摘要:

ObjectiveTo determine whether treatment of bacterial vaginosis (BV) in early pregnancy decreases the risk of preterm delivery and peripartum infectious morbidity.MethodsIn this multicenter, randomized, double-masked, placebo-controlled intervention trial, screening for BV was performed by vaginal Gram stain obtained from 5432 healthy women with singleton pregnancies during the first antenatal clinic visit at 10–17 weeks' gestation. Bacterial vaginosis-positive women with no past history of preterm delivery were randomized to a single course of treatment with either 2% vaginal clindamycin cream or identical placebo cream for 7 days. Repeat Gram stains were taken 1 week after treatment and at 30–36 weeks' gestation. Preterm delivery was defined as spontaneous delivery before 37 gestational weeks. Peripartum infectious morbidity was defined as postpartum endometritis, postpartum sepsis, postcesarean wound infection, or episiotomy wound infection, necessitating antimicrobial therapy. According to the power analysis, 180 patients were needed for both treatment arms to show a three-fold difference in the rates of preterm births.ResultsThe overall prevalence of BV was 10.4%. Of all BV-positive women, 375 (66%) were randomized to the treatment arms. The primary cure rate was 66% in the clindamycin group; in the placebo group, 34% spontaneously cleared BV (odds ratio [OR] 1.9, 95% confidence interval [CI] 1.3, 2.8). The rate of preterm deliveries was 5% in the clindamycin group and 4% in the placebo group (OR 1.3, 95% CI 0.5, 3.5). The rate of peripartum infectious morbidity was 11% in the clindamycin group and 18% in the placebo group (OR 1.6, 95% CI 0.9, 2.8). Bacterial vaginosis recurred in 7% of women. The rate of preterm deliveries was 15% in this subgroup compared with 2% among women who remained BV negative (OR 9.3, 95% CI 1.6, 53.5).ConclusionVaginal clindamycin did not decrease the rate of preterm deliveries or peripartum infections, but recurrent or persistent BV increased the risk for these complications.

ISSN:0029-7844    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

ObjectiveTo examine the occurrence of multiple risk behaviors during pregnancy among women who delivered a live birth and to examine the risk of delivering small for gestational age (SGA) infants for women with multiple risks.MethodsWe used data from the Pregnancy Risk Assessment Monitoring System to conduct the research. Pregnancy Risk Assessment System is a population-based, mixed-mode surveillance system that collects information on maternal behaviors and experiences. We used data for 1997 from 13 (n= 19,331) states that had response rates of over 70%. We considered ten self-reported individual risk behaviors or exposures (eg, smoking, unintended pregnancy) and several demographic variables. The main outcome was SGA.ResultsPregnant women engage in or are exposed to multiple risks and often these risks are inter-related. The occurrence of multiple risks appears to be associated with an increased likelihood of delivering an SGA infant. Compared with women with no reported risks or exposures, the adjusted odds ratios for delivering an SGA infant were as follows: 1.29 (95% confidence interval [CI] 0.69, 2.43) for one, 1.86 (95% CI 1.00, 3.44) for two, 1.67 (95% CI 0.90, 3.10) for three, 2.06 (95% CI 1.10, 3.89) for four, 3.53 (95% CI 1.71, 7.30) for five, and 3.82 (95% CI 1.97, 7.41) for six or more risks or exposures.ConclusionA large proportion of pregnant women engage in or are exposed to multiple risks. Women with a larger number of risks are at greater risk for delivering an SGA infant than women with fewer or no risks.

ISSN:0029-7844    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

ObjectiveTo assess the relationship between maternal corticotropin-releasing hormone (CRH) levels in second trimester sera, and the risk of preterm delivery in an ethnically heterogeneous sample of pregnant women.MethodsThis nested case-control study included two case groups (97 women who delivered before 35 weeks' gestation, 144 who delivered at 35–36 weeks' gestation), and a control group (244 women who delivered at or after 37 weeks' gestation) frequency matched by ethnicity (black, white) and by alpha-fetoprotein levels (normal, unexplained high). Corticotropin-releasing hormone was evaluated in stored maternal sera collected at 15–19 weeks' gestation from cases and controls.ResultsDelivery before 35 weeks' gestation was associated positively with a second trimester, ethnic-specific CRH above 1.5 multiples of the median in white women [odds ratio (OR) 2.3, 95% confidence interval (CI) 1.1, 5.1] and black women (OR 5.0, 95% CI 1.8, 13.3). Sensitivity was 29% in whites and 41% in blacks; specificity was 84% in whites and 80% in blacks. We estimated the positive and negative predictive values to be 6% and 97%, respectively, in white women, and 16% and 93%, respectively, in black women. It was also noted that, within case and control groups, black women had consistently lower CRH levels than white women.ConclusionFactors that lead to a premature increase in placental CRH production and are associated with an increased risk of preterm birth are evident as early as 15–19 weeks' pregnancy. When considering potential links between stressors, placental changes, CRH levels, and preterm birth, it might be important to stratify or adjust for ethnicity.

