Showing papers in "Obstetrical & Gynecological Survey in 2001"
TL;DR: In women who are seropositive for CMV, reinfection with a different strain of CMV can lead to intrauterine transmission and symptomatic congenital infection.
Abstract: Background Preconceptional immunity against cytomegalovirus (CMV) provides only partial protection against intrauterine transmission of the virus. Whether congenital CMV infection in the offspring of women who are seropositive for CMV can occur after maternal reinfection with a different strain of CMV is unknown. Methods Serum specimens from 46 women with preconceptional immunity against CMV that were obtained during the previous pregnancy and the current pregnancy were analyzed for antibodies against the strain-specific epitopes of CMV glycoprotein H. Virus-neutralizing activity in maternal serum samples was measured against the AD169 laboratory strain of CMV and the CMV isolates available from seven infected infants. In addition, the nucleotide sequences of the glycoprotein H gene from the seven CMV isolates were determined. Results Eleven of the 16 mothers with infected infants (69 percent) had antibodies against the glycoprotein H epitopes present on two laboratory strains of CMV, AD169 and Towne. Ten...
372 citations
TL;DR: The current data suggest that only those fibroids with a submucosal or an intracavitary component are associated with decreased reproductive outcomes, and that hysteroscopic myomectomy may be of benefit.
Abstract: A systematic literature review was performed to determine whether leiomyomata are associated with decreased fertility rates, and whether surgical removal increases fertility rates postoperatively. Meta-analysis was conducted when multiple studies addressed a single issue and were sufficiently homoge
312 citations
TL;DR: In this paper, transplantation of umbilical cord blood from unrelated donors who are not HLA-identical with the recipients can restore hematopoiesis after myeloablative therapy in children.
Abstract: Background Umbilical-cord blood from unrelated donors who are not HLA-identical with the recipients can restore hematopoiesis after myeloablative therapy in children. We studied the use of transplantation of umbilical-cord blood to restore hematopoiesis in adults. Methods Sixty-eight adults with life-threatening hematologic disorders received intensive chemotherapy or total-body irradiation and then transplants of HLA-mismatched umbilical-cord blood. We evaluated the outcomes in terms of hematologic reconstitution, the occurrence of acute and chronic graft-versus-host disease (GVHD), relapses, and event-free survival. Results Of the 68 patients, 48 (71 percent) received grafts of umbilical-cord blood that were mismatched for two or more HLA antigens. Of the 60 patients who survived 28 days or more after transplantation, 55 had neutrophil engraftment at a median of 27 days (range, 13 to 59). The estimated probability of neutrophil recovery in the 68 patients was 0.90 (95 percent confidence interval, 0.85 t...
267 citations
TL;DR: Much of congenital toxoplasmosis can be prevented by educating women of childbearing age and pregnant women to avoid eating raw or undercooked meat, to avoid cross-contamination of other foods with raw orUnder cooked meat, and to use proper cat-litter and soil-related hygiene.
Abstract: Toxoplasmosis is caused by infection with the protozoan parasite Toxoplasma gondii. In the United States, approximately 85% of women of childbearing age are susceptible to acute infection with T. gondii. Acute infections in pregnant women may cause serious health problems when the organism is transmitted to the fetus (congenital toxoplasmosis), including mental retardation, seizures, blindness, and death. An estimated 400 to 4000 cases of congenital toxoplasmosis occur in the U.S. each year. Manifestations of congenital toxoplasmosis may not become apparent until the second or third decade of life. Serologic tests are used to diagnose acute infection in pregnant women, but false-positive tests occur frequently, therefore, serologic diagnosis must be confirmed at a reference laboratory before treatment with potentially toxic drugs should be considered. Much of congenital toxoplasmosis can be prevented by educating women of childbearing age and pregnant women to avoid eating raw or undercooked meat, to avoid cross-contamination of other foods with raw or undercooked meat, and to use proper cat-litter and soil-related hygiene.
260 citations
TL;DR: The risk of uterine rupture is higher among those whose labor is induced than among those with repeated cesarean delivery without labor, and labor induced with a prostaglandin confers the highest risk.
Abstract: Background Each year in the United States, approximately 60 percent of women with a prior cesarean delivery who become pregnant again attempt labor. Concern persists that a trial of labor may increase the risk of uterine rupture, an uncommon but serious obstetrical complication. Methods We conducted a population-based, retrospective cohort analysis using data from all primiparous women who gave birth to live singleton infants by cesarean section in civilian hospitals in Washington State from 1987 through 1996 and who delivered a second singleton child during the same period (a total of 20,095 women). We assessed the risk of uterine rupture for deliveries with spontaneous onset of labor, those with labor induced by prostaglandins, and those in which labor was induced by other means; these three groups of deliveries were compared with repeated cesarean delivery without labor. Results Uterine rupture occurred at a rate of 1.6 per 1000 among women with repeated cesarean delivery without labor (11 women), 5.2 ...
247 citations
TL;DR: It is indicated that even light-to-moderate activity is associated with lower CHD rates in women, and the inverse association with physical activity was also present in women at high risk for CHD, including those who were overweight, had increased cholesterol levels, or were smokers.
