Reproductive health care for adolescents.
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Adolescent↗
Biomedical subjects
S Arulkumaran
Publications and source records attributed to S Arulkumaran.
The surgical management of postpartum haemorrhage.
This review summarizes the options available for the management of postpartum haemorrhage when ecbolic agents have failed to control the bleeding and an obvious rectifiable problem such as retained placental fragments, lower genital tract trauma, uterine inversion or uterine rupture have been excluded or dealt with. The review covers the range of surgical options but gives an in-depth explanation of the more recent developments such as uterine brace sutures, the use of the Sengstaken-Blakemore tube and embolization procedures.
Embolization, Therapeutic↗
Postpartum intrauterine pressure studies of the uterotonic effect of oral misoprostol and intramuscular syntometrine.
OBJECTIVES: To investigate the effect of oral misoprostol in dosages varying from 200 microg to 800 microg on postpartum uterine contractility and to establish their side effects. DESIGN: A prospective descriptive study. PARTICIPANTS: Fifty-seven women who delivered vaginally after spontaneous labours not requiring augmentation. METHODS: Within 5 minutes of delivery of the placenta, a calibrated Gaeltec catheter with an intrauterine pressure transducer at its tip was inserted transcervically into the uterine cavity. Cumulative uterine activity was recorded for 30 minutes in each woman before administering the oral misoprostol tablets and continued for a further 90 minutes after its administration. Thus each woman acted as her own control regarding changes in uterine contractility. Uterine activity was recorded on a Sonicaid Meridian fetal monitor, which measures active contraction area automatically. The incidence of side effects was also recorded. RESULTS: There was no statistical difference (P = 0.887) in the adjusted mean difference in cumulative uterine activity following all the doses of oral misoprostol, compared with intramuscular syntometrine, the largest difference being seen in oral misoprostol 200 microg (adjusted mean difference -2282 kPas s, 95% CI -7954 to 3390 kPas s). The mean onset of action of oral misoprostol (6.1, SD 2.1 min) was significantly slower than that of intramuscular syntometrine (3.2, SD 1.5 min; P = 0.002), but their durations of action were similar (P = 0.637). In the misoprostol group the commonest side effects were shivering (36%) and a rise in body temperature above 38 degrees C (40%). In the syntometrine group, the most commonly observed side effect was moderate uterine pain (nine out of ten women) and a rise in diastolic blood pressure of 20 mmHg (two out of ten women). CONCLUSION: The results of this study show that oral misoprostol has a definite uterotonic effect on the postpartum uterus. At doses of 200 microg to 400 microg, oral misoprostol has a similar uterotonic effect to intramuscular syntometrine. Higher doses of oral misoprostol are associated with significantly more side effects.
Administration, Oral↗
Fetal and maternal lactate increase during active second stage of labour.
OBJECTIVE: To determine longitudinally fetal and maternal blood lactate concentrations during the second stage of labour. DESIGN: Prospective, observational study of randomly selected labours. SETTING: Labour ward, Sultanah Aminah General Hospital, Johore Bahru, Malaysia. MAIN OUTCOME MEASURES: Fetal scalp and maternal venous blood lactate, umbilical arterial and vein lactate and acid-base balance at delivery. RESULTS: Sixty-nine women and their infants were monitored in the second stage of labour. Mean maternal venous lactate by the end of the first stage was 2.6 +/- 1.0 (+/- S.D.) mmol/L and increased to 3.6 +/- 1.4, 4.2 +/- 1.7. 4.8 +/- 1.6, 5.4 +/- 2.1 and 4.3 +/- 0.9 mmol/L, respectively, for every 15 minute of bearing down. Corresponding values for fetal scalp blood lactate were 2.4 +/- 1.1, 3.1 +/- 1.6, 3.2 +/- 1.8, 4.2 +/- 2.4, 4.9 +/- 2.8 and 5.8 +/- 1.9 mmol/L. The mean slope of maternal lactate increase was 0.070 mmol/L per minute (95% CI 0.050, 0.090) and for fetal lactate increase 0.032 mmol/L per minute (95% C.I.: 0.018, 0.045). The duration of active second stage was significantly associated with fetal lactate (P < 0.001) and maternal lactate (P = 0.03) at the time of crowning of the fetal head, and lactate in umbilical arterial and vein blood at delivery (P < 0.001). Expulsion time > or = 45 minutes, compared with shorter active second stage, and acidaemia at birth implied larger arterial-venous lactate differences (P < 0.001). Fetal lactate at crowning was also significantly associated with the umbilical arterial-veonus lactate difference (P = 0.03). CONCLUSIONS: Maternal and fetal lactate concentrations increase significantly with duration of the active second stage of labour, more rapidly in the mother. It is likely that fetal anaerobic metabolism is the main source for the fetal lactate increase.
Adult↗
Oxytocics reverse the tocolytic effect of glyceryl trinitrate on the human uterus.
