodsA retrospective study has been performed at the hospital of Tours from January 2002 to June 2009. Considering only primiparous women with similar ages, the outcome of 1574 single pregnancies issued from blastocyst transfers (n = 588) or early cleavage stage transfers (n = 959) has been compared. Data have been collected from FIVNAT forms, filled in by voluntary couples.ResultsThe rate of return of FIVNAT forms was 97.6%. The pregnancy and delivery outcomes, sex ratio, birth weight, health of newborns were similar between both groups.Discussion and conclusionRegarding pregnancy, obstetric and delivery outcomes after blastocyst transfers, the literature data remain poor, much debated, and mixing often single and multiple pregnancies. The results of this study seem reassuring but have to be confirmed by further studies.     

The value of adding a universal booking scan to an existing protocol of routine mid-gestation ultrasound scan

ObjectiveTo compare 2 routine obstetric ultrasound protocols regarding number of clinically relevant events detected and total ultrasound workload.MethodsAn interventional before-and-after study comparing 2 groups of 750 consecutive low-risk pregnant women was conducted. The 1st group was routinely offered mid-trimester ultrasound and selective ultrasound examinations for specific indications; the 2nd group was, in addition to this, offered a scan at 1st prenatal visit.ResultsThe groups were comparable at baseline, and 78% underwent booking scan. The expanded protocol showed no improvement in detection of most clinically relevant findings but did detect twins slightly earlier (P = 0.3) and significantly reduced the number of presumed post-term deliveries (8.4% vs 13.1%; OR 0.61 [95% CI, 0.41–0.90]). Although more women were scanned at any point or < 24 weeks (P < 0.001), the increase in women receiving a properly timed fetal anomaly scan was small (60.7% vs 52.3%; P = 0.003). Total ultrasound workload increased by 74%, mainly because of more follow-up scans (323 vs 122) and more women being scanned for the 1st time > 24 weeks (146 vs 51; P < 0.001).ConclusionThe results do not support a policy of routine booking scans and revealed no significant benefit apart from a small reduction in presumed post-term pregnancies.     

The association of maternal and fetal glucose homeostasis with fetal adiposity and birthweight

ObjectiveTo examine the association between maternal and fetal glucose levels and fetal adiposity and infant birthweight.Study designThis is a prospective study of 479 healthy, non-diabetic mother and infant pairs attending the National Maternity Hospital in Ireland. Fasting glucose was measured in early pregnancy (11.8 ± 2.3 weeks). At 28 weeks gestation a repeat fasting glucose was measured and 1 h glucose challenge testing (1 h GCT) was performed. At 34 weeks’ gestation (33 + 5–34 + 5 weeks) fetal growth and fetal anterior abdominal wall width, a marker of fetal adiposity, were measured. At delivery cord glucose was measured and neonatal anthropometry recorded.ResultsThere was a positive correlation between fasting glucose concentration during pregnancy and both infant birthweight and fetal anterior abdominal wall width at 34 weeks gestation. The incidence of macrosomia (birthweight > 4.5 kg) was significantly greater for maternal and cord blood glucose levels in the highest quartile compared to the lowest quartile (20.7% vs. 11.7%, p < 0.05 in the first trimester, 21.3% vs. 7.2%, p < 0.05, at 28 weeks, and 33.3% vs. 10%, p < 0.05, in cord blood). Maternal glucose concentrations at each time point, though not cord glucose, were related to early pregnancy maternal body mass index (r = 0.19, p < 0.001 in first trimester, r = 0.25, p < 0.001 at 28 weeks, r = 0.15, p < 0.01 with 1 h GCT).ConclusionMaternal glucose homeostasis is an important determinant of fetal size. We have shown that even small variations in fasting glucose concentrations can influence fetal growth and adiposity. This effect is seen from the first trimester and maintained until delivery.     

