ISSN:0029-7828    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Laparoscopy today is being used increasingly often during pregnancy, most often to perform appendectomy or cholecystectomy or to treat an adnexal mass. Variable fetal outcomes are reported. This review examined the records of 12 pregnant women who, in 1991 to 1997, underwent laparoscopic surgery. For comparison, nine patients had open procedures. Appendectomy and cholecystectomy were done both laparoscopically and by open surgery, whereas some patients had diagnostic laparoscopy.Patients in the laparoscopic and open surgery groups were similar in age, oxygen saturation, end-tidal CO2levels, and gestational age at delivery. Birth weights and Apgar scores also were comparable. The postoperative stay averaged 34 hours for patients having laparoscopic surgery and 91 hours after open surgery. Laparoscopic patients received significantly less parenteral narcotic analgesia. The average operating times, 51.3 minutes for open surgery and 63.5 minutes for laparoscopic surgery, did not differ significantly. One fetus was lost 7 days after laparoscopic cholecystectomy, but there was no meaningful difference in fetal outcomes depending on the operative approach.No longer is pregnancy an absolute contraindication to laparoscopic surgery. Laparoscopy nevertheless should be undertaken cautiously to diagnose or manage abdominal pathology in a pregnant woman, and only when there is no increased risk of fetal loss. Advantages of laparoscopic over open surgery include a shorter recovery time, a lesser need for narcotic analgesia, and a shorter hospital stay.

ISSN:0029-7828    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Infants whose mothers have type 1 diabetes are known to be at high risk of perinatal morbidity and mortality, but little is known about the specific risk of spontaneous abortion. This epidemiological study focused on rates of self-reported spontaneous abortion, defined as noninduced pregnancy loss before 20 weeks' gestation, in 495 individuals from the Children's Hospital of Pittsburgh Type 1 Diabetes Registry, diagnosed in 1950-1964. All were younger than 17 years at the onset of type 1 diabetes and were on insulin when discharged from hospital. Reproductive histories were self-reported in 1981, and the information was updated in 1990.Women and men had average ages of 7 1/2 and 7 years, respectively, at the onset of type I diabetes and in 1990 averaged approximately 40 years. Two thirds of the women had been pregnant, and although 61.5 percent of 384 pregnancies resulted in a live birth, there were numerous fetal losses and most were spontaneous abortions. A control group of partners of 150 type 1 diabetic men had a significantly higher rate of live births (90.3 percent) and significantly fewer spontaneous abortions, stillbirths, and induced abortions. Among women having two or more pregnancies, 16.2 percent of those with type 1 diabetes and 1.8 percent of partners of type 1 diabetic men had consecutive spontaneous abortions. Spontaneous abortions were reported by 26.4 percent of type 1 diabetic women before 1970; by 31 percent in the years 1970 to 1979; and by 15.7 percent in 1980 to 1989. No such temporal change was noted for partners of diabetic men. The apparent increase in spontaneous abortions in 1970 to 1979 was not statistically significant.Women with type 1 diabetes have in recent decades experienced a dramatic improvement in reproductive outcome, specifically a decline in spontaneous abortions. Presumably this is at least in part a result of substantial advances in diabetes treatment and in the prenatal care given to these women.

ISSN:0029-7828    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

This long-term follow-up study examined the effects of an abbreviated schedule of antenatal visits in 1117 low-risk women taking part in the Antenatal Care Project. All the participants had already borne a live infant. The women were randomly assigned either to the conventional schedule of 13 antenatal visits or to 6 to 7 visits. A postal questionnaire that included a number of validated psychometric scales including the Parenting Stress Index (PSI) was returned an average of 2.7 years after delivery. Baseline sociodemographic and obstetrical features were similar in the two groups of women.Final data were available for 839 women. Overall PSI scores were very similar in the two groups, and there were no substantial differences on any of the subscales. Women in the two groups did not differ in how much they worried about coping with their child. There also was no indication of important differences in the mother's psychological well-being, the use of health services, beliefs about health, or health-related behaviors. Earlier concerns over the possible long-term adverse effects of fewer antenatal visits seem to be unfounded.