OBJECTIVES: To investigate the effect of glyceryl trinitrate on isolated human pregnant uterine strips and whether the uterine relaxation induced by glyceryl trinitrate could be reversed by oxytocics used in current clinical practice. DESIGN: In vitro pharmacological study. SETTING: Department of Obstetrics & Gynaecology, National University of Singapore, National University Hospital. PARTICIPANTS: Eighteen women who delivered by caesarean section at term. METHODS: Myometrial strips were preloaded with an initial tension of 1.5g in organ baths containing Krebs-Henseleit solution which was aerated with oxygen in 5% carbon dioxide and maintained at 37 degrees C, pH 7.4. The effect of glyceryl trinitrate was studied in strips displaying regular spontaneous contractions. The ability of oxytocin, ergometrine or prostaglandin F2alpha to stimulate uterine contractions was assessed in strips where uterine activity was significantly inhibited by glyceryl trinitrate. RESULTS: Glyceryl trinitrate reduced the amplitude and frequency of spontaneous uterine contractions in a concentration-dependent manner, although the sensitivity of the myometrial strips varied considerably from one specimen to another. The concentration of glyceryl trinitrate producing complete inhibition of myometrial contractions ranged from 44-705 microM. In the presence of glyceryl trinitrate which markedly depressed spontaneous contractions, oxytocin (20 mU/mL), ergometrine (6.15 microM) and prostaglandin F2alpha (6.15 microM) were capable of reversing the uterine activity to either higher than or the untreated level of contractility. CONCLUSIONS: This study demonstrates that glyceryl trinitrate is a potent uterine relaxant in vitro and that the tocolytic effect could be reversed with ease by oxytocics.
Dinoprost↗
Microvascular vasodilator response to acetylcholine is increased in women with pre-eclampsia.
OBJECTIVES: To evaluate in vivo microvascular responses to incremental doses of the endothelial-dependent vasodilator, acetylcholine, and the endothelial-independent vasodilator, sodium nitroprusside, in women with pre-eclampsia and gestation-matched normotensive pregnant controls. DESIGN: Prospective clinical study. SETTING: Southern Derbyshire Acute Hospitals Trust, and University of Nottingham Division of Vascular Medicine. POPULATION: Thirteen women with pre-eclampsia and 16 normotensive pregnant controls. METHODS: Cutaneous microvascular vasodilator responses to iontophoretic administration of incremental doses of acetylcholine and sodium nitroprusside (25-100 microC) were evaluated under temperature-controlled conditions using laser Doppler fluximetry. RESULTS: Resting skin temperature and blood flow were similar among 13 women with pre-eclampsia [mean blood pressure 151/93 mmHg (4/3); mean gestation 35.6 weeks (1.0); and mean proteinuria 1.1 g/24h (0.2)] and 16 normotensive pregnant controls [mean blood pressure 111/63 mmHg (2/2); mean gestation 34.3 weeks (0.9)]. Peak vasodilator responses to acetylcholine were increased in women with pre-eclampsia (median flux ratio 15.1 [IQR 12.3-17.6] vs 11.7 [IQR 8.4-12.6], P < 0.05), whereas sodium nitroprusside responses were not different between the two groups: 11.4 [IQR 8.6-13.4] vs 9.5 [IQR 8.0-12.3]. CONCLUSION: In vivo microvascular vasodilator responses to acetylcholine are increased in women with pre-eclampsia, while endothelial-independent vasodilation is unchanged. Although the mechanism of acetylcholine induced vasodilation in small vessels is unclear, this study confirms previous animal data and provides in vivo evidence of altered microvascular endothelial cell function in pre-eclampsia.
Acetylcholine↗
Potassium channels in the human myometrium.
The contractility of the human uterus is under the fine control of a variety of interacting bioactive agents. During labour, the excitability of the uterus is drastically transformed in comparison with the non-labour state and is manifest at the membrane level via the activity of uterine ion channels. This article reviews the contribution of potassium (K(+)) channels to human uterine excitability. Experimental Physiology (2001) 86.2, 255-264.
Adenosine Triphosphate↗
Intrapartum tocolysis has no effect on fetal lactate concentration.
OBJECTIVE: To assess the fetal metabolic effects of intrapartum maternal tocolysis with terbutaline in the presence of fetal heart rate abnormalities, with a special emphasis on lactate concentration, in view of its potential use as a marker of fetal condition. DESIGN: Descriptive study. SETTING: Two labour wards, National University Hospital, Singapore, and Ostersund Hospital, Sweden. METHODS: Eight parturients with abnormal intrapartum fetal heart rate recordings were given bolus i.v. injection of 0.25 mg terbutaline and monitored both before and 20 minutes after treatment. RESULTS: Maternal venous glucose increased from 5.0 (0.9) (mean (SD)) to 5.6 (1.2) mmol/l (p=0.002) and fetal scalp blood glucose rose from 4.1 (1.8) to 4.7 (1.4) mmol/l (p=0.009) 20 minutes after the injection. No significant change was found in maternal or fetal lactate concentrations. CONCLUSION: Terbutaline tocolysis for "intrauterine resuscitation" does not affect fetal lactate concentration 20 minutes after treatment.