ISSN:0029-7844    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

ObjectiveTo identify associations between polymorphisms within the interleukin-1β gene cluster, all of which increase protein expression, and preeclampsia.MethodsWe genotyped a Hispanic population (69 women with preeclampsia and 47 controls) for two polymorphisms of the interleukin-1β gene (promoter region and exon 5) and one polymorphism of the interleukin-1 receptor antagonist gene in intron 2. Clinical data were collected from medical records. Values are given as means or medians. Statistical power to identify a difference in occurrence of interleukin-1β promoter, interleukin-1β exon 5, and interleukin-1 receptor antagonist gene polymorphisms in women with preeclampsia compared with controls was 21%, 15.9%, and 30.9%, respectively.ResultsWe found no association between any single polymorphism and occurrence of preeclampsia. Among women with preeclampsia, those with polymorphism of interleukin-1 receptor antagonist gene had higher mean systolic blood pressure (BP) at admission (178 ± 33.4 versus 159 ± 19.5 mmHg,P= .039). When all three polymorphisms combined were evaluated, women with preeclampsia and at least three mutant alleles (n= 8) had higher mean systolic BP at admission (182 ± 30 versus 160 ± 20.5 mmHg,P= .009) and increased alanine aminotransferase (67 [10–1024] versus 20 [3–407] IU/L,P= .04) and aspartate aminotransferase (119 [25–2239] versus 24 [4–489] IU/L,P= .002). At admission, BP in controls was independent of any polymorphism identified.ConclusionAlthough the power of this study was limited, our data do not support a role for polymorphisms of the interleukin-1β and interleukin-1 receptor antagonist genes in the pathogenesis of preeclampsia among Hispanic women. Our findings do suggest that polymorphisms within the gene cluster might influence severity of preeclampsia.

ISSN:0029-7844    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

ObjectiveTo determine the time course of plasma volume expansion in early pregnancy.MethodsWe prospectively measured plasma volume by Evans blue dye dilution during the menstrual (cycle day 2–3), follicular (cycle day 9–10), and luteal phases (cycle day urinary leutinizing hormone [LH] surge plus 9–10) of the menstrual cycle and at three additional time points (LH surge + 16 days, LH surge + 28 days, and LH surge + 70 days) in women achieving pregnancy. Twenty-one subjects were examined during 38 menstrual cycles to establish baseline menstrual cycle data. Ten subjects conceived within 1 year of menstrual cycle studies. All ten pregnancies were viable and reached the third trimester. Analyses used repeated-measures analysis of variance withP< .05 accepted for significance.ResultsMean plasma volume was found to change significantly across the period of observation (P< .008) in those who conceived. Plasma volume at LH surge + 70 days (12 menstrual weeks, 2320 ± 280 mL) was greater than either menstrual cycle estimates or early pregnancy estimates of plasma volume. There was no difference in plasma volume at LH surge + 16 days (2077 ± 288 mL) or LH surge + 28 days (2010 ± 271 mL) compared with menstrual cycle measurements during the menstrual phase (2156 ± 292 mL), follicular phase (2036 ± 280 mL), and luteal phase (2120 ± 425 mL). There was no significant difference between those who conceived and those who did not in their mean menstrual cycle plasma volume.ConclusionPlasma volume expansion in early human pregnancy cannot be identified until after the sixth menstrual week. By 12 menstrual weeks, plasma volume has expanded by approximately 14% ± 12% (mean ± SD) over follicular phase measurements.