ISSN:0029-7828    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

There are no previous reports of standardized breast cancer therapy for pregnant women. This report reviews experience gained over the past 8 years, when a group of breast surgeons and medical and radiation oncologists reached consensus management decisions. Twenty-four pregnant women with primary or, in two cases, recurrent breast cancer were treated under the protocol and received outpatient chemotherapy, surgery alone, or both surgery and radiotherapy as clinically indicated.Breast masses were imaged by ultrasound and/or mammography with abdominal shielding. A palpable mass was biopsied by the core-needle or fine-needle aspiration technique under local anesthesia. If nondiagnostic or if an impalpable mass was located, an excisional biopsy was done under local anesthesia. Two chest views were obtained, also with shielding, and renal and liver function were evaluated. Women were offered genetic counseling, focusing on possible fetal effects of chemotherapy. Most resectable tumors were managed by modified radical mastectomy with axillary node dissection, regardless of gestational age. Patients with stage III tumors received up to four cycles of neoadjuvant chemotherapy before locoregional treatment. Chemotherapy was used to treat stage I lesions. Cycles of fluorouracil, doxorubicin, and cyclophosphamide were given at 3- to 4-week intervals on an outpatient basis after the first trimester. Fetal growth was monitored ultrasonically every 3 to 4 weeks or as clinically indicated. Nonstress testing was done starting at 28 weeks' gestation.Eighteen of the 22 primary cancers were removed by modified radical mastectomy without complications, during pregnancy in 14 women and after delivery and chemotherapy in 4 others. Four patients required first-trimester surgery, but none of them aborted. No operation was associated with fetal compromise or preterm labor. Two patients had antepartum segmental mastectomy with axillary node dissection, followed by chemotherapy and postpartum radiotherapy. Three patients with stage I disease were not operated on, and one patient refused surgery. Two thirds of patients were node-positive at the time of surgery. Chemotherapy was tolerated in full dosage without major problems. In no case did leukopenia require intervention. There were no unexpected antepartum maternal problems. The median gestational age at delivery was 38 weeks, and no newborn infant had any unusual complication. All the infants had a 5-minute Apgar score of 9 or above. There were no congenital malformations. The three women who presented with a recurrent or stage I tumor died of disease within 2 years. Six of nine patients with stage II disease were alive and well after a median of 44 months. Nine of 11 stage II patients were alive after a median follow-up of 3 years, 8 of them without disease. A single patient with stage I disease had a recurrence. Pregnancy in a woman diagnosed as having invasive breast cancer may confidently be continued provided that a comprehensive multidisciplinary treatment approach is available.

ISSN:0029-7828    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

If an isolated choroid plexus cyst is found in a midtrimester fetus, the question arises of whether prenatal testing is warranted. These cysts arise when normal neuroepithelial folds fill with cerebrospinal fluid and cell debris. In themselves, they are harmless, and a majority of cysts will regress spontaneouslyin uteroor neonatally. Perhaps 1 percent of the general population have a choroid plexus cyst.Although there is no convincing evidence that a choroid plexus cyst is a marker for trisomy 21, it is an established marker for trisomy 18; as many as half of such fetuses may have a cyst. Because a large majority of trisomy 18 fetuses have other anomalies, amniocentesis and karyotyping would seem to be indicated regardless of maternal age. Risk estimates are problematic because trisomy 18 becomes more frequent with advancing maternal age and less frequent with increasing gestational age. The high natural attrition rate of trisomy 18 infantsin uterorenders the live birth risk of trisomy 18 the most appropriate figure to use when deciding whether to offer karyotyping. It seems reasonable to modify the baseline risk related to maternal age when a choroid plexus cyst is present.The authors recommend that:When a choroid plexus cyst is found, an experienced ultrasonographer conduct a detailed anatomical survey to rule out other defects.Karyotyping be offered whenever a cyst is found in addition to other fetal anomalies.When a seemingly isolated choroid plexus cyst is found in a midtrimester fetus, the risk of trisomy 18 be estimated on an individualized basis, relying chiefly on maternal age but also considering recently published data. (Recent studies suggest an increased risk of trisomy 18 and a likelihood ratio of approximately 9.0.)Amniocentesis be offered when the modified livebirth risk of fetal trisomy 18 approaches 1 in 250.

