Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section: a prospective randomized controlled trial

BACKGROUND/AIM: There are controversies about the routine use of oronasopharyngeal suction (ONPS) in healthy infants. This study aimed to compare the effects of oronasopharyngeal suction with those of no suction in normal, term infants delivered by cesarean section. METHODS: 140 term, healthy newborns of uncomplicated pregnancies were prospectively randomized to one of two groups according to the use of ONPS procedure. Differences in oxygen saturation levels, heart rates, and Apgar scores were determined. RESULTS: The mean SaO(2) values through the 2nd and 6th min of life were significantly higher in the no suction group (p < 0.001). The maximum time to reach SaO(2) of > or =92% (6 vs. 11 min) and > or =86% (5 vs. 8 min) saturation were shorter in the no suction group than in the ONPS group. The mean heart rates were consistently and significantly lower in the no suction group during the first 6 min except the second one. All neonates without suction had an Apgar score of 10 at the 5th min, while the mean +/- SD for ONPS group was 9.34 +/- 0.48 (p < 0.001). CONCLUSION: Although findings remained on statistical level and did not lead to clinically adverse outcomes, there is no statistical or physiological basis for oronasopharyngeal suction as a systematic procedure in healthy, term infants delivered by cesarean section.     

Effects of closed suction drainage in reducing pain after laparoscopic-assisted vaginal hysterectomy

STUDY OBJECTIVE: To estimate whether closed suction drainage of the pelvis after laparoscopic-assisted vaginal hysterectomy (LAVH) reduces the frequency and intensity of shoulder-tip, abdominal, and back pain. DESIGN: Prospective, randomized study (Canadian Task Force classification 1). SETTING: Teaching medical center. PATIENTS: One hundred sixty-four women. INTERVENTION: LAVH. MEASUREMENTS AND MAIN RESULTS: For group 1 (80 women), closed suction (Jackson-Pratt) drains were inserted into the peritoneal cavity and cul-de-sac, whereas for group 2 (84), no drains were placed. Shoulder-tip, abdominal, and back pain were evaluated by visual analog scores (VAS) 3, 24, and 48 hours after surgery. The frequency of shoulder-tip pain was significantly lower in group 1 at 24 hours (23% vs 40%, p = 0.013) and 48 hours (9% vs 21%, p = 0.024; VAS scores at 24 hrs 2.2 +/- 1.1 vs 3.8 +/- 1.3, p = 0.010; VAS scores at 48 hours 1.5 +/- 1.0 vs 2.5 +/- 1.2, p = 0.018). At 48 hours fewer women in group 1 experienced abdominal pain (31% vs 50%, p = 0.039; VAS scores 2.0 +/- 1.1 vs 4.0 +/- 1.3, p = 0.007). No statistically significant differences in frequency and VAS scores for back pain were found at any time. The quantity of oral analgesics was greater for group 2 than for group 1 (12.4 +/- 1.6 vs 9.0 +/- 1.4, p <0.001). Economic evaluation of analgesic requirements and material costs for the two groups showed that simple analgesics were more cost-effective than closed suction drainage in the treatment of pain. CONCLUSION: Closed suction drains may reduce the frequency and intensity of shoulder-tip and abdominal pain and postoperative analgesia requirements after LAVH, but simple oral analgesics are more cost effective.     

Acceptability of suction curettage and mifepristone abortion in the United States: a prospective comparison study

OBJECTIVE: We sought to compare the acceptability of suction curettage abortion with that of medical abortion with mifepristone and misoprostol in American women. STUDY DESIGN: We performed a prospective, serially enrolled, cohort analysis. The study population consisted of 152 subjects receiving mifepristone and misoprostol and 174 subjects undergoing suction curettage abortion aged > or =18 years with intrauterine pregnancies of up to 63 days' estimated gestation. Questionnaires regarding expectations and experiences were administered before the abortion and at the 2-week follow-up visit. RESULTS: Subjects undergoing medical abortions reported significantly greater satisfaction than those undergoing surgical abortions (mean rank, 121 vs 149; P <.01) but were no more likely to recommend the method they had just experienced to a friend (97% vs 93.3%). If a future abortion was required, however, 41.7% of subjects undergoing surgical abortions indicated they would opt for a medical abortion, whereas only 8.6% of subjects receiving medical abortions would choose a surgical abortion (P <.001). Failure of the abortion decreased satisfaction in the medical group and increased the likelihood of choosing a surgical abortion for a subsequent procedure (P <.001). Surgical subjects who experienced more anxiety than expected during the abortion were more likely to choose a medical procedure for a subsequent abortion (P <.01). CONCLUSION: Women receiving mifepristone and misoprostol were more satisfied with their method and more likely to choose the same method again than were subjects undergoing surgical abortion. Failure of a medical abortion and increased anxiety during surgical abortion were associated with preference for the alternative technique in a future procedure.     

