摘要:

ObjectiveTo examine the relationship between birth weight and brachial plexus injury and estimate the number of cesareans needed to reduce such injuries.MethodsAll 80 neonatal records coded for brachial plexus injury from October 1985 to September 1993 at the Brigham and Women's Hospital in Boston, Massachusetts, were studied along with linked maternal files. Birth weight, method of delivery, presence or absence of shoulder dystocia, and any diagnosis of maternal gestational or nongestational diabetes were abstracted. Data for the group with brachial plexus injury were compared with data for live-born infants without this injury during the same period. The sensitivity and specificity of birth weight as a predictor of brachial plexus injury were calculated. Further, the number of cesarean deliveries necessary to prevent a single brachial plexus injury was estimated using various weight cutoffs (4000, 4500, and 5000 g) for elective cesarean delivery.ResultsAmong 77,616 consecutive deliveries, there were 80 brachial plexus injuries identified, for an incidence of 1.03 per 1000 live births. The incidence of brachial plexus injury increased with increasing birth weight, operative vaginal delivery, and the presence of glucose intolerance. In the group of women without diabetes, between 19 and 162 cesarean deliveries would have been necessary to prevent a single immediate brachial plexus injury. Among women with diabetes, between five and 48 additional cesareans would have been required.ConclusionAlthough birth weight is a predictor of brachial plexus injury, the number of cesarean deliveries necessary to prevent a single injury is high at most birth weights. Because of the large number of cesarean deliveries needed to prevent a single brachial plexus injury in infants born to women without diabetes, it is difficult to recommend routine cesarean delivery for suspected macrosomia in these women.

ISSN:0029-7844    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

ObjectiveTo examine the relation of cigarette consumption and exhaled carbon monoxide levels during pregnancy and to assess the effect of these smoking measures on birth weight.MethodsCigarette consumption and exhaled carbon monoxide levels were recorded at the first prenatal visit and the 36-week visit from women who smoked early in pregnancy. Analysis of variance was used to compare birth weights for differing levels of cigarette consumption and exhaled carbon monoxide. Correlation and regression analyses were used to estimate the effects of the smoking measures at both prenatal visits on birth weight.ResultsCigarette consumption and exhaled carbon monoxide levels at both visits were associated significantly with birth weight. After the first prenatal visit, a reduction in cigarette consumption of at least nine cigarettes per day or in exhaled carbon monoxide of 8 parts per million (ppm) was associated with gains in birth weight of 100 g or more. The proportion of low birth weight (LBW) infants increased significantly with increasing levels of cigarette consumption and with increasing concentrations of exhaled carbon monoxide.ConclusionSubstantial reductions in cigarette consumption or in exhaled carbon monoxide levels after the first prenatal visit are needed to achieve gains in birth weight. Not smoking, or having an exhaled carbon monoxide level less than 5 ppm minimizes the likelihood of having an LBW infant.

ISSN:0029-7844    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

ObjectiveTo establish and test the effectiveness of a low-risk scoring system to predict obstetric outcome for the selection of women suitable for confinement in low-intervention units.MethodsRetrospective analyses were performed on data from 2900 women enrolled in the Western Australian Pregnancy Cohort Study and 1353 women managed at a midwifery-based birth center. A combination of the principal predictors of obstetric outcome, incorporating a previously published scoring system and various clinical features, was used to exclude high-risk cases at 18 weeks' and 36 weeks' gestation. Stepwise multivariate logistic regression analyses of the remaining pregnancies then produced a low-risk scoring system.ResultsThis system predicted a 55% chance of an uncomplicated delivery in a midwifery-based setting after allocating 54% of women to the low-risk category. It predicted an 82% chance of an uncomplicated delivery in a primary medical care setting with the allocation of 84% of women as low risk.ConclusionThe results of this study suggest that adding induction and augmentation of labor, together with low pelvic instrumental delivery, to the treatment options in a low-intervention unit would raise the rate of successful confinement within the unit from 55% to 82%. Our scoring system now requires prospective evaluation to further assess its clinical value.

ISSN:0029-7844    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

ObjectiveTo perform a cost-effectiveness analysis of various protocols used in the diagnostic evaluation of pregnancies complicated by elevated levels of maternal serum alpha-fetoprotein (MSAFP).MethodsThe variables incorporated in this model were the prevalence of relevant fetal anomalies; the sensitivity and specificity of MSAFP at 2.0 or 2.5 multiples of the median (MoM); and the sensitivity, specificity, cost, and safety of targeted ultrasound and amniocentesis. We expressed the cost-effectiveness of each strategy as the total cost of the diagnostic evaluation divided by the number of anomalous fetuses identified, yielding the cost per identified anomalous fetus.ResultsIn a hypothetical cohort of 100,000 singleton pregnancies, a strategy of targeted ultrasound for MSAFP of at least 2.0 MoM detected 90 of 110 structurally abnormal fetuses, without iatrogenic fetal loss, at a cost of $5700 per anomalous fetus. A strategy of amniocentesis with karyotype determination for MSAFP of at least 2.5 MoM detected 15 additional abnormal fetuses (87 structural abnormalities, ten autosomal aneuploidies, and eight sex chromosomal aneuploidies), with nine iatrogenic fetal losses, at an incremental cost of $46,100 per anomalous fetus.ConclusionThe increased cost and iatrogenic fetal loss rate may not justify the increased diagnostic yield of amniocentesis as compared with ultrasound in the evaluation of pregnancies complicated by elevated MSAFP.