Comparison of the umbilical artery blood gas, nucleated red blood cell, C-reactive protein, and white blood cell differential counts between neonates of diabetic and nondiabetic mothers

ObjectiveThe aim of this study was to compare the neonatal umbilical artery blood gas values, C-reactive protein (CRP) levels, nucleated red blood cells (NRBCs), and white blood cells (WBCs) differential counts between offspring’s of the diabetic mothers who needed insulin during pregnancy and normal mothers after cesarean delivery.Materials and MethodsA prospective study was performed involving 68 pregnant diabetic women who needed insulin during pregnancy and 410 healthy pregnant women and their neonates with gestational ages between 35 weeks and 41 weeks. Arterial blood was analyzed for pH and blood gas values and venous blood was analyzed for CRP level, NRBC, and WBC differential counts.ResultsThe mean NRBC count in the neonates of diabetic mothers and healthy mothers was 560 ± 985/μL and 202 ± 281/μL, respectively (p < 0.001). The umbilical arterial blood gas showed a lower pH (7.22 ± 0.07 vs. 7.24 ± 0.04, p = 0.004) and a higher pCO₂ (49.33 ± 10.08 vs. 47 ± 8.67, p = 0.045) in neonates of diabetic mothers compared with the controls. Values of pO₂, HCO₃^?, base excess, WBC differential counts, and CRP levels were almost similar in the two groups.ConclusionLower pH, higher pCO₂, and elevated NRBC counts were found in the neonates of diabetic mothers that may be suggestive of chronic intrauterine acidosis.     

Comparison of intrapartum outcome among immigrant women from Ethiopia and the general obstetric population in Israel

ObjectiveTo compare intrapartum outcome between ethnic Ethiopian women and the general obstetric population in Israel.MethodsIn a retrospective study, computerized data from all Ethiopian women who delivered between January 2004 and August 2011 at a university teaching hospital in Afula, Israel, were assessed. The control group comprised non-Ethiopian Israeli women, who were matched at a ratio of 1:2 on the basis of deliveries that took place immediately before and after delivery by an Ethiopian woman. The primary outcome was incidence of operative delivery.ResultsDuring the study period, 576 Ethiopian women delivered along with 1152 matched control women. Ethiopian women had a higher incidence of pre-eclampsia (6.8% versus 4.0%, P = 0.01) and early postpartum hemorrhage (4.3% versus 1.6%, P = 0.003) than control women. After adjustment for potential confounders, the incidence of vacuum or cesarean delivery was significantly higher among Ethiopian than among control women (odds ratio, 1.68; 95% confidence interval, 1.28–2.20; P = 0.002). The incidence of composite major perinatal morbidity, including Erb palsy and cord pH less than 7.1, tended to be higher among Ethiopian women than among control women (2.3% versus 1.1%; P = 0.053).ConclusionAlthough prepartum and intrapartum care are standardized, Ethiopian women had a less favorable intrapartum outcome.     

Comparison of the efficacy and safety of titrated oral misoprostol and a conventional oral regimen for cervical ripening and labor induction

ObjectiveTo compare the efficacy and safety of titrated oral misoprostol and a conventional oral regimen for cervical ripening and labor induction.MethodsA randomized double-blind trial of women with term singleton pregnancies with indications for labor induction. Participants were allocated to receive 20 mL of misoprostol solution (1 μg/mL) orally every 1 hour for 4 doses then titrated to 40 μg every 1 hour (titrated group) or 50 μg of misoprostol orally every 4 hours up to 12 hours (conventional group). Primary outcomes were success rate of cervical ripening within 12 hours, interval from first dose until more favorable cervix or active labor occurred, and total dose of misoprostol.ResultsSixty-four participants were included. Mean total dose of misoprostol and incidence of tachysystole were significantly higher in the titrated compared with the conventional group (236.2 ± 110.1 μg vs 103.1 ± 35.7 μg; P = 0.001 and 25.0% vs 6.3%; P = 0.03), whereas success rate, interval from drug administration to more favorable cervix and delivery, proportion of patients delivered vaginally within 12 hours and 24 hours, need for oxytocin augmentation, cesarean delivery rate, maternal adverse effects and complications, and neonatal outcome were not significantly different (P > 0.05).ConclusionConventional oral misoprostol is as effective as titrated misoprostol for cervical ripening and labor induction, but has a lower incidence of tachysystole and a lower total dose of misoprostol is required. ClinicalTrial.gov: NCT00886860.     