应用胎粪吸引管气管内吸引防治胎粪吸入综合征的临床效果分析

目的 评价气管内吸引防治胎粪吸入综合征(meconium aspiration syndrome,MAS)的有效性,探讨新生儿活力与胎粪吸入的关系. 方法 2004年1月至2006年12月我院分娩胎粪Ⅲ度污染新生儿(简称粪染儿)495例,随机分为观察组249例,生后常规气管插管、应用胎粪吸引管抽吸胎粪;对照组246例,生后插管、气管内冲洗.观察两组MAS发生率、并发症及预后. 结果 观察组与对照组MAS发生率分别为7.6%和11.4%(x2=2.45,P＞0.05);观察组重型MAS发生率明显低于对照组[0.8%(2/249)和4.5%(11/246),x2=6.51,P＜0.05];观察组机械通气率为0.4%,对照组为2.8%(x2=3.12,P＞0.05);观察组病死率为0,对照组病死率1.2%(3/246).观察组1 min Apgar评分9～10分有活力新生儿气管抽出胎粪中位数为0.86 ml,明显少于≤8分无活力新生儿的1.65 ml(z=1.44,P＜0.05);观察组有活力粪染儿中17.8%(38/214)气管内可抽到胎粪,其中26.3%(10/38)可抽出大量胎粪.结论 (1)粪染儿生后早期进行气管内吸引不能减少MAS发生率,但可减轻临床症状,防止并发症,降低病死率.(2)有活力新生儿亦可发生胎粪吸入,应积极处理.     

The impact of digital cervical examination on expectantly managed preterm rupture of membranes

OBJECTIVE: The purpose of this study was to examine the effects of digital cervical examination on maternal and neonatal outcomes among women with preterm rupture of membranes. STUDY DESIGN: This analysis includes data from a previously reported trial of antibiotic treatment during expectant management of rupture of membranes at 24 to 32 weeks' gestation in singleton and twin gestations. Patients from both the randomized trial (n = 299 in the antibiotic group and n = 312 in the placebo group) and the observational component (n = 183) are included in this analysis. The groups were divided into those with one (n = 161) or two digital cervical examinations (n = 27) and those with no digital cervical examinations (n = 606). RESULTS: The gestational ages at enrollment were similar in the two groups (29 +/- 2 weeks' gestation for one or two examinations vs 29 +/- 2 weeks' gestation for no examinations; P =.85). There were no differences in chorioamnionitis (27% vs 29%; P =.69), endometritis (13% vs 11%; P =.5), or wound infection (0.5% vs 1%; P >.999) between the group with one or two examinations and the no-examination group. Infant outcomes were also similar in the two groups, including early sepsis (6% vs 5%; P =.68), respiratory distress syndrome (51% vs 45%; P =.18), intraventricular hemorrhage (7% vs 7%; P =.67), necrotizing enterocolitis (5% vs 3%; P =.19), and perinatal death (7% vs 5%; P =.45). A composite outcome made up of these neonatal outcomes was not different (56% vs 48%; P =.10) between the group with one or two examinations and the no-examination group. The time from rupture to delivery was shorter in the digital examination group (median value, 3 vs 5 days; P <. 009). Multivariable analysis to adjust for antibiotic study group, group B streptococcal culture status, race, and maternal transfer did not modify these results. CONCLUSION: Performance of one or two digital cervical examinations during the course of expectant management of rupture of membranes between 24 and 32 weeks' gestation was associated with shorter latency but did not appear to worsen either maternal or neonatal outcome.     

Modified Joel-Cohen technique for caesarean delivery.

OBJECTIVE: To investigate whether a series of changes in the current caesarean section operative routine, based on new knowledge, would be beneficial. DESIGN: A prospective controlled trial. SETTING: Labour ward with approximately 3000 deliveries annually in a suburban area of Gothenburg, Sweden. PARTICIPANTS: Seventy-two pregnant women scheduled for delivery by caesarean section were randomised to either modified Joel-Cohen technique (n = 36) or Pfannenstiel technique (n = 36). MAIN OUTCOME MEASURES: Blood loss during surgery and operating time. RESULTS: The median estimated intra-operative blood loss was 250 mL in the modified Joel-Cohen group and 400 mL in the Pfannenstiel group (P = 0.026). The proportion of women with > or = 300 mL was 16/36 in the modified Joel-Cohen group vs 28/36 in the Pfannenstiel group (OR 0.229, 95% CI 0.082-0.637). Median operating time was 20 min in the modified Joel-Cohen group compared with 28 min in the Pfannenstiel group (P < 0.001). The proportion of women with > or = 25 min was 1/36 in the modified Joel-Cohen group vs 33/36 in the Pfannenstiel group (OR 0.003, 95% CI 0.000-0.026). CONCLUSIONS: We conclude that the modified Joel-Cohen technique of caesarean delivery reduced intraoperative blood loss and operating time compared with the Pfannenstiel technique.     

