Diagnostic value of cervical fetal fibronectin in detecting extrauterine pregnancy.

OBJECTIVE: To determine whether fetal fibronectin (FFN) might serve as a marker to distinguish intrauterine versus extrauterine pregnancy. DESIGN: Prospective cohort study. SETTING: Academic research center. PATIENT(S): Cervicovaginal FFN samples were obtained from 46 women who were at high risk for or presented with signs and/or symptoms of extrauterine pregnancy. INTERVENTION(S): Samples of blood were analyzed for FFN with use of an enzyme-linked immunoabsorbent assay (ELISA). MAIN OUTCOME MEASURE(S): Fetal fibronectin level. RESULT(S): The rate of extrauterine pregnancy in our study was 26.1%, with 12 extrauterine and 34 intrauterine pregnancies identified by ultrasonography or at time of surgery. Seventeen samples had FFN levels of > 50 ng/mL and were considered positive (range, 0-1,000 ng/mL). Positive FFN levels were observed in 41.7% (5 of 12) of women with extrauterine pregnancies versus 35.3%) (12 of 34) of women with intrauterine pregnancies. The sensitivity, specificity, and positive and negative predictive values for extrauterine pregnancy were 41.7%, 64.7%, 29.4%, and 75.9%, respectively. CONCLUSION(S): The use of FFN does not appear to alter significantly the likelihood of identifying extrauterine pregnancy over current laboratory or ultrasonographic methods.     

Correlation of the intercondylar notch width of the femur to the width of the anterior and posterior cruciate ligaments

The purpose of this study was to determine if a correlation exists between the intercondylar notch width (NW) of the femur and the width of the anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL). A study group of 124 consecutive patients (mean age 36.6 +/- 15.2 years; 67 men, 57 women) underwent a magnetic resonance imaging evaluation for knee pain but did not have an ACL or PCL tear or arthrosis. A T2 weighted coronal cut was identified and was located at the middle of the tibial spine, which represented the plane where the ACL and PCL cross each other when the knee is in 10 degrees of flexion. The NW and the width of the ACL and PCL were measured at the level of the middle of the popliteal hiatus on a physician-independent console that allowed for digital measurements in millimeters. Our results showed a statistically significant correlation between NW and ACL width (r = 0.87; P < 0.001) and between NW and PCL width (r = 0.75; P < 0.001). The mean ACL width was 6.4 +/- 1.4 mm (range 3-10 mm). The mean PCL width was 10.2 +/- 2.0 mm (range 6-17 mm). The mean ACL width was 5.7 +/- 1.1 mm for women and 7.1 +/- 1.2 mm for men (P < 0.001). The mean PCL width was 9.5 +/- 1.7 mm for women and 10.9 +/- 2.0 for men (P < 0.001). Our results indicate that NW correlates with ACL and PCL width. In addition, ACL and PCL widths are narrower in women than men.     

Maternal morbidity associated with multiple repeat cesarean deliveries

OBJECTIVE: Although repeat cesarean deliveries often are associated with serious morbidity, they account for only a portion of abdominal deliveries and are overlooked when evaluating morbidity. Our objective was to estimate the magnitude of increased maternal morbidity associated with increasing number of cesarean deliveries. METHODS: Prospective observational cohort of 30,132 women who had cesarean delivery without labor in 19 academic centers over 4 years (1999-2002). RESULTS: There were 6,201 first (primary), 15,808 second, 6,324 third, 1,452 fourth, 258 fifth, and 89 sixth or more cesarean deliveries. The risks of placenta accreta, cystotomy, bowel injury, ureteral injury, and ileus, the need for postoperative ventilation, intensive care unit admission, hysterectomy, and blood transfusion requiring 4 or more units, and the duration of operative time and hospital stay significantly increased with increasing number of cesarean deliveries. Placenta accreta was present in 15 (0.24%), 49 (0.31%), 36 (0.57%), 31 (2.13%), 6 (2.33%), and 6 (6.74%) women undergoing their first, second, third, fourth, fifth, and sixth or more cesarean deliveries, respectively. Hysterectomy was required in 40 (0.65%) first, 67 (0.42%) second, 57 (0.90%) third, 35 (2.41%) fourth, 9 (3.49%) fifth, and 8 (8.99%) sixth or more cesarean deliveries. In the 723 women with previa, the risk for placenta accreta was 3%, 11%, 40%, 61%, and 67% for first, second, third, fourth, and fifth or more repeat cesarean deliveries, respectively. CONCLUSION: Because serious maternal morbidity increases progressively with increasing number of cesarean deliveries, the number of intended pregnancies should be considered during counseling regarding elective repeat cesarean operation versus a trial of labor and when debating the merits of elective primary cesarean delivery. LEVEL OF EVIDENCE: II-2.     