Group B streptococcus and Escherichia coli colonization in pregnant women and neonates in Lithuania

ObjectiveTo evaluate the prevalence of maternal and neonatal colonization with group B streptococcus (GBS) and Escherichia coli, and examine GBS serotypes and susceptibility to antibiotics.MethodsA prospective cross-sectional study was carried out in Lithuania between October 2006 and June 2007. Lower vaginal/rectal swabs were obtained from pregnant women (n = 998) and ear canal/throat swabs were obtained from their newborns (n = 827) for culture.ResultsOverall, maternal and neonatal GBS colonization rates were 15.3% and 6.4%, respectively. Serotypes III (34.5%) and Ia (29.7%) were most common. All GBS isolates were susceptible to penicillin and 4.1% were resistant to erythromycin. Overall, maternal and neonatal E. coli colonization rates were 19.9% and 14.4%, respectively. In total, 71.4% of newborns with E. coli colonization were born to E. coli-negative mothers. E. coli was resistant to ampicillin and piperacillin in 25.9% and 16.6% of cases, respectively. The majority of E. coli-colonized newborns were contaminated with maternal fecal, but not vaginal, E. coli strains.ConclusionMaternal and neonatal GBS colonization rates, serotypes, and susceptibility to antibiotics were comparable to those reported in previous studies. Population-based data regarding early-onset neonatal infection rates will enable the formulation of a prevention program for early-onset GBS disease in Lithuania.     

Quality of erection questionnaire correlates: change in erection quality with erectile function, hardness, and psychosocial measures in men treated with sildenafil for erectile dysfunction

IntroductionThe validated Quality of Erection Questionnaire (QEQ) is a six-question, patient-reported outcome measure for comprehensively evaluating satisfaction with the quality of erections in terms of hardness, onset, and duration, which can be used to develop and monitor individualized treatment goals.AimsTo further validate the QEQ by determining responsiveness/sensitivity to change in erectile function, erection hardness grade, and psychosocial outcomes in men treated with sildenafil for erectile dysfunction (ED).MethodsThis open-label, noncomparative, multicenter trial of sildenafil (50 or 100 mg as needed for 10 weeks) enrolled men with ED who were in a stable, sexual relationship for at least 6 months. Previous phosphodiesterase type 5 inhibitor use must have been no more than 6 doses ever and no doses more recently than the previous 4 weeks.Main Outcome MeasuresThe baseline to week 10 change in the QEQ total score and its correlations with the end-of-treatment Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) score and with changes in: (i) International Index of Erectile Function (IIEF) domain scores; (ii) Self-Esteem And Relationship (SEAR) questionnaire component scores; and (iii) the frequency of erections graded hard enough for penetration (grade 3) or completely hard (grade 4) on the event log Erectile Hardness Grading Scale.ResultsThe mean ± standard deviation transformed QEQ total score tripled from 22.0 ± 21.1 to 69.9 ± 35.9 (P < 0.0001), and correlated positively with the end-of-treatment EDITS index score (r = 0.71) and with changes in IIEF domain scores (r = 0.29–0.86), SEAR component scores (r = 0.37–0.78), and the percentage of occasions that grade 3 or 4 erections were achieved (r = 0.66).ConclusionsThe brief, easy-to-administer QEQ is responsive to the benefits of sildenafil treatment of men for ED and has convergent validity with measures of clinical and psychosocial outcomes. Lowy M, Collins S, Bloch M, Gillman M, Lording D, Sutherland P, Wang H, and Stecher V. Quality of Erection Questionnaire correlates: Change in erection quality with erectile function, hardness, and psychosocial measures in men treated with sildenafil for erectile dysfunction. J Sex Med 2007;4:83–92.     