Saphenous vein sparing during inguinal lymphadenectomy to reduce morbidity in patients with vulvar carcinoma

OBJECTIVES: To compare short- and long-term morbidity associated with saphenous vein sparing versus ligation during inguinal lymphadenectomy for vulvar carcinoma. METHODS: A retrospective evaluation of patients with carcinoma of the vulva that underwent inguinal lymphadenectomy was performed. Operative reports were evaluated and patients were divided into those who had sparing of the saphenous vein versus ligation. Postoperative short- and long-term complications were compared between the two groups using Pearson chi squared analysis. RESULTS: There were a total of 49 inguinal lymphadenectomies performed on 29 patients. The saphenous vein was spared in 18 (37%) groin dissections compared to 31(63%) in which the saphenous vein was ligated. The two groups were similar in regards to clinical characteristics. All patients received closed suction drains and prophylactic antibiotics. Median number of nodes dissected was similar. Cellulitis was more common in the vein-ligated group compared to the vein-spared group (45% vs. 0%; P < 0.001). Wound breakdown occurred in 25% of dissections where the saphenous vein was ligated versus 0% in dissections where the vein was spared (P = or < 0.02). Short-term edema (< or = 6 months) was similar between vein-ligated and vein-spared groups (67% vs. 72%, P < 1.0). Subsequently, chronic lymphedema (> 6 months) persisted in 38% of the vein-ligated group compared to 11% in the vein-spared group (P < 0.05). The incidence of recurrent disease was similar in both groups (19.3 % vs. 22.2% P < 0.1). CONCLUSIONS: Routine preservation of the saphenous vein during inguinal lymphadenectomy for vulvar carcinoma may reduce the incidence of wound cellulitis, wound breakdown, and chronic lymphedema.     

Age contrasts in clinical characteristics and pattern of care in patients with epithelial ovarian cancer

OBJECTIVE: The objective of this study was to document and highlight aspects of ovarian cancer treatment that pertain, especially, to elderly women. METHODS: Data were collected retrospectively from all epithelial ovarian cancer patients who were diagnosed in the Gynecologic Oncology Unit at Meir Hospital, Kfar-Saba, Israel, from January 1994 to December 1998. RESULTS: The study group comprised 143 patients (<70 years n = 97, > or =70 years n = 46). Both groups presented with the same distribution of stages. The elderly group had fewer primary debulking surgical interventions (54.3%) than the younger group (84.5%) (P = 0.001)). Age was not a limiting factor in achieving optimal debulking in those patients who did undergo surgery (older 53%, younger 54%). Almost 92% of the younger patients entered a first-line chemotherapy regimen compared to 65.2% of the older patients (P = 0.001). The elderly patients were more likely to receive neoadjuvant chemotherapy (43.3.3% vs 13.4%, P < 0.01) and hematological toxicity was significantly more common (75% vs 36.3%; P = 0.001), although no significant difference was noted between the groups in Grade 3-4 patients (> or =70 years, 62.5% vs <70 years, 45.5%; P = 0.2). The elderly patients were more likely to have dose reductions and treatment delays compared to the younger patients (60% vs 22.4%; P < 0.001, and 46.6% vs 19.1%; P = 0.004, respectively) and they had similar overall response rates (RR) and complete response (80% vs 87.6% and 60% vs 71.9%, respectively). CONCLUSIONS: Older women who present with the same distribution of stages as their younger counterparts are likely to be treated more conservatively than younger ovarian cancer patients. In this study, however, when surgery was performed, the optimal tumor debulking rates were similar in each group. Although high morbidity, most often hematological toxicity, occurs in elderly patients following chemotherapy, the overall RR compared favorably with that of younger patients.     

Closed suctioning of intubated neonates maintains better physiologic stability: a randomized trial.

OBJECTIVE: To evaluate the physiological variance in a closed (CS) vs an open suction (OS) protocol in intubated infants. STUDY DESIGN: Infants were stratified into three weight groups in a randomized crossover trial. Heart rate, respiratory rate, blood pressure, oxygen saturation, transcutaneous oxygen and carbon dioxide, and end-tidal carbon dioxide were recorded prior to suctioning, during suctioning, and recovery to baseline. Following the procedures, recovery time to baseline parameters was measured. Data were analyzed using repeated measures ANOVA. RESULTS: Overall, there was significantly less deviation from baseline physiological parameters with CS. Infants <1000 g had clinically significant decreases in heart rate with the OS method (-18% OS vs -6% CS; p=0.016). Recovery time in the OS group was twice that of the CS cohort (4 vs 2 minutes; p<0.001). CONCLUSION: CS maintains better physiologic stability in intubated infants.     

Surgical Management of Early-Stage Endometrial Cancer in the Elderly: Is Laparoscopy Feasible?