ISSN:0029-7844    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

ObjectiveTo examine the association between hypertensive disorders of pregnancy and second-trimester maternal serum alpha-fetoprotein (MSAFP) and hCG levels.MethodsThe proportions of abnormal second trimester MSAFP and hCG levels in the serun samples from 65 women with true pregnancy-induced hypertension or preeclampsia (cases) were compared to the proportions of abnormal levels in all 1943 women without this disorder in the same cohort in a hospital setting. Maternal serum alpha-fetoprotein and hCG levels of the 65 cases also were compared to those of 325 completely uncomplicated matched control pregnancies, selected from the same cohort. Fisher exact test and Studentttest were used for statistical analysis andP< .05 was considered statistically signigicant.ResultsAn MSAFP level at least 2.5 multiples of the median (MoM) was found in two of 65 cases (3.1%) and in 27 of 1943 women (1.4%) in the rest of the cohort, a nonsignificant difference (relative risk [RR] = 2.2;P= .24). The statistical power to identify a significant difference for this RR was .27. An hCG level of at least 2.5 MoM was found in six cases (9.2%) and in 89 (4.6%) of women in the rest of the cohort, also a nonsignificant difference (RR = 2.0;P= .12). The statistical power to identify a significant difference for this RR was.38. The mean (± standard deviation) logarithms of the MSAFP and hCG MoMs in the 65 cases (0.039 ± 0.191 and 0.048 ± 0.265, respectively) were not significantly different from those in the 325 matched controls (0.006 ± 0.148 and −0.010 ± 0.244, respectively;P= .12 and .08, respectively).ConclusionAlthough a weak association cannot be excluded, this study found no clinically important increase in risk of developing subsequent hypertensive disorders of pregnancy among women with abnormal second-trimester levels of MSAFP or hCG.

ISSN:0029-7844    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

ObjectiveTo examine risk factors and maternal and neonatal outcomes in ten cases of intrapartum rupture of the unscarred uterus.MethodsUterine ruptures in women without previous cesarean deliveries were identified from an ongoing log for a 12-year period beginning January 1, 1983. Detailed information was obtained by review of hospital records.ResultsFrom January 1, 1983, through December 31, 1994, we identified 13 uterine ruptures in women without previous cesarean deliveries. Three resulted from motor vehicle accidents and were excluded from analysis. Ten occurred during labor and are the subjects of our report. The incidence of intrapartum rupture of an unscarred uterus was 1 in 16,849 deliveries. Associated factors included oxytocin use (four cases), prostaglandin use (three cases), use of vacuum or forceps (three cases), grand multiparity (two cases), and malpresentation (two cases). Intervention was prompted by fetal heart rate decelerations in seven cases and by severe hemorrhage in three. Uterine rupture was associated with acute abdominal pain in six cases, maternal tachycardia in five, and severe hypotension in two. Neonatal outcomes were normal in nine cases. There were no maternal or perinatal deaths.ConclusionIntrapartum rupture of the unscarred uterus is a rare obstetric emergency. Maternal and perinatal outcomes are optimized by awareness of risk factors, recognition of clinical signs and symptoms, and prompt surgical intervention.

ISSN:0029-7844    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

ObjectiveTo determine the risk of adverse pregnancy outcome among crack cocaine users in a large homogeneous prenatal population with objective documentation of drug use.MethodsA retrospective cohort study was performed on a population of inner-city women who were offered routine voluntary urine drug screening and who delivered between January and December 1992 at a large county hospital. The study population consisted of 483 users (positive drug screens) and 3158 non-users (negative drug screens). Univariate analysis and multiple logistic regression were used to identify the relation between crack cocaine use and adverse perinatal outcome.ResultsUsers were significantly more likely than nonusers to deliver low birth weight (LBW) infants (31.3% versus 14.9%; crude odds ratio [OR] 2.6; 95% confidence interval [CI] 2.1, 3.2), growth-restricted infants (29.0% versus 13.0%; crude OR 2.7; 95% CI 2.2, 3.4), and preterm infants (28.2% versus 17.1%; crude OR 1.9; 95% CI 1.5, 2.4). In addition, users were more likely to have abruptions (3.3% versus 1.1%; crude OR 3.0; 95% CI 1.6, 5.6) and infants with low 5-minute Apgar scores (7.9% versus 4.5%; crude OR 1.8; 95% CI 1.2, 2.7). After adjusting for confounders (including alcohol use and smoking), only the risks of LBW and fetal growth restriction (FGR) remained significant, with adjusted OR 1.6 (95% CI 1.03, 2.4) and adjusted OR 1.7 (95% CI 1.2, 2.3), respectively. Although there was no significant difference in the rate of low 5-minute Apgar scores between users and non-users after controlling for confounders, users with a positive urine drug screen within 1 week of delivery were significantly more likely than non-users to deliver infants with low 5-minute Apgar scores: crude OR 2.4; adjusted OR 2.0 (95% CI 1.1, 3.7).ConclusionIn this inner-city population, crack cocaine use is associated with adverse pregnancy outcomes, as noted by increased risks of LBW and FGR.