Abstract: ContextPhysically active women have lower coronary heart disease (CHD) rates
than inactive women. However, whether the association differs by intensity
of activity or in women at high risk for CHD is unclear.ObjectiveTo examine the relation between physical activity, specifically investigating
walking (a light-to-moderate activity depending on pace), and CHD among women,
including those at high risk for CHD.Design, Setting, and ParticipantsCohort study of 39 372 healthy female health professionals aged
45 years or older, enrolled throughout the United States between September
1992 and May 1995, with follow-up to March 1999. Recreational activities,
including walking and stair climbing, were reported at study entry.Main Outcome MeasureCorrelation of CHD with energy expended on all activities, vigorous
activities, and walking.ResultsA total of 244 cases of CHD occurred. Adjusting for potential confounders,
the relative risks (RRs) of CHD for less than 200, 200-599, 600-1499, and
1500 or more kcal/wk expended on all activities were 1.00 (referent), 0.79
(95% confidence interval [CI], 0.56-1.12), 0.55 (95% CI, 0.37-0.82), and 0.75
(95% CI, 0.50-1.12), respectively (P for linear trend
= .03). Vigorous activities were associated with lower risk (RR, 0.63; 95%
CI, 0.38-1.04 comparing highest and lowest categories). Walking also predicted
lower risk among women without vigorous activities. Among these women, the
multivariate RRs for walking 1 to 59 min/wk, 1.0 to 1.5 h/wk, and 2 or more
h/wk, compared with no regular walking, were 0.86 (95% CI, 0.57-1.29), 0.49
(95% CI, 0.28-0.86), and 0.48 (95% CI, 0.29-0.78), respectively. For walking
paces of less than 3.2 km/h (2.0 mph), 3.2 to 4.7 km/h (2.0-2.9 mph), and
4.8 km/h (3.0 mph) or more, compared with no regular walking, RRs were 0.56
(95% CI, 0.32-0.97), 0.71 (95% CI, 0.47-1.05), and 0.52 (95% CI, 0.30-0.90),
respectively. When analyzed simultaneously, time spent walking (P for linear trend = .01) but not walking pace (P for linear trend = .55) predicted lower risk. The inverse association
between physical activity and CHD risk did not differ by weight or cholesterol
levels (P for interaction = .95 and .71, respectively),
but there were significant interactions by smoking and hypertension status.
Physical activity was inversely related to risk in current smokers but not
hypertensive women (P for interaction = .01 and .001,
respectively).ConclusionsThese data indicate that even light-to-moderate activity is associated
with lower CHD rates in women. At least 1 hour of walking per week predicted
lower risk. The inverse association with physical activity was also present
in women at high risk for CHD, including those who were overweight, had increased
cholesterol levels, or were smokers.
206 citations
TL;DR: The primary outcome measure was a composite of neonatal death, chronic lung disease, or major cerebral abnormality on ultrasonography before discharge from hospital.
Abstract: Summary Background Preterm, prelabour rupture of the fetal membranes (pPROM) is the commonest antecedent of preterm birth, and can lead to death, neonatal disease, and long-term disability. Previous small trials of antibiotics for pPROM suggested some health benefits for the neonate, but the results were inconclusive. We did a randomised multicentre trial to try to resolve this issue. Methods 4826 women with pPROM were randomly assigned 250 mg erythromycin (n=1197), 325 mg co-amoxiclav (250 mg amoxicillin plus 125 mg clavulanic acid; n=1212), both (n=1192), or placebo (n=1225) four times daily for 10 days or until delivery. The primary outcome measure was a composite of neonatal death, chronic lung disease, or major cerebral abnormality on ultrasonography before discharge from hospital. Analysis was by intention to treat. Findings Two women were lost to follow-up, and there were 15 protocol violations. Among all 2415 infants born to women allocated erythromycin only or placebo, fewer had the primary composite outcome in the erythromycin group (151 of 1190 [12·7%] vs 186 of 1225 [15·2%], p=0·08) than in the placebo group. Among the 2260 singletons in this comparison, significantly fewer had the composite primary outcome in the erythromycin group (125 of 1111 [11·2%] vs 166 of 1149 [14·4%], p=0·02). Co-amoxiclav only and coamoxiclav plus erythromycin had no benefit over placebo with regard to this outcome in all infants or in singletons only. Use of erythromycin was also associated with prolongation of pregnancy, reductions in neonatal treatment with surfactant, decreases in oxygen dependence at 28 days of age and older, fewer major cerebral abnormalities on ultrasonography before discharge, and fewer positive blood cultures. Although co-amoxiclav only and co-amoxiclav plus erythromycin were associated with prolongation of pregnancy, they were also associated with a significantly higher rate of neonatal necrotising enterocolitis. Interpretation Erythromycin for women with pPROM is associated with a range of health benefits for the neonate, and thus a probable reduction in childhood disability. However, co-amoxiclav cannot be routinely recommended for pPROM because of its association with neonatal necrotising enterocolitis. A follow-up study of childhood development and disability after pPROM is planned.
199 citations
TL;DR: The cumulative experience suggests that laparoscopic surgery may be performed safely during pregnancy, although more studies are needed to establish its exact rate of adverse events.