OBJECTIVE: To give insight into the utility of laparoscopic staging of endometrial cancer in the elderly population by reviewing the surgical management of clinically stage I endometrial cancer patients. METHODS: A retrospective analysis evaluating patients that were > or =65 years old and had planned laparoscopic staging, traditional staging via a laparotomy, or a transvaginal hysterectomy as management of their early endometrial cancer. The laparoscopic group had complete staging with bilateral pelvic and paraaortic lymph node dissections and was compared to the group who had staging performed via laparotomy. Patients were identified by our institution's database and data were collected by review of their medical records. Data were collected on demographics, pathology, and procedural information including completion rates, operating room (OR) time, estimated blood loss (EBL), transfusions, lymph node count, complications, and length of stay. Associations between variables were analyzed by Student's t tests and chi(2) testing using Excel v. 9.0. RESULTS: From February 25, 1994, through December 21, 2000, 125 elderly patients were identified. Sixty-seven patients had planned laparoscopic staging (Group 1), 45 patients had staging via planned laparotomy (Group 2), and 13 patients had a transvaginal hysterectomy (Group 3). Group 1 and Group 2 were compared regarding surgical and postoperative data. Age was not different between these groups (75.9 vs 74.7 years, P = NS). Quetelet index was also similar (29.4 vs 29.9, P = NS) 32.8% of Group 1 had > or =1 previous laparotomy compared to 51.1% in Group 2 (P = NS). In Group 1, 53/67 (79.1%) had stage I or II disease compared to 29/45 (64.4%) in Group 2 (P = NS). Laparoscopy was completed in 52/67 (77.6%) attempted procedures. The reasons for conversion to laparotomy were obesity 7/67 (10.4%), bleeding 4/67 (6.0%), intraperitoneal cancer 3/67 (4.5%), and adhesions 1/67 (1.5%). OR time was significantly longer in successful Group 1 patients compared to Group 2 patients (236 vs 148 min, p = 0.0001). EBL was similar between these groups (298 vs 336 ml, P = NS). Ten of 52 (19.2%) of successful Group 1 patients received a blood transfusion compared to 1/45 (2.2%) of Group 2 patients (P < 0.0001). Pelvic, common iliac, and paraaortic lymph node counts were similar between successful Group 1 patients and those in Group 2 combined with those that received a laparotomy in Group 1 (17.8, 5.2, 6.6 vs 19.1, 5.1, 5.2, P = NS). Length of stay (LOS) was significantly shorter in Group 1 versus Group 2 (3.0 vs 5.8 days, P < 0.0001). There were less fevers (6.0 vs 15.6%, P = 0.01), less postoperative ileus's (0 vs 15.6%, P < 0.001), and less wound complications (6.0 vs 26.7%, P = 0.002) in Group 1 compared to Group 2. Group 3 average age was 77.5 years. Concurrent medical comorbidities were the main reason for the transvaginal approach. OR time averaged 104.5 min. The average length of stay was 2.1 days with no procedural or postoperative complications. CONCLUSIONS: The favorable results from this retrospective study refute the bias that age is a relative contraindication to laparoscopic surgery. Laparoscopic staging was associated with an increased OR time and an increased rate of transfusion but equivalent blood loss and lymph node counts. Possible advantages are decreased length of stay, less postoperative ileus, and less infections complications. Transvaginal hysterectomy still remains a proven option for women with serious comorbid medical problems with short OR times, minimal complications, and short lengths of stay.     

Comparison of glyburide and insulin for the management of gestational diabetics with markedly elevated oral glucose challenge test and fasting hyperglycemia.

OBJECTIVE: To compare the effectiveness of glyburide and insulin for the treatment of Gestational diabetes mellitus (GDM) in women who had OGCT >or=200 mg/dl and fasting hyperglycemia. STUDY DESIGN: A retrospective study was performed among a subset of women treated with glyburide or insulin for GDM from 1999 to 2002 with an OGCT >or=200 mg/dl and pretreatment fasting plasma glucose >or=105 mg/dl. Exclusion criteria included pretreatment fasting >or=140 mg/dl, gestational age >or=34 weeks and multiple gestation. Maternal and neonatal outcomes were assessed. Statistical methods included bivariate and multivariable logistic regression analyses. RESULTS: In 1999 to 2000, 78 women were treated with insulin; in 2001 to 2002, 44 of 69 (64%) received glyburide. There were no statistically significant differences between the two groups with regards to mean OGCT (230+/-25 vs 223+/-23 mg/dl, P=0.07) and mean pretreatment fasting (120+/-10 vs 119+/-11 mg/dl, P=0.45). Seven women (16%) failed glyburide. Women in the insulin group were younger (31.5+/-5.8 vs 35.2+/-4.7 years, P<0.001) and had a higher mean BMI (32.4+/-6.4 vs 29.1+/-5.8 kg/m(2), P=0.003) compared to glyburide group. There were no significant differences in birth weight (3524+/-548 vs 3420+/-786 g, P=0.65), macrosomia (19 vs 23%, P=0.65), pre-eclampsia (12 vs 11%, P=0.98) or cesarean delivery (39 vs 46%, P=0.45). Neonates in the glyburide group were diagnosed more frequently with hypoglycemia (34 vs 14%, P=0.01). When controlled for confounders, macrosomia was found to be associated with glyburide treatment (OR 3.5, 95% CI 1.1 to 11.4). CONCLUSION: In women with GDM who had a markedly elevated OGCT and fasting hyperglycemia, glyburide achieved similar birth weights and delivery outcomes but was associated with an increased risk of macrosomia. The possible increased risk of neonatal hypoglycemia in the glyburide group warrants further investigation.     