ISSN:0029-7844    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

ObjectiveTo assess the effect of pelvic floor education after vaginal delivery on pelvic floor characteristics in nulliparous women.MethodsWe examined 107 nulliparas during pregnancy and at 9 weeks and 10 months after vaginal delivery. Methods used included a questionnaire, clinical examination, perineosonography, urethral pressure profiles, and intravaginal and intra-anal pressure recordings during pelvic floor contraction. After the second examination, the women were assigned in alternating manner to either 12 sessions of pelvic floor exercises with biofeedback and electrostimulation (n= 51) or no training (n= 56). The two groups were compared at the third examination.ResultsStress urinary incontinence incidence decreased in 2% of control subjects compared with 19% of women who underwent pelvic floor education (P= .002), whereas the incidence of fecal incontinence (5% versus 4%,P= 1) and the percentage of women who recovered predelivery pelvic floor contraction strength (33% versus 41%,P= .4) were no different. We observed no significant differences in bladder neck position and mobility, urethral functional length, maximal urethral closure pressure, pressure transmission ratio, residual area of continence at stress standing, or intravaginal or intra-anal pressures during pelvic floor contraction between groups at the third examination.ConclusionPelvic floor education, begun 2 months postpartum, significantly reduced the incidence of stress urinary incontinence, but not fecal incontinence or weak pelvic floor. Similarly, bladder neck behavior, urodynamic characteristics, intravaginal or intra-anal pressures during pelvic floor squeezing also were not modified.

ISSN:0029-7844    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

ObjectiveTo assess the effect of abdominal sacrocolpopexy with obliteration of the pouch of Douglas on anatomy and function of the posterior compartment.MethodsWe prospectively studied 33 consecutive women with pelvic organ prolapse who had abdominal sacrocolpopexies [expanded polytetrafluoroethylene (Gore-Tex)] with pouch of Douglas obliterations and posterior extensions of mesh, using a standardized questionnaire, urodynamic studies, pelvic floor fluoroscopies, and vaginal-rectal examinations (Baden-Walker classification). Concomitant colpoperineorrhaphy was done if rectoceles remained at rectovaginal examination at the end of sacrocolpopexy. The goal was to correct rectoceles transabdominally.ResultsThirty-one women returned for follow-up investigations after 12–48 months (mean 26 months). Mean age was 61 years (range 41–77 years). There was no recurrence of vaginal vault prolapse, enterocele, or anterior rectal wall prolapse. Among 28 preoperative rectoceles, 16 recurred (57%) and one occurred de novo. Defecation problems (outlet constipation) were present in 21 women (64%) preoperatively and persisted or were altered in 12 (57%) after sacrocolpopexy. Grade of rectocele was associated significantly with symptoms of outlet constipation preoperatively, but not postoperatively (P= .002).ConclusionAbdominal sacrocolpopexy with obliteration of the pouch of Douglas and posterior extension of the mesh was effective for vaginal vault prolapse, enterocele, and anterior rectal wall procidentia, but not concomitant rectocele. Twenty-eight percent of women described altered defecation with stool stopping higher in the rectosigmoid colon (“high outlet constipation”), which might have been caused by denervation during rectal mobilization.

ISSN:0029-7844    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

ObjectiveTo evaluate the cost-effectiveness of routine cystoscopy at the time of abdominal, vaginal, and laparoscopically assisted vaginal hysterectomy in terms of cost per ureteral injury identified and treated.MethodsUsing a hospital-based perspective, a decision-analysis model was constructed to estimate the outcomes and costs of cystoscopy or no cystoscopy at the time of abdominal hysterectomy. A similar model was constructed for vaginal and laparoscopically assisted vaginal hysterectomy to account for the cost of conversion to laparotomy. Cost estimates were based on estimated costs of Duke University Medical Center and from average Medicare reimbursements for similar Diagnostic Related Groups from the Health Care Financing Administration. The incidence of ureteral injury was obtained from a review of the literature. Sensitivity analyses were performed for the following variables: ureteral injury rate, silent ureteral injury rate, cost of cystoscopy, and cost of therapeutic interventions. We assumed a silent renal death rate of 0%.ResultsRoutine cystoscopy at abdominal hysterectomy was cost-saving above a threshold ureteral injury rate of 1.5%. At a ureteral injury rate of 0.2%, the marginal increase in the cost of routine intraoperative cystoscopy was $108 per abdominal hysterectomy, with an associated cost of $54,000 per ureteral injury identified. In comparison, at a ureteral injury rate of 2%, routine cystoscopy gave a marginal cost savings of $44 per hysterectomy, with a cost savings of $2200 per ureteral injury identified intraoperatively. At the baseline ureteral injury rate of 0.5%, routine cystoscopy had a marginally increased cost of $83 per hysterectomy, with an incremental cost-effectiveness of $16,600 spent per ureteral injury identified. The model constructed for vaginal hysterectomy and laparoscopically assisted vaginal hysterectomy yielded a threshold ureteral injury rate of 2%, above which routine cystoscopy was cost-saving. In both models, the incidence of ureteral injury and the cost of readmission were the two variables with the greatest influence on cost-effectiveness.ConclusionThe cost-effectiveness of routine intraoperative cystoscopy depends on the rate of ureteral injury independent of the route of hysterectomy. If that rate exceeds 1.5% for abdominal hysterectomy and 2% for vaginal or laparoscopically assisted vaginal hysterectomy, then routine cystoscopy is cost-effective.