Abstract: In the last decade, operative laparoscopic procedures are performed increasingly in both gynecology and general surgery. The major advantages of this newer minimally invasive approach are: decreased postoperative morbidity, less pain and decreased need for analgesics, early normal bowel function, shorter hospital stay, and early return to normal activity. With the advancement of laparoscopic surgery, its use during pregnancy is becoming more widely accepted. The most commonly reported laparoscopic operation during pregnancy is laparoscopic cholecystectomy (LC). Other laparoscopic procedures commonly performed during pregnancy include: management of adnexal mass, ovarian torsion, ovarian cystectomy, appendectomy, and ectopic pregnancy. The possible drawbacks of laparoscopic surgery during pregnancy may include injury of the pregnant uterus and the technical difficulty of laparoscopic surgery due to the growing mass of the gravid uterus. Also, the potential risk of decreased uterine blood flow secondary to the increase in intraabdominal pressure and the possible risk of carbon dioxide absorption to both the mother and fetus should be taken into account. To date, data on laparoscopic surgery during pregnancy are insufficient to draw conclusions on its safety and exact complication rate. This is due to the few cases reported and the lack of prospective studies. Furthermore, there is a common tendency to underreport unsuccessful cases. Finally, most reports in the literature come from centers and surgeons with special interest, experience, and skills in laparoscopy, and their results may not reflect the real complication rates. We have reviewed the pertinent English literature from the last decade. The cumulative experience suggests that laparoscopic surgery may be performed safely during pregnancy, although more studies are needed to establish its exact rate of adverse events.
169 citations
TL;DR: The reader will be able to list the potential sources of lead intoxication in the authors' society, to describe the effects of low level exposure in utero, and to outline the management strategy of the lead exposed pregnant patient.
Abstract: Despite a steady decline in average blood lead levels in the U.S. population, approximately 0.5% of women of childbearing age may have blood levels exceeding 10 microg/dl. Strong correlations between maternal and umbilical cord blood lead levels demonstrate that lead is transferred from the mother to the fetus. High lead levels are known to cause neurobehavioral effects in infants and children, and the cumulative effects of low levels of lead exposure in utero and after birth can have similar detrimental effects. Modern sources of exposure include occupational exposure during automotive or aircraft paint manufacturing, lead production or smeltering, exposure to stained glass soder, and environmental exposure during home renovation. Prenatal screening for lead exposure may include use of a five-item questionnaire similar to the pediatric questionnaire. Management of prenatal lead exposure focuses on removal of the lead source. Rarely, highly toxic chelation therapy is needed for maternal indications. Recognition and removal of lead sources during the prenatal period can prevent maternal and neonatal morbidity.
144 citations
TL;DR: This review focuses on the physiology of androgens in postmenopausal women and includes a discussion of the definition of an androgen deficiency state, the anticipated effects of androgen on several parameters of health, and possible ways in which androgens may be administered to women.
Abstract: The physiology of normal androgen production in women has not been well understood. Aging, per se, accounts for much of the reduction in both ovarian and adrenal androgen production; and natural menopause does not result in an abrupt decline in testosterone production. Therefore, the definition of an androgen deficiency state in women, in the absence of adrenal suppression and/or bilateral oophorectomy, has been difficult. Nevertheless there are well-documented beneficial effects of androgen on many organ systems, including bone and the brain. This review focuses on the physiology of androgens in postmenopausal women and includes a discussion of the definition of an androgen deficiency state, the anticipated effects of androgen on several parameters of health, and possible ways in which androgens may be administered to women.
143 citations
TL;DR: Since well-baby care use is similar for abused and nonabused mothers, pediatric practices may be important settings for screening women for violence.
Abstract: Main Outcome Measures Prevalence of physical abuse during the 12 months be- fore pregnancy, during pregnancy, and after infant delivery; injuries and medical in- terventions resulting from postpartum abuse; and patterns of abuse over time in re- lation to sociodemographic characteristics and use of well-baby care. Results The prevalence of abuse before pregnancy was 6.9% (95% confidence in- terval (CI), 5.6%-8.2%) compared with 6.1% (95% CI, 4.8%-7.4%) during preg- nancy and 3.2% (95% CI, 2.3%-4.1%) during a mean postpartum period of 3.6 months. Abuse during a previous period was strongly predictive of later abuse. Most women who were abused after pregnancy (77%) were injured, but only 23% received medi- cal treatment for their injuries. Virtually all abused and nonabused women used well- baby care; private physicians were the most common source of care. The mean num- ber of well-baby care visits did not differ significantly by maternal patterns of abuse. Conclusion Since well-baby care use is similar for abused and nonabused mothers, pediatric practices may be important settings for screening women for violence.
TL;DR: In this paper, a case-control study was conducted at 3 hospital maternity units in London, England, between July 1997 and June 2000, to determine whether endothelial function is impaired in nonpregnant women with previous preeclampsia and whether vascular dysfunction is mediated by oxidative stress.
Abstract: ContextPreeclampsia is believed to result from release of placental factors
that damage maternal vascular endothelium. However, because most studies have
been conducted during pregnancy, it has not been possible to separate maternal
from placental mechanisms underlying endothelial dysfunction in preeclampsia.ObjectiveTo determine whether endothelial function is impaired in nonpregnant
women with previous preeclampsia and whether endothelial dysfunction is mediated
by oxidative stress.Design and SettingCase-control study conducted at 3 hospital maternity units in London,
England, between July 1997 and June 2000.ParticipantsA total of 113 women with previous preeclampsia (n = 35 with recurrent
episodes; n = 78 with a single episode) and 48 women with previous uncomplicated
pregnancies, all of whom were at least 3 months (median, 3 years) postpartum.Main Outcome MeasuresBrachial artery flow-mediated (endothelium-dependent) and glyceryl trinitrate–induced
(endothelium-independent) dilatation were compared between previously preeclamptic
women and controls. To investigate oxidative stress, these measurements were
repeated after administration of ascorbic acid, 1 g intravenously, in 15 cases
and 15 controls.ResultsMean (SD) flow-mediated dilatation was lower in women with previous
preeclampsia compared with controls (recurrent group, 0.9% [4.1%]; single-episode
group, 2.7% [3.5%]; and control group, 4.7% [4.3%]; P<.001).