Comparison of a closed (Trach Care MAC) with an open endotracheal suction system in small premature infants.

OBJECTIVE: To determine whether ventilated, low birth weight infants treated with closed versus open tracheal suction in a neonatal intensive care unit (NICU) differ as to airway bacterial colonization, nosocomial pneumonia, bloodstream infection (BSI), incidence and severity of bronchopulmonary dysplasia (BPD), neonatal mortality, frequency of suction, reintubation, and nurse preference. STUDY DESIGN: A total of 175 low birth weight infants (< or = 1250 gm) consecutively born (1997 to 1999), intubated, and ventilated in the delivery room were randomized on admission to the NICU to a closed (Trach Care MAC) or open suction group. Closed multi-use catheters were changed daily; open catheters were changed after every use. Two-pass endotracheal suctioning (both groups) was performed every 8 hours or as needed. Side-port connectors were not used; thus open suction required disconnection from ventilators. Tracheal aspirate cultures were obtained on admission and weekly thereafter. Nosocomial BSI (occurring after 48 hours of life) was documented by positive blood cultures. Radiographs taken before, during, and after tracheal aspirate cultures or BSIs were graded using a semiquantitative system for pneumonia and a modified score for BPD. Nurse preference regarding suction method was recorded. RESULTS: Of the original 175 patients, 10 (5 from each group) died and 32 others (16 form each group) were extubated at or before 7 days of life. The study population comprised 67 patients in the closed group and 66 in the open group who were ventilated longer than 1 week. Groups were not statistically different in terms of demographic and clinical characteristics, such as birth weight (837 vs 876 gm), ventilation (27 vs 26 days), and length of stay (49 vs 40 days). Airway colonization with Gram-positive cocci occurred in the majority of patients by 2 weeks of life, regardless of group. A total of 39% of infants in the closed group and 44% of infants in the open group became airway colonized with Gram-negative bacilli; differences were statistically significant. No Gram-negative bacilli species was more likely to be associated with either suction. Nosocomial pneumonia was diagnosed in five patients from each group. Nosocomial BSIs occurred in six closed suction infants and five open suction infants. A comparable number of infants in each group developed severe BPD and were discharged from the hospital on oxygen. A total of 28% of closed suction patients and 27% of open suction patients died. Infants in the closed versus open group were suctioned on average 4.4 and 4.1 times per day and were reintubated 9.7 and 8.6 times per 100 ventilator days, respectively. A total of 40 of 44 NICU nurses considered closed suction to be easier to use, less time-consuming, and better tolerated by the patient. CONCLUSIONS: Closed suction obviates the physiological disadvantage of ventilator disconnection without increasing the rate of bacterial airway colonization, frequency of endotracheal suction and reintubation, duration of mechanical ventilation, length of hospitalization, incidence of nosocomial pneumonia, nosocomial BSI, severity of BPD, and neonatal mortality. Although slightly more expensive, closed suction is perceived by nursing staff to be easier, less time-consuming, and better tolerated by small premature infants requiring mechanical ventilation for > or = 1 week.     

Modified Joel-Cohen technique for caesarean delivery

Objective To investigate whether a series of changes in the current caesarean section operative routine, based on new knowledge, would be beneficial.
Design A prospective controlled trial.
Setting Labour ward with approximately 3000 deliveries annually in a suburban area of Gothenburg, Sweden.
Participants Seventy-two pregnant women scheduled for delivery by caesarean section were randomised to either modified Joel-Cohen technique (   n = 36  ) or Pfannenstiel technique (   n = 36  ).
Main outcome measures Blood loss during surgery and operating time.
Results based on new knowledge, would be beneficial. The median estimated intra-operative blood loss was 250 mL in the modified Joel-Cohen group and 400 mL in the Pfannenstiel group (   P = 0.026  ). The proportion of women with 2 300 mL was 16/36 in the modified Joel-Cohen group vs 28/36 in the Pfannenstiel group (OR 0.229,95% CI 0.082–0.637). Median operating time was 20 min in the modified Joel-Cohen group compared with 28 min in the Pfannenstiel group (   P < 0.001  ). The proportion of women with 2 25 min was 1/36 in the modified Joel-Cohen group vs 33/36 in the Pfannenstiel group (OR 0.003, 95% CI Conclusions We conclude that the modified Joel-Cohen technique of caesarean delivery reduced intra 0.000–0.026).
Conclusions We conclude that the modified Joel-Cohen technique of caesarean delivery reduced intra-operative blood loss and operating time compared with the Pfannenstiel technique.     