Contraceptive Withdrawal in Adolescents: A Complex Picture of Usage

Study ObjectiveContraceptive withdrawal, or coitus interruptus, is a widespread method in adolescents, but factors affecting usage have not been longitudinally investigated. Study objectives were to examine usage numbers of withdrawal among a group of sexually active adolescent females and to investigate the influence of personal, partner, and family factors on usage patterns.Design/Setting/ParticipantsSubjects (N = 387; 14 to 17 years at enrollment; 92% African American) were recruited from primary care adolescent health clinics in areas with high rates of pregnancy and sexually transmitted infection. As part of a larger longitudinal study, subjects contributed face-to-face quarterly and annual questionnaires assessing contraceptive behavior, recent sexual behaviors, as well as partner- and family-based attitudes/beliefs.Interventions, Main Outcome MeasuresThe outcome variable was: withdrawal use during the previous 12 weeks (no/yes); predictor variables included 19 individual, family and partner variables. All models additionally controlled for any current hormonal use (no/yes; any method), current condom use (no/yes) and past withdrawal use (past 30 days; no/yes). Logistic regression, with GEE estimation to adjust for repeated within-subject observations, was performed in SUDAAN, 9.0.ResultsSubjects supplied 1632 quarterly interviews; withdrawal was mentioned in about 25% of the interviews (392/1632). Controlling for primary contraceptive method, withdrawal was mentioned in 13.2% (51/307) of interviews with hormonal methods, in 32.4% (255/787) of the interviews with condoms and in 4.7% (78/1632) of interviews with no method. Current hormonal use was associated with a decreased likelihood of also using withdrawal (OR = 0.34), whereas past withdrawal use increased the likelihood of current withdrawal by about 4-fold (OR = 4.18). Condom use was not associated with withdrawal use. Current withdrawal use was more likely with a more diverse sexual repertoire (OR = 1.65), more sexual partners in the past 3 months (OR = 1.46), higher sexual control (OR = 1.15), lower perceived STI risk (OR = 0.46), higher sexual self-efficacy (OR = 1.24), lower sexual coercion (OR = 0.56) higher condom negativity (OR = 1.16), living with a boyfriend (OR = 2.17) and lower family sexual health support (OR = 0.88).ConclusionContraceptive withdrawal in adolescents should not be considered ‘rare.’ Careful clinical consideration of usage within the context of other contraceptive behaviors, sexual behaviors/attitudes, and relationship issues could better inform effective contraceptive counseling efforts.     

Transvaginal laparoscopic surgery for ovarian cysts

ObjectiveTo evaluate the effectiveness and feasibility of transvaginal laparoscopic surgery (TLS) using endoscopic instruments for management of ovarian cysts.MethodsIn a retrospective study, data from 140 patients with benign ovarian cysts who underwent TLS at Konkuk University Hospital between June 2007 and December 2008 were evaluated. The preoperative characteristics of patients, operative time, blood loss, complications, and postoperative outcomes were evaluated.ResultsThe mean age of patients was 38 years (range, 16–82 years). TLS was accomplished in 136 women (97.1%). The more common pathology findings included 35 dermoid cysts, 28 endometriotic cysts, 23 mucinous cysts, 21 serous cysts, and 13 functional ovarian cysts. The median operative time was 35 minutes (range 15–110 minutes). The maximum diameter of the ovarian cysts ranged from 3 to 20 cm (mean 6 cm). The median estimated blood loss was 38 mL (range 10–80 mL). No patients received a blood transfusion. All of the patients were discharged within 24 hours of surgery. No major complications occurred.ConclusionTransvaginal laparoscopic surgery was found to be a feasible and cosmetically beneficial surgical technique for managing selected patients with benign ovarian cysts.     