In contrast, glyceryl trinitrate–induced dilatation was similar in the
3 groups (recurrent, 19.5% [5.9%]; single-episode, 21.0% [8.0%]; and control,
21.0% [8.3%]; P = .65). Impaired flow-mediated dilatation
in previously preeclamptic women was not accounted for by recognized vascular
risk factors. Ascorbic acid administration increased flow-mediated dilatation
in previously preeclamptic women (baseline, 2.6% [3.3%]; after administration,
5.6% [3.0%]; P = .001) but not in controls (baseline,
6.2% [3.3%]; after administration, 6.7% [5.0%]; P
= .72).ConclusionsOur results indicate that endothelial function is impaired in women
with previous preeclampsia and is not explained by established maternal risk
factors but is reversed by antioxidant ascorbic acid administration.
TL;DR: In this article, the effect of breastmilk transmission of HIV-1 to infants was examined in a randomized clinical trial of breastfeeding and formula feeding to identify the frequency of breast milk transmission of infants to infants.
Abstract: Summary Background We have completed a randomised clinical trial of breastfeeding and formula feeding to identify the frequency of breastmilk transmission of HIV-1 to infants. However, we also analysed data from this trial to examine the effect of breastfeeding on maternal death rates during 2 years after delivery. We report our findings from this secondary analysis. Methods Pregnant women attending four Nairobi city council clinics were offered HIV tests. At about 32 weeks' gestation, 425 HIV-1 seropositive women were randomly allocated to either breastfeed or formula feed their infants. After delivery, mother-infant pairs were followed up monthly during the first year and quarterly during the second year until death, or 2 years after delivery, or end of study Findings Mortality among mothers was higher in the breastfeeding group than in the formula group (18 vs 6 deaths, log rank test, p=0·009). The cumulative probability of maternal death at 24 months after delivery was 10·5% in the breastfeeding group and 3·8% in the formula group (p=0·02). The relative risk of death for breastfeeding mothers versus formula feeding mothers was 3·2 (95% CI 1·3–8·1, p=0·01). The attributable risk of maternal death due to breastfeeding was 69%. There was an association between maternal death and subsequent infant death, even after infant HIV-1 infection status was controlled for (relative risk 7·9, 95% CI 3·3–18·6, p Interpretation Our findings suggest that breastfeeding by HIV-1 infected women might result in adverse outcomes for both mother and infant.
TL;DR: It seems that NVP and hCG are related and that nutrient restriction during critical periods of embryonic development may ensure production of hCG at optimal levels, protect placental development, and optimize nutrient partitioning between maternal and fetal tissues.
Abstract: For a majority of women, nausea and vomiting of pregnancy (NVP) is an unpleasant but normal feature of pregnancy. NVP has a largely unknown etiology, but it is widely agreed that physiological, psychological, genetic, and cultural components are contributing factors. The occurrence of NVP may be of
TL;DR: In this article, the authors found that the frequency of major malformations, growth retardation, and hypoplasia of the midface and fingers is increased in infants exposed to anticonvulsant drugs in utero.
Abstract: Background The frequency of major malformations, growth retardation, and hypoplasia of the midface and fingers, known as anticonvulsant embryopathy, is increased in infants exposed to anticonvulsant drugs in utero. However, whether the abnormalities are caused by the maternal epilepsy itself or by exposure to anticonvulsant drugs is not known. Methods We screened 128,049 pregnant women at delivery to identify three groups of infants: those exposed to anticonvulsant drugs, those unexposed to anticonvulsant drugs but with a maternal history of seizures, and those unexposed to anticonvulsant drugs with no maternal history of seizures (control group). The infants were examined systematically for the presence of major malformations, signs of hypoplasia of the midface and fingers, microcephaly, and small body size. Results The combined frequency of anticonvulsant embryopathy was higher in 223 infants exposed to one anticonvulsant drug than in 508 control infants (20.6 percent vs. 8.5 percent; odds ratio, 2.8; 9...
TL;DR: It is suggested that HRT after breast cancer has no adverse impact on recurrence and mortality, and residual confounding may exist.