笑气吸入用于分娩镇痛的有效性与安全性研究

目的　探讨笑气吸入分娩镇痛的有效性与安全性。方法　将 130 0例单胎头位、足月初产妇分为两组。其中 ,研究组 6 5 8例 ,在产程中吸入 5 0 %笑气与 5 0 %氧气的混合气体实行分娩镇痛 ;对照组 6 4 2例 ,产程中间断吸入氧气。观察两组产妇疼痛的缓解程度、产程时间、分娩方式、羊水情况、分娩失血量、新生儿出生时的Apgar评分、产妇桡动脉与新生儿脐动脉血气分析的结果、笑气吸入的副反应。结果　研究组产妇分娩镇痛的有效率为 80 9% ,总产程时间为 4 6 8min ,活跃期时间为 15 3min ,剖宫产率为 11 6 % ,羊水污染率 2 2 0 % ,新生儿窒息率 1 2 % ,产时出血平均 2 37ml,39 4 %的产妇出现头晕表现的副反应 ;而对照组产妇分娩镇痛的有效率为 0 9% ,活跃期时间为 187min ,剖宫产率为 19 3% ,与研究组比较 ,差异有显著性 (P <0 0 5 ) ;而产程时间 4 80min ,羊水污染率 2 4 3% ,新生儿窒息率 1 7% ,产时出血平均 2 5 3ml,与研究组比较 ,差异无显著性 (P >0 0 5 ) ;对照组产妇无明显的头晕等副反应。两组产妇桡动脉及脐动脉血气分析结果比较 ,差异无显著性 (P >0 0 5 )。结论　 5 0 %笑气与 5 0 %氧气的混合气体用于分娩镇痛安全方便 ,易被产妇接受 ,可有效地缓解分娩疼痛 ,增加阴道分娩率 ,对产程及母儿     

The impact of age on long-term outcome in patients with endometrial cancer treated with postoperative radiation

PURPOSE: Endometrial cancer is the most commonly diagnosed gynecologic malignancy in the United States. Age has been associated with worse outcome in univariate analysis. However, the patterns of failure and associated risk factors in older patients remain unclear. We reviewed our institution's experience to assess the effect of age in a population of endometrial cancer patients treated with surgery and adjuvant radiation therapy. METHODS: From 1992-2002, 243 endometrial cancer patients underwent a total abdominal hysterectomy and adjuvant radiation. Forty-nine patients with stage I-II (occult) endometrial adenocarcinoma (no clear cell or serous papillary) were treated postoperatively with vaginal intracavitary high-dose rate (HDR) brachytherapy alone using Iridium-192 (median dose 30 Gy) to a median length of 4 cm. Forty-eight patients with stage I-III endometrial adenocarcinoma (no clear cell or papillary serous) were treated with postoperative pelvic RT (median dose 45 Gy) and intracavitary HDR brachytherapy (median dose 20 Gy). One hundred forty-six patients underwent postoperative whole abdomino-pelvic irradiation (WAPI) secondary to unfavorable histology (clear cell or serous papillary) or two of the following: deep myometrial invasion, grade 3, or FIGO stage III. Age was analyzed as a continuous and a categorical variable. The age of 63 year split the age group using various statistical analyses. RESULTS: Median follow-up of all patients was 4.2 years. Patients grouped by age of < or =63 years or older had similar FIGO stage (P = 0.5), grade (P = 0.09), treatment modality (P = 0.7), and lymphovascular space invasion (LVSI) (P = 0.6). Twenty-five percent (60/243) of patients developed recurrence. Of these failures, 15% (15/102) were age < or =63 years and 32% (45/141) were age >63 years at diagnosis (P = 0.02). For all patients, the 5-year event-free survival (EFS), cause specific survival (CSS), and overall survival (OS) were 64%, 82%, and 72%, respectively. Five-year EFS for patients age < or =63 years and >63 years was 76% vs. 55% (P < 0.001). Five-year OS for age < or =63 years and >63 years was 85% vs. 63% (P < 0.001). Five-year CSS for age < or =63 years and >63 years was 91% vs. 75% (P = 0.003). Various factors were analyzed to determine an association with age. Older patients with stage III-IVA had significantly more failures than patients less than age 63 (P = 0.002). Older patients (>63 years) were found to have serous papillary histology (28%) more often than younger patients (15%) (P = 0.02). Greater depth of invasion was associated with older age (P = 0.01). On univariate analysis, older age (P = 0.003), LVSI (P = 0.002), FIGO stage (P < 0.001), grade (P < 0.001), and depth of invasion (P = 0.03) predicted for failure. On Cox multivariate analysis, older age (P = 0.006, HR 2.83), higher FIGO stage (P = 0.001, HR 1.96), and higher grade (P = 0.002, HR 2.66) were significant prognostic factors for recurrence. No difference was seen between the two age groups from date of surgery and start of radiation. The duration of therapy was not different between the two groups. CONCLUSIONS: Older endometrial cancer (age >63 years) patients have a significantly decreased overall survival, cause-specific survival, and greater risk of recurrence following postoperative RT independent of other prognostic factors and/or treatment technique. The impact of treatment-related variables did not alter the age-related outcome.     

