Propagation of stress fracture of the patella

Anterior knee pain in athletes is common and usually self limited. There should be a high index of suspicion and low threshold for special imaging in cases with acute onset and specific tenderness. The risk of propagation of stress fracture of the patella in athletes is highlighted. The case report presented illustrates the potential sequence of events.     

Women's experiences and preferences following Caesarean birth

AIMS: To seek women's views on their planned mode of birth in a subsequent pregnancy when they had a single prior Caesarean birth in the immediately preceding pregnancy. METHODS: This study was conducted at the Women's and Children's Hospital, Adelaide. Using a hospital maintained database, women were identified based on who had given birth by primary Caesarean section between December 2002 and June 2003 to a live born infant. The women were sent a questionnaire to assess their experiences related to their Caesarean birth and their plans for mode of birth in any subsequent pregnancy. RESULTS: A total of 319 eligible women were identified from the database and sent a questionnaire, with responses obtained from 208 women (65.2%). Most women were satisfied with their birth experience with a mean satisfaction score of 6.3 (+/- 2.8). The most common response when women were asked to indicate the aspects of their birth experience that they liked was those caring for them (153 women; 48%), followed by the reassurance provided about the health of their baby (106 women; 33%) and their own health (88 women; 28%). One fifth of women (63 women; 20%) indicated that they were glad that they had experienced labour. Eighty-five women (41%) indicated that they would in future plan for a vaginal birth, 48 women (23%) would plan for Caesarean section, and 72 women (35%) were unsure. CONCLUSIONS: A proportion of women have a strong preference for mode of birth in a subsequent pregnancy, which is established within 6 months of the woman's birth experience.     

Induction of labour for women with a previous Caesarean birth: a systematic review of the literature

AIMS: To compare the benefits and harms of planned elective repeat Caesarean section with induction of labour and to assess different methods of cervical ripening and induction of labour for women with a previous Caesarean birth who require induction of labour in a subsequent pregnancy. METHODS: The Cochrane controlled trials register and MEDLINE (1966-current) were searched using the following terms: vaginal birth after C(a)esare(i)an, trial of labo(u)r, elective C(a)esare(i)an, C(a)esare(i)an repeat, induction of labo(u)r, prostaglandins, prostaglandin E(2), misoprostol, prostaglandin E(1) analogs, mifepristone, oxytocin, Syntocinon, randomis(z)ed controlled trial, randomis(z)ed trial and clinical trial, to identify all published randomised controlled trials with reported data comparing outcomes for women and infants who have a planned elective repeat Caesarean section with induction of labour; and different methods of induction of labour, where a prior birth was by Caesarean section. RESULTS: There were no randomised controlled trials identified where women with a prior Caesarean birth, whose labour required induction in a subsequent pregnancy, compared elective repeat Caesarean section with induction of labour. There were three randomised controlled trials identified in which women with a prior Caesarean section were allocated to different methods of induction of labour - vaginal prostaglandin E(2) versus intravenous oxytocin; mifepristone versus placebo; and vaginal misoprostol versus intravenous oxytocin. These studies varied considerably in the methods used and meta-analysis was not appropriate. CONCLUSIONS: There is a paucity of safety information for induction of labour agents in the women with a scarred uterus, and caution should be exercised in their use.     

Outcome of pregnancy in homozygous sickle cell disease

OBJECTIVE: Previous reports on pregnancy in homozygous sickle cell (SS) disease are biased by hospital-based, more severely affected subjects and may have underestimated recurrent early pregnancy losses. We report pregnancy outcome in a representative sample of SS subjects subsequently referred to as "subjects" or "sickle cell subjects," and matched normal controls followed from birth. METHODS: The outcomes of 94 pregnancies in 52 subjects and 157 pregnancies in 68 controls followed in a cohort study from birth are presented. Outcome measures included the age at menarche, interval to first pregnancy, outcome of pregnancy, and maternal complications. Possible predictors of low birth weight are assessed. Outcomes were compared by the Kaplan-Meier analysis for interval to first pregnancy and by Student t test, chi(2) test, or Fisher exact test, as appropriate. Correction was made for multiple testing, and multiple linear regression was used for analysis of birth weight. RESULTS: Compared with controls, SS subjects had later menarche (median age 15.4 versus 13.0 years) and first pregnancy (median age 23.7 versus 20.1 years), and more spontaneous abortions (36% versus 10%). Babies of SS subjects had a lower gestational age (P <.001) and lower birth weight (P <.001), the latter being significantly affected by sickle-related events in pregnancy. There was no difference in pregnancy-induced hypertension, preeclampsia, or antepartum or postpartum hemorrhage, but a retained placenta was marginally more common in SS subjects (Fisher exact test, P =.007 after adjustment for multiple testing). Two SS subjects died, a mortality rate of 2.1%. CONCLUSION: The increased fetal loss and maternal morbidity in mothers with homozygous sickle cell disease is confirmed. LEVEL OF EVIDENCE: II-2     