Abstract: Although hormone replacement therapy (HRT) is generally not recommended for women who have been treated for breast cancer, some patients have used HRT because of its beneficial impact on bone density and lipid profiles. This study was undertaken to investigate the impact of the use of HRT on recurrence and survival of women who have had breast cancer. The records of 2755 women aged 35 to 74 years who had a diagnosis of invasive breast cancer between 1977 and 1994 were identified in the cancer surveillance system of a large health maintenance organization. The 174 patients who had used HRT after being treated for breast cancer serve as the study population. They were each matched to four control subjects who corresponded in age, stage of disease, and year of diagnosis. All study subjects were disease-free when HRT was initiated, and control subjects were disease-free for a corresponding interval of time since diagnosis. Oral, vaginal, or combination HRT use was fairly equally distributed among study subjects (38, 41, and 16%, respectively). The average duration of use was 15 months. Nearly 80% of the women used unopposed estrogens. In the course of the study, 16 of the 174 women (9%) who used HRT had breast cancer recurrence, compared with 101 of the women (15%) who did not use HRT. The rate of breast cancer recurrence was 9% (16 of 174) among the women who used HRT and 15% (101 of 696) among nonusers. Calculated in numbers of person-years, the rate of recurrence in users was 17 per 1000, compared with 30 per 1000 in nonusers. The relative risk of developing a recurrence in women who had ever used HRT was 0.58 (95% CI = 0.34-0.98). This risk was similar in other analyses adjusting for possible contributing variables, including bilateral oophorectomy, hysterectomy, mastectomy, and use of tamoxifen. No appreciable change was seen in opposed versus unopposed estrogen users or method of HRT delivery (oral vs. vaginal). The relative risk approached 1 with greater duration of use and larger accumulated HRT dose. Five HRT users (3%) and 59 nonusers (8%) died of breast cancer during the study period, yielding a breast cancer mortality rate, expressed in person-years, of 5 per 1000 for HRT users and 15 per 1000 for nonusers. The relative risk of dying of breast cancer for HRT users was 0.31 (95% CI = 0.13-0.78) and remained essentially the same when adjusted for obesity, positive lymph nodes, and oral or vaginal HRT use. Similarly, the total death rate from any cause, which was 10% among users and 17% among nonusers (relative risk = 0.54, 95% CI = 0.33-0.90), did not change appreciably with adjustments. Women with estrogen receptor-negative tumors who used HRT had an unadjusted relative risk of breast cancer recurrence of 0.31 (95% CI = 0.10-0.98), compared with 0.81 (95% CI = 0.30-2.17) for women with estrogen receptor-negative tumors who did not use HRT.
TL;DR: A meta-analysis of observational studies suggested that HRT was associated with a decreased risk of dementia (summary odds ratio, 0.66; 95% confidence ≥ 0.53-0.82) but most studies had important methodological limitations as discussed by the authors.
Abstract: ContextSome observational data suggest that hormone replacement therapy (HRT)
may reduce the risk of cognitive decline and dementia but results have been
conflicting.ObjectiveTo review and evaluate studies of HRT for preventing cognitive decline
and dementia in healthy postmenopausal women.Data SourcesStudies with English-language abstracts identified in MEDLINE (1966-August
2000), HealthSTAR (1975-August 2000, PsychINFO (1984-August 2000); Cochrane
Library databases; and articles listed in reference lists of key articles.Study SelectionRandomized controlled trials and cohort studies were reviewed for the
effects of HRT on cognitive decline; cohort and case-control studies were
reviewed for dementia risk. No randomized controlled trials regarding dementia
risk were identified.Data ExtractionTwenty-nine studies met inclusion criteria and were rated. Two reviewers
rated study quality independently and 100% agreement was reached on Jadad
scores and 80% agreement was reached on US Preventive Services Task Force
quality scores. A final score was reached through consensus if reviewers disagreed.Data SynthesisStudies of cognition were not combined quantitatively because of heterogeneous
study design. Women symptomatic from menopause had improvements in verbal
memory, vigilance, reasoning, and motor speed, but no enhancement of other
cognitive functions. Generally, no benefits were observed in asymptomatic
women. A meta-analysis of observational studies suggested that HRT was associated
with a decreased risk of dementia (summary odds ratio, 0.66; 95% confidence
interval, 0.53-0.82). However, possible biases and lack of control for potential
confounders limit interpretation of these studies. Studies did not contain
enough information to assess adequately the effects of progestin use, various
estrogen preparations or doses, or duration of therapy.ConclusionsIn women with menopausal symptoms, HRT may have specific cognitive effects,
and future studies should target these effects. The meta-analysis found a
decreased risk of dementia in HRT users but most studies had important methodological
limitations.
TL;DR: The usefulness of fetal biometry in gestational-age assessment and estimation of fetal weight, to delineate the application of fetalBiometry in the evaluation of abnormal fetal growth, and to list the most accurate measurements for predicting gestational age are described.
Abstract: Sonographic measurements of fetal ultrasound parameters are the basis for accurate determination of gestational age and detection of fetal growth abnormalities. Selection of the most useful single biometric parameter depends on the timing and purpose of measurement and is influenced by specific limitations. CRL (crown-rump length) is the best parameter for early dating of pregnancy. Biparietal diameter (BPD) maintains the closest correlation with gestational age in the second trimester. In cases of variation in the shape of the skull, head circumference is an effective alternative. Abdominal circumference is the most useful dimension to evaluate fetal growth, and femur length is the best parameter in the evaluation of skeletal dysplasia. Use of multiple predictors improves the accuracy of estimates. An individual approach to each pregnancy is recommended for fetal growth assessment. The various epidemiological factors involved in fetal growth should be considered and specific charts for different communities should be used when possible. The methods of fetal weight estimation with their limitations and potential errors are presented. Clinical application of fetal biometry in abnormal growth is discussed in cases of small- and large-for-gestational-age fetuses, chromosomal aberrations, and skeletal dysplasias.
TL;DR: This study confirmed, in the absence of reinfection, the continuing clinical effectiveness of single-dose metronidazole for the large majority of trichomoniasis cases and suggests that high-level resistance is uncommon.
Abstract: OBJECTIVE
To determine the prevalence of in vitro resistance to metronidazole among unselected isolates of Trichomonas vaginalis and correlate in vitro findings with response to metronidazole therapy.
STUDY DESIGN
Vaginal fluid from women attending a gynecology clinic at an urban hospital was cultured, isolates were tested for in vitro resistance to metronidazole, and these results were correlated with therapeutic outcome.