Advancing obstetric and neonatal care in a regional hospital in Ghana via continuous quality improvement

ObjectiveTo reduce maternal and neonatal death at a large regional hospital through the use of quality improvement methodologies.MethodsIn 2007, Kybele and the Ghana Health Service formed a partnership to analyze systems and patient care processes at a regional hospital in Accra, Ghana. A model encompassing continuous assessment, implementation, advocacy, outputs, and outcomes was designed. Key areas for improvement were grouped into “bundles” based on personnel, systems management, and service quality. Primary outcomes included maternal and perinatal mortality, and case fatality rates for hemorrhage and hypertensive disorders. Implementation and outcomes were evaluated tri-annually between 2007 and 2009.ResultsDuring the study period, there was a 34% decrease in maternal mortality despite a 36% increase in patient admission. Case fatality rates for pre-eclampsia and hemorrhage decreased from 3.1% to 1.1% (P < 0.05) and from 14.8% to 1.9% (P < 0.001), respectively. Stillbirths were reduced by 36% (P < 0.05). Overall, the maternal mortality ratio decreased from 496 per 100 000 live births in 2007 to 328 per 100 000 in 2009.ConclusionMaternal and newborn mortality were reduced in a low-resource setting when appropriate models for continuous quality improvement were developed and employed.     

Impact of the creation of a specialized clinic for prenatal blood sampling and follow-up care in pregnant women

ObjectiveTo evaluate (1) the effect on gestational diabetes mellitus (GDM) screening rates of having a specialized clinic for pregnant women offering blood sampling and screening for GDM, and (2) the impact on perinatal outcomes of having early GDM screening and follow-up provided by the specialized clinic.MethodsWe performed a retrospective cohort study, based on electronic health records. We compared data from women who delivered during a period when the Blood Sampling in Pregnancy (BSP) clinic was operating (2008–2009; n = 2780) to a time period before the clinic was established (2006–2007; n = 2591). During the 2008–2009 period, we compared data from women who had GDM screening in the first trimester with women who had screening during the second trimester and with women who were not screened.ResultsFollowing the creation of the BSP clinic, overall GDM screening rates reached 72.4% in 2008–2009, compared with 48.9% in 2006-2007 (P < 0.001) and GDM screening was more likely to be performed in the first trimester (36.7% vs. 0.4%; P < 0.001). During the period when the BSP clinic was operating (2008-2009), women who had GDM screening in the first trimester had lower rates of Caesarean section (15.7% vs. 22.1 %; P < 0.001) and neonatal complications (bradycardia: 3.6% vs. 6.8%; P = 0.003; respiratory distress: 9 6% vs 13 2%; P = 0 02; and admission to NICU: 15.4% vs. 26.8%; P < 0.001) than women who did not perform GDM screening.ConclusionIn our population, creation of a clinic offering specialized care to pregnant women improved GDM screening rates. With the support of the BSP clinic, women who had early GDM screening were less likely to undergo Caesarean section and their offspring had fewer perinatal complications.     

A prospective study of nerve-sparing radical hysterectomy for uterine cervical carcinoma in Taiwan

ObjectiveSurgical therapy for cervical carcinoma carries a significant risk of functional impairment to the bladder. This study evaluates the feasibility and complications of nerve-sparing radical hysterectomy (NRH) in Taiwan.MethodsBetween March 2010 and March 2011, consecutive patients diagnosed with early stage cervical cancer (FIGO stage Ia2 to Ib1) and tumor size < 3 cm were recruited prospectively to undergo NRH or conventional radical hysterectomy (RH). Patients with histories of urinary stress incontinence or bladder dysfunction disease were excluded. A modified Tokyo nerve-sparing radical hysterectomy was performed.ResultsA total of 30 patients were enrolled. Among these, 18 patients underwent NRH with successful bilaterally nerve-sparing procedures in 15 cases (83%), unilaterally nerve-sparing procedures in 2 cases (11%), and a failure in 1 case (6%). The indwelling catheter was removed on postoperative day 6. The mean ± SD duration from operation to spontaneous voiding was 6.8 ± 1.5 days for women who underwent NRH; the corresponding duration for women who underwent RH or failed NRH was 20.6 ± 3 days. None of the patients who underwent NRH required intermittent catheterization. All 12 patients who underwent RH needed self-catheterization after discharge. There was a significant reduction in the incidence of postoperative self-catheterization (p < 0.01) and bladder dysfunction (p < 0.006). Average satisfaction score analyzed by the Likert-scale questionnaire was 4.5 for the NRH group and 1.9 for RH group (p < 0.0001).ConclusionsWe concluded that the new technique of NRH can reduce postoperative bladder dysfunctions.