Neonatal Outcome after Trial of Labor Compared with Elective Repeat Cesarean Section

ABSTRACT: Background: Trial of labor after cesarean section has been an important strategy for lowering the rate of cesarean delivery in the United States, but concerns regarding its safety remain. The purpose of this study was to evaluate the outcome of newborns delivered by elective repeat cesarean section compared to delivery following a trial of labor after cesarean. Methods: All low‐risk mothers with 1 or 2 previous cesareans and no prior vaginal deliveries, who delivered at our institution from December 1994 through July 1995, were identified. Neonatal outcomes were compared between 136 women who delivered by elective repeat cesarean section and 313 women who delivered after a trial of labor. To investigate reasons for differences in outcome between these groups, neonatal outcomes within the trial of labor group were then compared between those mothers who had received epidural analgesia (n = 230) and those who did not (n = 83). Results: Infants delivered after a trial of labor had increased rates of sepsis evaluation (23.3% vs 12.5%, p = 0.008); antibiotic treatment (11.5% vs 4.4%, p = 0.02); intubation to evaluate for the presence of meconium below the cords (11.5% vs 1.5%, p < 0.001); and mild bruising (8.0% vs 1.5%, p = 0.008). Within the trial of labor group, infants of mothers who received epidural analgesia were more likely to have received diagnostic tests and therapeutic interventions including sepsis evaluation (29.6% vs 6.0%, p = 0.001) and antibiotic treatment (13.9% vs 4.8%, p = 0.03) than within the no‐epidural analgesia group. Conclusions: Infants born to mothers after a trial of labor are twice as likely to undergo diagnostic tests and therapeutic interventions than infants born after an elective repeat cesarean section, but the increase occurred only in the subgroup of infants whose mothers received epidural analgesia for pain relief during labor. The higher rate of intervention could relate to the well‐documented increase in intrapartum fever that occurs with epidural use. (BIRTH 30:2 June 2003)     

不同妊娠期经阴道子宫颈环扎术后妊娠结局分析

Objective?To investigate the differences in pregnancy outcomes between the different transvaginal cervical cerclage. Methods?This retrospective study included pregnant women with cervical insufficiency admitted to Peking University People’s Hospital between January 2013 and September 2021. There were 37 patients in the study group underwent Shirodkar’s cerclage, and 32 patients in the control group underwent McDonald’s cerclage. The pregnancy outcomes were compared. Results?Compared with the control group, the study group showed more weight gain during pregnancy[(12.66±6.00) kg/m2, (9.21±5.79) kg/m2; P=0.022], long operation time [45 min(40-51.3 min) vs. 20.5 min (17.3-25.0), P<0.001] and later cerclage removal [36.71(36.14-37) vs. 34.43(24.32-36.75), P=0.003]. Gestational weeks at delivery in the Shirodkar group were more advanced than in the McDonald group[38.9 (36.3-39.8) vs.35.0 (30.1-39.0), P=0.005]. Compared with the McDonald group, the Shirodkar group had higher incidences of deliveries≥28 gestational weeks (91.9% vs. 68.8%, P=0.027), deliveries≥34 gestational weeks (81.1% vs. 59.4%, P=0.037), deliveries≥37 gestational weeks (67.6% vs. 37.5%, P<0.001), induced labor (43.2% vs. 12.5%, P=0.006), and fewer fetal loss (8.1% vs. 31.3%, P=0.017). Multivariate regression analysis of preterm birth factors showed that Shirodkar cervical cerclage was a protective factor to reduce the incidence of preterm birth(OR=0.063, 95%CI: 0.008, 0.492, P=0.008). Conclusion?Shirodkar cerclage appears to have advantages over McDonald cerclage in preventing fetal loss and a fewer frequency of preterm deliveries.     

A randomised controlled trial comparing two temporising management strategies, one with and one without plasma volume expansion, for severe and early onset pre-eclampsia