RESULTS
Among 911 women, T vaginalis was detected by culture in 82 (9.0%). Of the 82 isolates, 2 (2.4%; 95% CI, 0.3-8.5%) had low-level in vitro resistance (minimum lethal concentration, 50 micrograms/mL). Women with positive wet mount examinations were treated with metronidazole, 2 g, once and asked to return in one week. Of the 42 infected women agreeing to return for a repeat examination and culture, 26 (61.9%) did, and all (including one woman with a resistant isolate) were cured.
CONCLUSION
Isolates of T vaginalis resistant to metronidazole occur widely throughout the United States. Although the in vitro susceptibility of T vaginalis to metronidazole has been very poorly studied, our study is consistent with a decade-old prevalence estimate of in vitro resistance (5%), and suggests that high-level resistance is uncommon. This study confirmed, in the absence of reinfection, the continuing clinical effectiveness of single-dose metronidazole for the large majority of trichomoniasis cases.
TL;DR: There is a significant lack of information from large-scale studies about when treatment is necessary and the relative efficacy, rates of side effects, and acceptability of these various treatment options for early pregnancy failure.
Abstract: Approximately one in four women will experience a miscarriage during her lifetime. For more than 50 years, the standard management of early pregnancy failure has been a dilatation and curettage (D & C). Typically, the procedure is performed in an operating room, which significantly increases cost. There is little objective information in the modem literature to prove that a D & C for all patients will lower morbidity or improve emotional well being. Treatment options include expectant management, D & C in an outpatient setting, and medical management with misoprostol (not approved by the U.S. Food and Drug Administration for treatment of early pregnancy failure). The medical literature supports that expectant management may result in more complications, including the need for "emergent" curettage, if clinicians do not understand the true normal course of expectant management. In general, women prefer some form of active management. Dilatation and curettage can be performed safely in the office or other outpatient setting using manual vacuum aspiration. Vaginal misoprostol will cause expulsion in 80% to 90% of women up to 13 weeks' uterine size or gestation, including patients who have a gestational sac present. However, these data come from only three trials involving a total of 42 subjects treated with vaginal misoprostol, and another study of 42 women who received vaginal misoprostol for "missed abortion" before a scheduled D & C. There is a significant lack of information from large-scale studies about when treatment is necessary and the relative efficacy, rates of side effects, and acceptability of these various treatment options for early pregnancy failure.
TL;DR: Current oral contraceptive use and elective abortion were not associated with fibroids, and Advancing age was the only significant risk factor for African-American women.
Abstract: Uterine leiomyomas are reported to be the most common benign gynecologic tumors affecting premenopausal women, and they are often associated with considerable morbidity. The purpose of this study was to identify risk factors for uterine fibroids among women undergoing tubal sterilization. Cases comprised women aged 17-44 years whose uterine fibroids were first visualized at the time of tubal sterilization (1978-1979 or 1985-1987) or who reported a history of uterine fibroids (n = 317). Controls were randomly selected from women with no laparoscopic evidence of or history of fibroids (n = 1,268). Adjusted odds ratios were estimated using unconditional logistic regression separately for White (n = 1,235) and African-American (n = 350) women. Risk factors for White women included: age 40-44 years (odds ratio (OR) = 6.3; 95% confidence interval (CI): 3.5, 11.6), > or =5 years since last delivery (OR = 1.9; 95% CI: 1.1, 3.1), lifetime cigarette smoking of > or =1 pack/day (OR = 1.6; 95% CI: 1.1, 2.3), menstrual cycle length of >30 days (OR = 1.6; 95% CI: 1.1, 3.3), and menstrual bleeding for > or =6 days (OR = 1.4; 95% CI: 1.0, 2.0). Parous women were at reduced risk compared with nulliparous women (OR = 0.2; 95% CI: 0.1, 0.3). Advancing age was the only significant risk factor for African-American women (ages 40-44 years, OR = 27.5; 95% CI: 5.6, 83.6). Current oral contraceptive use and elective abortion were not associated with fibroids.
TL;DR: Raloxifene treatment for three years does not affect overall cognitive scores in postmenopausal women with osteoporosis and there was a trend toward less decline on the two tests of verbal memory and attention.
Abstract: Background In postmenopausal women, estrogen may have a beneficial effect on cognition or reduce the risk of decline in cognitive function. Whether raloxifene, a selective estrogen-receptor modulator, might have similar actions is not known. Methods As part of the Multiple Outcomes of Raloxifene Evaluation trial, we studied 7478 postmenopausal women with osteoporosis (mean age, 66 years), who were enrolled at 178 sites in 25 countries. The women were randomly assigned to receive raloxifene (60 mg or 120 mg) or placebo daily for three years. We compared the mean scores of the groups on six tests of cognitive function, which were administered at base line and at six months and one, two, and three years. Women were classified as having a decline in cognitive function if the change in their scores at three years was in the worst 10 percent. Results The mean cognitive scores in the three groups of women were similar at base line. The scores improved slightly in all three groups during the three-year study peri...
TL;DR: A MEDLINE and Cochrane systematic review search from 1980 to 2000 was performed to collect information and evidence on diagnosis and treatment of women suffering from chronic pelvic pain.
Abstract: Chronic pelvic pain (CPP) is a major health problem. It is the reason for 10% of all outpatient visits to gynecologist as well as being responsible for approximately 40% of laparoscopies and 10% to 15% of hysterectomies. A significant number of patients have no obvious etiology for their pain at the time of laparoscopy. The condition may not be cured in a large number of patients. This is ultimately unsatisfying for both the patient and physician. Although CPP may not be curable, it can be managed so those patients attain normal or near-normal levels of functions. To identify and review the methods used for diagnosis and treatment of chronic pelvic pain in women, a MEDLINE and Cochrane systematic review search from 1980 to 2000 was performed to collect information and evidence on diagnosis and treatment of women suffering from chronic pelvic pain.