Growth rate of non-vestibular intracranial schwannomas

A group of nine patients with non-vestibular intracranial neuromas (four jugular, four facial, one trigeminal) underwent an interval scanning management policy, with serial annual magnetic resonance (MR) imaging. Tumour volume was assessed by manual measurement of the tumour area by MR imaging. Tumour volume was assessed by manual measurement of the tumour area on MR imaging axial cuts. The mean tumour size at presentation was 4.6 cm(3) (range 0.7-17.8 cm(3)). During a mean follow-up of 36 months (range 22-50 months), five out of nine tumours grew significantly at a rate of more than 5% of their initial volume per year. Only those tumours growing at a rate of more than 20% initial volume per year exhibited symptom progression. During a 36-month period of interval scanning, just over 50% of non-vestibular intracranial neuromas exhibited significant growth. Symptom progression was found to be a strong indicator of a high growth rate. This proportion exhibiting growth is higher than that demonstrated by unilateral sporadic vestibular schwannomas, but less than in patients with neurofibromatosis II. Early treatment of non-vestibular intracranial neuromas should therefore be considered.     

Survey of current prenatal screening for Down syndrome in Australian hospitals providing maternity care

BACKGROUND: The present study assessed the screening tests for Down syndrome available to women within Australian hospitals. METHODS: Postal questionnaires. RESULTS: A total of 282 (57%) hospitals responded with over two-thirds offering some form of screening test which varied by geographical region and level of institution. First trimester maternal serum screening was offered by 11% of hospitals. Nuchal translucency screening was offered by 52% of hospitals with higher use in Australian Capital Territory and New South Wales than in the other regions. Second trimester maternal serum screening was offered by 75% of hospitals with higher rates in Australian Capital Territory, South Australia and the lowest rate in Queensland. CONCLUSIONS: A high proportion of women are offered screening but with wide variation in the tests used.     

Effect of magnesium sulfate given for neuroprotection before preterm birth: a randomized controlled trial

Context  Prenatal magnesium sulfate may reduce the risk of cerebral palsy or death in very preterm infants. Objective  To determine the effectiveness of magnesium sulfate given for neuroprotection to women at risk of preterm birth before 30 weeks' gestation in preventing pediatric mortality and cerebral palsy. Design, Setting, and Patients  Randomized controlled trial at 16 tertiary hospitals in Australia and New Zealand with stratification by center and multiple pregnancy. A total of 1062 women with fetuses younger than 30 weeks' gestation for whom birth was planned or expected within 24 hours were enrolled from February 1996 to September 2000 with follow-up of surviving children at a corrected age of 2 years. Interventions  Women were randomly assigned to receive a loading infusion of 8 mL (4 g [16 mmol] of 0.5 g/mL of magnesium sulfate solution or isotonic sodium chloride solution [0.9%]) for 20 minutes followed by a maintenance infusion of 2 mL/h for up to 24 hours. Main Outcome Measures  Rates of total pediatric mortality, cerebral palsy, and the combined outcome of death or cerebral palsy at a corrected age of 2 years. Results  Data were analyzed for 1047 (99%) 2-year survivors. Total pediatric mortality (13.8% vs 17.1%; relative risk [RR], 0.83; 95% confidence interval [CI], 0.64-1.09), cerebral palsy in survivors (6.8% vs 8.2%; RR, 0.83; 95% CI, 0.54-1.27), and combined death or cerebral palsy (19.8% vs 24.0%; RR, 0.83; 95% CI, 0.66-1.03) were less frequent for infants exposed to magnesium sulfate, but none of the differences were statistically significant. Substantial gross motor dysfunction (3.4% vs 6.6%; RR, 0.51; 95% CI, 0.29-0.91) and combined death or substantial gross motor dysfunction (17.0% vs 22.7%; RR, 0.75; 95% CI, 0.59-0.96) were significantly reduced in the magnesium group. Conclusions  Magnesium sulfate given to women immediately before very preterm birth may improve important pediatric outcomes. No serious harmful effects were seen.      

Aberrant internal carotid artery in the middle-ear space

The incidence of an aberrant internal carotid artery in the middle ear is approximately one per cent and most patients are asymptomatic. We present two patients with an aberrant internal carotid artery who presented with pulsatile tinnitus and an intra-tympanic mass. Here we discuss the clinical presentation, relevant radiographic investigations and further management of these patients.