Risk of uterine rupture with a trial of labor in women with multiple and single prior cesarean delivery

OBJECTIVE: To determine whether the risk for uterine rupture is increased in women attempting vaginal birth after multiple cesarean deliveries. METHODS: We conducted a prospective multicenter observational study of women with prior cesarean delivery undergoing trial of labor and elective repeat operation. Maternal and perinatal outcomes were compared among women attempting vaginal birth after multiple cesarean deliveries and those with a single prior cesarean delivery. We also compared outcomes for women with multiple prior cesarean deliveries undergoing trial of labor with those electing repeat cesarean delivery. RESULTS: Uterine rupture occurred in 9 of 975 (0.9%) women with multiple prior cesarean compared with 115 of 16,915 (0.7%) women with a single prior operation (P = .37). Multivariable analysis confirmed that multiple prior cesarean delivery was not associated with an increased risk for uterine rupture. The rates of hysterectomy (0.6% versus 0.2%, P = .023) and transfusion (3.2% versus 1.6%, P < .001) were increased in women with multiple prior cesarean deliveries compared with women with a single prior cesarean delivery attempting trial of labor. Similarly, a composite of maternal morbidity was increased in women with multiple prior cesarean deliveries undergoing trial of labor compared with those having elective repeat cesarean delivery (odds ratio 1.41, 95% confidence interval 1.02-1.93). CONCLUSION: A history of multiple cesarean deliveries is not associated with an increased rate of uterine rupture in women attempting vaginal birth compared with those with a single prior operation. Maternal morbidity is increased with trial of labor after multiple cesarean deliveries, compared with elective repeat cesarean delivery, but the absolute risk for complications is small. Vaginal birth after multiple cesarean deliveries should remain an option for eligible women. LEVEL OF EVIDENCE: II-2.     

Allergic fungal sinusitis in children

Allergic fungal sinusitis (AFS) is a subtype of eosinophilic chronic rhinosinusitis (CRS) characterized by type I hypersensitivity, nasal polyposis, characteristic computed tomography scan findings, eosinophilic mucus, and the presence of fungus on surgical specimens without evidence of tissue invasion. This refractory subtype of CRS is of the great interest in the pediatric population, given the relatively early age of onset and the difficulty in managing AFS through commercially available medical regimens. Almost universally, a diagnosis of AFS requires operative intervention. Postoperative adjuvant medical therapy is a mainstay in the treatment paradigm of pediatric AFS.     

Relationships of Race and Socioeconomic Status to Postpartum Depressive Symptoms in Rural African American and Non-Hispanic White Women

This study examines the potential racial disparity in postpartum depression (PPD) symptoms among a cohort of non-Hispanic white and African American women after taking into consideration the influence of socioeconomic status (SES). Participants (N = 299) were recruited from maternity clinics serving rural counties, with oversampling of low SES and African Americans. The Edinburgh Postnatal Depression Scale (EPDS) was administered 1 and 6 months postpartum, and subjective SES scale at 6 months postpartum. Demographic information was collected during enrollment and 1 month postpartum, with updates at 6 months postpartum. Separate logistic regressions were conducted for 1 and 6 month time points for minor-major PPD (EPDS ≥ 10) and major PPD (EPDS > 12); with marital status, poverty, education, subjective SES, and race predictors entered in block sequence. After including all other predictors, race was not a significant predictor of minor-major or major PPD at 1 or 6 months postpartum. Subjective SES was the most consistent predictor of PPD, being significantly associated with minor-major PPD and major PPD at 6 months postpartum, with higher subjective SES indicating lower odds of PPD, even after accounting for all other predictors. This study shows that significant racial disparities were not observed for minor-major or major PPD criteria at 1 or 6 months postpartum. The most consistent and significant predictor of PPD was subjective SES. Implications of these findings for future research, as well as PPD screening and intervention are discussed.