TL;DR: It is concluded that urethral pressure profilometry is not a useful diagnostic test for stress urinary incontinence in women and its use in clinical management is not supported by current evidence.
Abstract: Urethral pressure profilometry is commonly used as a diagnostic test for stress urinary incontinence. The objective of this article is to review the published literature on urethral pressure profilometry to summarize its usefulness. MEDLINE was used to search the published English literature from 1966 to October 2000 for full-length original research articles on urethral pressure profilometry and stress urinary incontinence in women. Terms related to urethral pressure profilometry are defined consistently but techniques are not standardized, introducing variation in test results. Reproducibility of urethral pressure profilometry parameters is poor, both because of biological variation and variation within the test procedure itself (related in part to lack of standardization). Parameters of urethral pressure profilometry do not distinguish between continent and incontinent women and do not characterize the severity of incontinence or urethral incompetence. It is, therefore, concluded that urethral pressure profilometry is not a useful diagnostic test for stress urinary incontinence in women. Its use in clinical management is not supported by current evidence.
TL;DR: In this paper, a population-based observational study was conducted to determine risk factors for the occurrence of third degree perineal tears during vaginal delivery, which is defined as any rupture involving the anal sphincter muscles.
Abstract: Objective To determine risk factors for the occurrence of third degree perineal tears during vaginal delivery. Design A population-based observational study. Population All 284,783 vaginal deliveries in 1994 and 1995 recorded in the Dutch National Obstetric Database were included in the study. Methods Third degree perineal rupture was defined as any rupture involving the anal sphincter muscles. Logistic regression analysis was used to assess risk factors. Main outcome measures An overall rate of third degree perineal ruptures of 1.94% was found. High fetal birthweight, long duration of the second stage of delivery and primiparity were associated with an elevated risk of anal sphincter damage. Mediolateral episiotomy appeared to protect strongly against damage to the anal sphincter complex during delivery (OR: 0.21, 95% CI: 0.20–0.23). All types of assisted vaginal delivery were associated with third degree perineal ruptures, with forceps delivery (OR: 3.33, 95%-CI: 2.97–3.74) carrying the largest risk of all assisted vaginal deliveries. Use of forceps combined with other types of assisted vaginal delivery appeared to increase the risk even further. Conclusions Mediolateral episiotomy protects strongly against the occurrence of third degree perineal ruptures and may thus serve as a primary method of prevention of faecal incontinence. Forceps delivery is a stronger risk factor for third degree perineal tears than vacuum extraction. If the obstetric situation permits use of either instrument, the vacuum extractor should be the instrument of choice with respect to the prevention of faecal incontinence.
TL;DR: Exposure to nitrate in drinking water at concentrations above the 45 mg/liter maximum contaminant level was associated with increased risk for anencephaly, but not for spina bifida, and dietary nitrate exposure was not associated withIncreased risk for neural tube defects.
Abstract: In this population-based case-control study conducted in California between June 1989 and May 1991, the authors investigated the association between maternal periconceptional exposure to nitrate from drinking water and diet and risk for neural tube defects. The mothers of 538 cases and 539 nonmalformed controls were interviewed regarding residential history, consumption of tap water at home, and dietary intake during the periconceptional period. Dietary nitrate exposure was not associated with increased risk for neural tube defects. Exposure to nitrate in drinking water at concentrations above the 45 mg/liter maximum contaminant level was associated with increased risk for anencephaly (odds ratio (OR) = 4.0, 95% confidence interval (Cl): 1.0, 15.4), but not for spina bifida. Increased risks for anencephaly were observed at nitrate levels below the maximum contaminant level among groundwater drinkers only (OR = 2.1, 95% Cl: 1.1, 4.1 for 5-15 mg/liter; OR = 2.3, 95% Cl: 1.1, 4.5 for 16-35 mg/liter; and OR = 6.9, 95% Cl: 1.9, 24.9 for 36-67 mg/liter compared with <5 mg/liter). Adjustment for identified risk factors for anencephaly did not substantially alter these associations, nor did control for maternal dietary nitrate, total vitamin C intake, and quantity of tap water consumed. The lack of an observed elevation in risk for anencephaly in association with exposure to mixed water containing nitrate at levels comparable with the concentration in groundwater may indicate that something other than nitrate accounts for these findings.
TL;DR: The fetus depends on maternal nutrients, such as EFAs, for multiple bodily functions including eicosanoid metabolism as well as brain growth and retinal development, so if the mother is deficient in certain fatty acids, this deficiency tends to be compounded in the fetus.