OBJECTIVES: Plasma volume expansion may benefit both mother and child in the temporising management of severe and early onset hypertensive disorders of pregnancy. DESIGN: Randomised clinical trial. Setting Two university hospitals in Amsterdam, The Netherlands. POPULATION: Two hundred and sixteen patients with a gestational age between 24 and 34 completed weeks with severe pre-eclampsia, haemolysis, elevated liver enzymes and low platelets (HELLP) syndrome or severe fetal growth restriction (FGR) with pregnancy-induced hypertension, admitted between 1 April 2000 and 31 May 2003. METHODS: One hundred and eleven patients were randomly allocated to the treatment group, (plasma volume expansion and a diastolic BP target of 85-95 mmHg) and 105 to the control group (intravenous fluid restriction and BP target of 95-105 mmHg). Main OUTCOME MEASURES: Neonatal neurological development at term age (Prechtl score), perinatal death, neonatal morbidity and maternal morbidity. RESULTS: Baseline characteristics were comparable between groups. The median gestational age was 30 weeks. In the treatment group, patients received higher amounts of intravenous fluids (median 813 mL/day vs 14 mL/day; P < 0.001) with a concomitant decreased haemoglobin count (median -0.6 vs-0.2 mmol/L; P < 0.001). Neither neurological scores nor composite neonatal morbidity differed. A trend towards less prolongation of pregnancy (median 7.4 vs 11.5 days; P= 0.054) and more infants requiring oxygen treatment >21% (66 vs 46; P= 0.09) in the treatment group was observed. There was no difference in major maternal morbidity (total 11%), but there were more caesarean sections in the treatment group (98%vs 90%; P < 0.05). CONCLUSION: The addition of plasma volume expansion in temporising treatment does not improve maternal or fetal outcome in women with early preterm hypertensive complications of pregnancy.     

Splenectomy in the context of primary cytoreductive operations for advanced epithelial ovarian cancer

OBJECTIVE: To determine if the need to perform splenectomy due to metastatic disease in the context of complete primary cytoreduction for ovarian cancer diminishes the prognosis for survival. METHODS: Between 1990 and 2004, 356 stage IIIC epithelial ovarian cancer patients underwent resection of all visible disease before systemic platinum-based combination chemotherapy. Forty-nine (13.8%) required a splenectomy due to metastatic disease. Survival was analyzed (log rank) on the basis of whether splenectomy was necessary. The frequency of performing other procedures, operative time, blood loss, transfusion rate, and hospitalization, was compared (Chi-square test; discrete and binomial data, t test; continuous data) on the basis of whether a splenectomy was required. RESULTS: Survival was not influenced (log rank) by the requirement of splenectomy (required; median 56.4 months, estimated 5-year survival of 48% vs. not required; median 76.8 months, estimated 5-year survival of 58% P = 0.4). The splenectomy subgroup more commonly required en-bloc resection of reproductive organs with rectosigmoid (89.8% vs. 55.7%, P < 0.001), diaphragm stripping (63.3% vs. 33.6%, <0.001)), full-thickness diaphragm resection (28.6% vs. 9.4%, P < 0.001), and resection of grossly positive retroperitoneal nodes (67.3% vs. 46.3%, P = 0.006). The splenectomy group had a longer operative time (238 min vs. 192 min, P = 0.004), estimated blood loss (1663 ml vs. 1167 ml, P = 0.001), transfusion rate (5.3 units prbc vs. 3.2 units prbc, P = 0.002), and hospitalization (16.1 vs. 12.2 days P = 0.001). CONCLUSIONS: The need for splenectomy to achieve complete cytoreduction is a reflection of advanced disease but is not a manifestation of tumor biology precluding long-term survival.     

Nitric oxide donor isosorbide mononitrate for pre-induction cervical ripening at 41 weeks' gestation: A randomized controlled trial

OBJECTIVE: Nitric oxide donors have been shown to cause cervical ripening. The aim of this study was to determine whether sustained release isosorbide mononitrate (ISMN-SR) 60 mg administered vaginally is effective for pre induction cervical ripening at 41 weeks' gestation. METHODS: A double-blind randomised controlled trial was carried out at the University Obstetric Unit, Galle, Sri Lanka for a period of 9 months, commencing 1st August 2003. One hundred and fifty-six consecutive women with uncomplicated singleton pregnancies at 41 weeks' gestation with a modified Bishop Score <5 were allocated by stratified (primip/multip) block randomization to receive either ISMN-SR 60 mg (n = 78) or vitamin C 100 mg (n = 78) vaginally. Modified Bishop Score at 41 weeks + 2 days' gestation and the proportions establishing spontaneous labor or becoming favorable for induction of labor (IOL) by 41 weeks + 2 days' gestation were evaluated in each group. RESULTS: At the commencement of the study there were no differences between the mean age, parity or modified Bishop Score of the two groups. In the ISMN-SR group, there was a marked increase in the proportion establishing spontaneous labor (28% vs 7.5%, P < 0.01) and being favorable for IOL (40% vs 9% P < 0.001), 2 days after therapy. In the ISMN-SR group, there was a significantly higher increase in the mean modified Bishop Score (3.8, 95% CI 2.3-5.3 vs 1.3, 95% CI 0.3-2.2, P < 0.01) and a marked decrease in the proportion of subjects requiring further ripening of the cervix with a Foley catheter. (32% vs 79%, P < 0.001). The cesarean section rates were similar in both groups. CONCLUSION: Sustained release ISMN administered vaginally is effective for preinduction cervical ripening.