ISSN:0029-7828    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Grand multiparas who lived under conditions of poverty, who often are undernourished and anemic, are at particular risk of uterine rupture when labor is induced with oxytocin. This study examined the potential value of misoprostol, a synthetic prostaglandin E1analog, when used vaginally to induce labor in women with at least five previous deliveries. The 165 participants included 134 with a live fetus and 31 who had experienced intrauterine fetal death. All had a single fetus, and no patient had previously had operative delivery. Membrane rupture was the most common indication for induction, followed by preeclampsia and intrauterine fetal death. No patient received oxytocin in addition to misoprostol. The women with a live fetus received a vaginal dose of 50 μg, while those with a dead fetus received 100 μg.Vaginal misoprostol was generally well tolerated. There were no uterine ruptures in this series. Two patients had placental retention, and three, postpartum bleeding. The cesarean section rate was 11 percent in women with an unripe cervix and only 1.4 percent when the cervix was ripe. The overall rate of 6 percent is about one third of the prevailing rate at the study site. The application-to-expulsion interval (AEI) averaged 10 hours in women with a live fetus and 152 hours with a dead fetus. Respective values in women with ruptured and intact membranes were approximately 9 and 13 hours. Women with a ripe cervix had an average AEI of 82 hours, compared with 142 hours with an unripe cervix.Vaginal misoprostol is an effective and relatively inexpensive means of inducing labor in grand multiparous women. It is a useful alternative to oxytocin whether or not the fetus is alive, especially in low-income settings where there is an appreciable risk of uterine rupture.

ISSN:0029-7828    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Up to half of women reported with a ruptured anal sphincter sustained during vaginal delivery become incontinent. Reported rates of rupture range up to 2.5 percent where mediolateral episiotomy is practiced but as high as 7 percent after midline episiotomy. Most often an obstetrician performs a primary repair immediately after delivery by approximating the torn muscle ends with interrupted or figure-of-8 sutures(Fig. 1). Many women nevertheless suffer anal incontinence. Colorectal surgeons prefer an overlap repair technique, with which 75 percent of the patients reportedly become continent. This report reviewed the results of repair in 32 consecutive women who suffered a ruptured anal sphincter during vaginal delivery.Fig. 1. Diagrammatic illustration demonstrating conventional end-to-end approximation of the disrupted anal sphincter with 2 "figure of 8" sutures. Reprinted with permission from Blackwell Science Ltd.All repairs were done in an operating room under general or regional anesthesia and muscle relaxation. After identifying the torn muscle ends, they were mobilized and pulled across to overlap in a "double-breasted" manner(Fig. 2). The anal mucosa and internal sphincter were repaired as necessary before joining the torn ends of the external sphincter with 3/0 Ethicon (polydioxanone sulfate) sutures. The perineal muscles were reconstructed with 2/0 Vicryl sutures, and the vaginal epithelium with continuous 3/0 Vicryl sutures. Finally, subcuticular sutures were placed to close the perineal skin. I.V. antibiotics were given intraoperatively, and oral cefuroxime and metronidazole were continued for 1 week. Women were given stool softeners and a bulking agent.Fig. 2. Diagrammatic illustration to demonstrate the technique of overlap repair of the external anal sphincter. As illustrated, the first suture is inserted about 1.5 cm from the torn edge of the muscle (open arrow) and carried through to within 0.5 cm of the edge of the other arm of external sphincter. A second row of sutures (small arrows) is inserted to attach the loose end of the overlapped muscle. Reprinted with permission from Blackwell Science Ltd.A standard questionnaire asking about bowel and bladder symptoms was administered before and 3 months after repair. Manometry was done to record the peak resting and squeeze pressures, and anal endosonography was carried out. All but 1 of the 32 women had an overlap repair of the external sphincter, and 27 were followed up for about 42 months on average. Surgery was performed a median of 85 minutes after delivery and lasted a median of 70 minutes. Twelve women had an obviously torn internal sphincter repaired, but follow-up endosonography showed that other women had such a defect. The external sphincter overlapped sonographically in 82 percent of women; four of the remaining five women had a defect. No woman had persistent or perineal pain or trouble evacuating the bowel when followed up, and none developed an anorectal-vaginal fistula. Six women, nearly one fourth of those assessed, described stress urinary incontinence, and in four cases, this was a new symptom. Of 15 women who had resumed sexual activity, 2 described dyspareunia. In this study, an overlap repair of the torn anal sphincter yielded good subjective and objective results compared with those obtained by end-to-end approximation.