Abstract: Healthy intrauterine growth and development, appropriately timed parturition, and safe birth continue to be critical determinants of each child’s chances of achieving their full biological potential. Essential fatty acids (EFAs) and their metabolites are involved in the synthesis of eicosanoids that play essential and multifaceted roles in human reproduction, especially during pregnancy, parturition, and lactation. Fatty acid-derived prostaglandins (PGs), hydroxyeicosatetraenoic molecules (HETE), leukotrienes (LTs), thromboxanes (TXs), and prostacyclins (PIs) play well-documented “final common pathway” molecular roles in both normal term labor as well as in preterm parturition (1). Abnormalities of thromboxane and prostacyclin physiology also occur with preeclampsia, eclampsia, and pregnancy-induced hypertension (PIH), which often require preterm delivery (2). Docosahexaenoic acid (22: 6v-3, DHA) and other EFA derivatives are important components of the rapidly growing brain and retinal tissues of the perinate (3). DHA, a long-chain omega-3 (v-3) fatty acid (LCPUFA) is expressed in breast milk, and breast-fed and DHA-nutritionally supplemented children demonstrate improved performance on various tests of brain and vision functioning (4). Ensuring maternal and perinatal nutritional sufficiency during pregnancy and lactation is investigated increasingly as an effective and inexpensive strategy for optimizing pregnancy and lactational outcome (5). Informed families and providers are invested both in preventing the occurrence and consequences of prematurity and inadequate uterine growth (6). Families and providers are similarly interested in optimizing healthy growth and development of the fetus’ developing organs, especially brain, retina, and the cardiovascular system (7). Preterm birth continues to cause neonatal morbidity and life time disabilities (8). Preterm birth is associated with potentially immense direct and indirect costs, as well as liabilities for care providers. Preterm birth is best understood as a syndrome caused by numerous diseases such as intrauterine infection and inflammation, uterine over-distention or intrauterine bleeding. Such causes of prematurity are best considered as “complex diseases.” Complex diseases involve interactions between multiple bodily systems or parameters including nutrition, immunity, coagulation, and the endocrine system. For example, the fetus depends on maternal nutrients, such as EFAs, for multiple bodily functions including eicosanoid metabolism as well as brain growth and retinal development. Thus, if the mother is deficient in certain fatty acids, this deficiency tends to be compounded in the fetus (9). Such complex disease processes are best dealt with using primary prevention techniques—such as ensuring nutritional sufficiency, particularlyv-3 LCPUFA sufficiency, during pregnancy and lactation.
TL;DR: In this paper, a statin dosage of less than 20 mg/d (standardized to simvastatin) was associated with an adjusted OR of fracture of 1.13 (95% CI, 0.96-1.33).
Abstract: bral fractures, the ORs were 1.01 (95% CI, 0.80-1.27), 0.59 (95% CI, 0.31-1.13), and 1.15 (95% CI, 0.62-2.14), respectively. Relative to nonuse, a statin dosage of less than 20 mg/d (standardized to simvastatin) was associated with an adjusted OR of fracture of 1.13 (95% CI, 0.96-1.33); this OR was 1.07 (95% CI, 0.82-1.38) at dosages of 20 to 39.9 mg/d and 0.85 (95% CI, 0.47-1.53) at dosages of 40 mg/d or more. The adjusted OR was 0.71 (95% CI, 0.50-1.01) for statin use durations of 0 to 3 months, 1.31 (95% CI, 0.87-1.95) for durations of 3 to 6 months, 1.14 (95% CI, 0.82-1.58) for durations of 6 to 12 months, and 1.17 (95% CI, 0.99-1.40) for durations of more than 12 months. Conclusion In this study, use of statins at dosages prescribed in clinical practice was not associated with a reduction in risk of fracture. JAMA. 2001;285:1850-1855 www.jama.com
TL;DR: In this article, a cross-sectional analysis of the baseline characteristics of 651 patients enrolled in a multicenter randomized treatment trial for pelvic inflammatory disease was performed, and the finding most associated with endometritis was a positive test result for Chlamydia trachomatis or Neisseria gonorrhoeae (adjusted odds ratio, 4.3; 95% confidence interval, 2.89-6.63).
Abstract: Objective: Careful detection and treatment of pelvic inflammatory disease are essential for the prevention of adverse sequelae. The purpose of this study was to evaluate the diagnostic test characteristics of clinical criteria for the diagnosis of pelvic inflammatory disease. Study Design: We performed a cross-sectional analysis of the baseline characteristics of 651 patients enrolled in a multicenter randomized treatment trial for pelvic inflammatory disease. Clinical and laboratory findings were recorded for all patients, and endometrial sampling was performed. We calculated sensitivity and specificity and performed receiver operating characteristic curve analysis and multivariate logistic regression, using histologic endometritis as the criterion standard. Results: The minimal criteria for pelvic inflammatory disease, as recommended by the Centers for Disease Control and Prevention, had a sensitivity of 83%, in comparison with a 95% sensitivity for adnexal tenderness ( P =.001). Of the supportive clinical criteria, the finding most highly associated with endometritis was a positive test result for Chlamydia trachomatis or Neisseria gonorrhoeae (adjusted odds ratio, 4.3; 95% confidence interval, 2.89-6.63). A multivariate logistic regression model indicated that combinations of criteria significantly improve the prediction of endometritis. Conclusion: Sensitivity can be maximized by using the presence of adnexal tenderness as a minimal criterion for the diagnosis of pelvic inflammatory disease, and supportive criteria are helpful in estimating the probability of endometritis. (Am J Obstet Gynecol 2001;184:856-64.)
TL;DR: In this article, the authors summarized the current state of knowledge of obstetric vacuum extraction, including the history, indications and contraindications, technique of the procedure, currently marketed instruments, special uses of the vacuum extractor, comparison of vacuum extraction with forceps delivery, and maternal and fetal outcomes.
Abstract: This article summarizes the current state of knowledge of obstetric vacuum extraction. The discussed topics include the history of vacuum extraction, indications and contraindications, technique of the procedure, currently marketed instruments, special uses of the vacuum extractor, comparison of vacuum extraction with forceps delivery, and maternal and fetal outcomes. Areas of controversy are identified and discussed. Vacuum extraction is replacing forceps as the preferred method of instrumental delivery.