ISSN:0029-7844    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

ObjectiveTo estimate the prevalence of psammoma bodies in routine cervical cytology specimens and describe clinical diagnoses associated with them in pre- and postmenopausal women.MethodsWe identified all reports that contained psammoma bodies from a retrospective review of 34,816 cytology reports over 4 consecutive years from the computerized pathology database at Yale New-Haven Medical Center. Slides were reviewed to confirm and qualify psammoma bodies. Medical records of women with psammoma bodies were reviewed and information on follow-up was collected.ResultsWe identified 18 women with psammoma bodies on their Papanicolaou smears. The median age was 49.5 years (range 17–78 years). Seven of eight postmenopausal women had gynecologic malignancies. Five presented with postmenopausal bleeding and had uterine serous or clear-cell carcinomas. One presented with a pelvic mass that was ovarian serous carcinoma. Another had a serous carcinoma of the fallopian tube with only psammoma bodies on Papanicolaou smears. Only one of the remaining 11 nonmalignant cases was a postmenopausal woman.ConclusionThe prevalence of psammoma bodies in consecutively screened Papanicolaou smears was 18 of 34,816. Psammoma bodies on Papanicolaou smears are ominous in postmenopausal women. Their presence in asymptomatic premenopausal women warrants further evaluation, but not necessarily surgical exploration

ISSN:0029-7844    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

ObjectiveTo evaluate the independent contribution of clinical and constitutional factors in the development of early and late incisional hernias in women undergoing surgery for uterine cancer.MethodsOver 10 years, patients undergoing extended abdominal hysterectomy for cervical or endometrial malignancies through a vertical incision were followed for the identification of incisional hernias. Logistic regression and survival analyses were used for statistics.ResultsFour hundred fifty-five women were included in the study, 77 of whom (16.9%) developed incisional hernias. The median (range) body mass index was higher in women who developed an incisional hernia than in those who did not (28 [19–44] kg/m2versus 24 [16–41] kg/m2;P< .01). The frequencies of diabetes (14.3% versus 4.8%;P< .01), wound sepsis (10.4% versus 1.3%;P< .05), and fascial closure with interrupted sutures (70.1% versus 55.6%;P< .05) were significantly higher in women with incisional hernia than in those without. Multiple logistic regression revealed that, after adjustment for confounding variables, the only factors associated with incisional hernia formation within 1 year from the operation were body mass index above 27 kg/m2(odds ratio [OR] 3.68; 95% confidence interval [CI] 1.38, 9.81;P< .01) and wound infection (OR 5.05; 95% CI 1.39, 18.37;P< .01), whereas the factors associated with incisional hernia formation at least 3 years after surgery were diabetes (OR 6.68; 95% CI 2.02, 22;P< .01) and wound infection (OR 8.55; 95% CI 1.54, 47.5;P< .01). For hernia developing after 5 years (OR 8.32; 95% CI 1.41, 55.65;P< .05) and 8 years (OR 49.52; 95% CI 2.72, 907.14;P< .01), the only significant association was found with diabetes.ConclusionLate incisional hernia formation does not depend on conditions present at the time of operation or on surgical technique. Other factors such as diabetes seem to play an important role in the development of late incisional hernia.

ISSN:0029-7844    

出版商:OVID    

年代:2001

数据来源: OVID