ISSN:0029-7828    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

In Botswana it is customary, when a woman conceives her first child, for her mother or another female relative to care for her at her parents' home through the last trimester and for at least a month after birth. A traditional birth attendant attends the woman during labor to provide constant support and encouragement. After birth, the mother and child are isolated from most other persons including the father to protect against infection. Today, many women give birth in hospital where their own mothers may not attend them, and may be alone for long periods because of a shortage of midwives. This study randomly assigned 109 primigravid women in uncomplicated labor to an experimental group who, in addition to standard hospital care, had a female relative present throughout labor (53) or to a control group managed according to the usual hospital routine (56). The two groups were demographically and clinically similar in all respects.The women provided support from a female relative generally did better than those given routine hospital care. They received significantly less analgesia, were less likely to have the membranes ruptured artificially, and received fewer oxytocic drugs in early labor. They also were more likely than the women in the control group to have a normal delivery. The rate of spontaneous vaginal delivery was 91 percent in the study group and 71 percent in the control group. Both vacuum extractions and operative deliveries were more prevalent in the control group. Perineal trauma was comparable in the two groups of women.These findings agree with those of other randomized trials in the U. S. and Guatemala, showing that fewer obstetrical interventions are needed when a companion is present throughout labor. This itself is a low-cost intervention that lacks adverse effects and saves time and money. It is especially appropriate in developing countries where it is still traditional practice for a companion to be present, and may also prove useful in developed countries where the male partner tends to be involved.

ISSN:0029-7828    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Data from retrospective observational studies suggest that fetal exposure to magnesium sulfate may correlate with a lower risk of both intraventricular hemorrhage and cerebral palsy in live-born infants. The present study, also retrospective, was done to learn whether extremely low birth weight (1000 gm or less) infants who live at least 2 days after being born to a woman given magnesium for uterine tocolysis had neonatal outcomes differing from those of unexposed infants. Only potentially viable singleton infants with a gestational age of at least 20 weeks were included. None had major congenital anomalies. The final study group of 308 infants, seen in a 12-month period, included 124 exposedin uteroto magnesium sulfate and 184 who were not so exposed.Mortality from day 3 to 4 months of life was similar in the two groups. Women given magnesium sulfate for tocolysis were less often black, were more often in active labor at the time of delivery, and received more steroids, but in other respects, the groups were comparable. The infants were similar in birth weight and gestational age at delivery, and there were no significant differences in neonatal morbidity. Multivariate analysis affirmed the lack of any significant association between neonatal disorders and exposure to magnesium sulfate. This included measures of neurological morbidity such as seizure activity and intraventricular bleeding. A prospective randomized trial is needed before concluding that intrapartum magnesium sulfate does not improve the neurological outcome in very premature infants.

ISSN:0029-7828    

出版商:OVID    

年代:1999

数据来源: OVID