ISSN:0029-7844    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

ObjectiveTo evaluate the laparoscopic management of adnexal masses suspicious at ultrasound.MethodsIn a prospective study, adnexal masses suspicious at ultrasound were managed by laparoscopy. Indications for laparotomy included general contraindications to laparoscopy, obviously disseminated ovarian cancer, and technically impossible laparoscopic treatment. After laparoscopic diagnosis, frozen sections were used to confirm a diagnosis of malignancy. Treatment was performed by laparoscopy whenever feasible.ResultsOver a 3-year period, 247 of the 599 adnexal masses (41.2%) treated in our department were suspicious or solid at ultrasound. Seventeen patients were evaluated by laparotomy and 230 by laparoscopy. Overall, 204 women (82.6%) were treated by laparoscopy, including seven of the 37 malignant tumors (18.9%) and 197 of the 210 benign masses (93.8%). One case of tumor dissemination occurred after a laparoscopic adnexectomy and morcellation of a grade 1 immature teratoma.ConclusionLaparoscopic diagnosis of adnexal masses suspicious at ultrasound avoids many laparotomies for the treatment of benign masses and allows an improved inspection of the upper abdomen. The laparoscopic treatment of adnexal masses suspicious at surgery should be evaluated further in carefully designed prospective studies.

ISSN:0029-7844    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

ObjectiveTo address the incidence of deep wound dehiscence and incisional hernia formation with two types of mass closure after vertical midline laparotomy performed in patients with gynecologic cancer.MethodsContinuous and interrupted mass closures were compared randomly in 632 patients. Both methods were performed with absorbable material. Of the 614 subjects who could be evaluated, 308 underwent a continuous, nonlocking closure with looped polyglyconate suture, and 306 were closed with interrupted polyglycolic acid according to the Smead-Jones technique.ResultsThree (1%) subjects with the continuous closure and five (1.6%) with the interrupted closure had an abdominal wound infection (P= .50). One patient whose incision was closed with continuous suturing had a deep wound dehiscence (without evisceration). The follow-up period was 6 months to 3 years. No patient had evidence of chronic sinus drainage. Thirty-two (10.4%) of the patients who had the continuous closure and 45 (14.7%) of those who were closed with the interrupted method had evidence of incisional hernia (P= .14). No hernia developed in any patient with a wound infection. Four (1.3%) hernias after the continuous closure and eight (2.6%) after the interrupted closure required surgical repair because of patient discomfort (P= .38).ConclusionThe interrupted closure was not superior to the continuous closure for short- and long-term wound security. The continuous method was preferable because it was more cost-efficient and faster.

ISSN:0029-7844    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

ObjectiveTo compare the prevalence of human papilloma-virus (HPV)-associated vulvovaginal lesions in human immunodeficiency virus (HIV)-positive and HIV-negative women.MethodsFor this cross-sectional study, all participants received a complete gynecologic examination including colposcopic evaluation and a structured interview about sociodemographic characteristics and risk factors for vulvovaginal disease. In addition, HPV DNA was assayed for in cervicovaginal lavages using polymerase chain reaction.ResultsVulvar and/or vaginal condyloma acuminata were detected in 22 of 396 (5.6%) HIV-positive and in 3 of 375 (0.8%) HIV-negative women (odds ratio [OR] 7.3,P< .001). High-grade vulvar intraepithelial neoplasia (VIN) was present in two of the HIV-positive and none of the HIV-negative women. Human immunodeficiency virus-positive women with condyloma or VIN were significantly more likely to have cervical intraepithelial neoplasia (33%) than those without vulvovaginal lesions (17%) (OR 2.9, 95% confidence interval [CI] 1.1, 74). In multivariate logistic regression analysis, both HIV seropositivity (adjusted OR 5.3, 95% CI 1.3, 35.3) and HPV infection (adjusted OR 6.1, 95% CI 1.7, 39.4) were associated with vulvovaginal condyloma.ConclusionThe prevalence of vulvovaginal condyloma was increased in HIV-positive women even when controlling for HPV infection. Human papillomavirus-associated disease was more likely to be multicentric and involve the vulva, vagina, and cervix in HIV-positive than HIV-negative women. Detection of high-grade VIN in two of the HIV positive women suggests that they may also be at risk for developing invasive vulvar carcinoma.

ISSN:0029-7844    

出版商:OVID    

年代:1997

数据来源: OVID