Acid-Base Equilibrium↗
Intrapartum fetal surveillance.
Intrapartum hypoxia was thought to contribute to the incidence of cerebral palsy, seizures and mental retardation. Electronic fetal monitoring was expected to prevent or reduce this incidence. Electronic fetal monitoring has a high false positive rate and fetal blood sampling, which is an invasive procedure, only allows an intermittent assessment. Efforts are being made to improve fetal heart rate analysis and clinical management. Fetal pulse oximetry, fetal electrocardiogram waveform analysis and the intermittent measurement of lactate levels by fetal blood sampling may become established as an adjunct to electronic fetal monitoring.
Cardiotocography↗
Intrapartum fetal pulse oximetry. Part I: Principles and technical issues.
UNLABELLED: Fetal pulse oximetry has been advocated as a means of improving the specificity of cardioto-cography in intrapartum fetal surveillance. The objective of this article, the first of two reviewing the current literature on fetal pulse oximetry, is to discuss the principles of this new and evolving technology, its development, and the various factors that can affect its readings during fetal monitoring. It serves as a prelude to the second article, which profiles the clinical application of fetal pulse oximetry. Literature pertaining to this topic was selected from a MEDLINE search from 1965 through September 1999, with additional sources obtained through cross-referencing. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians LEARNING OBJECTIVES: After completion of this article, the reader will be able to explain the principles of fetal pulse oximetry, and describe the factors that affect the calibration of fetal pulse oximeters and the factors that affect the fetal pulse oximeter readings.
Equipment Design↗
Intrapartum fetal pulse oximetry. Part 2: Clinical application.
UNLABELLED: Part II continues by discussing the clinical application of fetal pulse oximetry in intrapartum fetal surveillance as reviewed in the literature. It profiles the predictive ability of fetal pulse oximetry and its correlation with conventional methods of fetal monitoring. In addition, an account is made of its limitations, safety, and acceptability in clinical practice. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians LEARNING OBJECTIVES: After completion of this article, the reader will be able to describe the predictive abilities of fetal pulse oximetry and its correlation with conventional methods of fetal monitoring, to define the critical threshold of fetal oxygen saturation, and to summarize the safety of fetal pulse oximetry.
Equipment Safety↗
Intrapartum fetal oxygen saturation monitoring in a busy labour ward.
OBJECTIVE: To measure the ease of use of a fetal pulse oximeter in a busy labour ward. DESIGN: Descriptive study in the Labour Ward, National University Hospital, Singapore, involving 145 labouring women with singleton pregnancies, and fetuses in cephalic presentation, with cervical dilatation >2 cm and amniotic membranes ruptured. RESULTS: Placement was comfortable. Oxygen saturation (SpO2) readings were obtained in 127 women (87.5%). Adequate readings were obtained a median of 69% of the time the transducer was in situ. SpO2 values in the last 10 min prior to delivery correlated poorly with parameters of neonatal outcome. CONCLUSION: The Nellcor N-400 fetal pulse oximeter and FS14 fetal sensor is a feasible method of intrapartum fetal monitoring in a busy labour ward and is acceptable to labouring women.
Female↗
Sexual dysfunction related to antihypertensive agents: results from the animal model.
The present investigation elucidates the deleterious effects of three prototypical antihypertensive drugs namely, propranolol, clonidine and captopril on the erectile physiology. In order to delineate the direct drug effects from vascular insufficiency inherent in hypertensive states, the study was conducted on a normotensive animal model. The adverse effects of these drugs were estimated as changes in sexual behaviour and intracavernous pressure response of electrical stimulation in the treated rats compared to normal age-matched controls (n = 10, each group). Copulation studies indicated significant impairment of sexual function in the groups on propranolol and clonidine. The cavernous pressure response to nerve stimulation at the end of sixteen weeks further reinforced the gross compromise on sexual function in these two treated groups. In contrast, the captopril administration produced only marginal alterations to the responses recorded. The results from this study clearly indicate that propranolol and clonidine interfere with sexual behaviour and nerve mediated response to erection whereas captopril which is devoid of significant effects on these parameters, may be a better therapeutic option.
Animals↗
Elevated low-density lipoprotein cholesterol (LDL-C) enhances pro-erectile neurotransmission in the corpus cavernosum.
Hypercholesterolaemia is thought to foster atherosclerosis and impotence through its effects on vascular endothelium. In this study, we investigated the pharmacological changes in rabbit corpus cavernosum (CC) secondary to incubation with lysolecithin and hypercholesterolaemia. A daily egg yolk dietary supplement induced gross hypercholesterolaemia in our rabbits. Group A of test animals (n-12) was fed with the yolk content of single egg and group B (n-6), that from two eggs for eight weeks. Serum level estimation revealed a progressive elevation of cholesterol to 15 and 30 times respectively, in the two treated groups as compared to values in the control group (n-6). Early histological manifestations of atherosclerosis were perceived as fat cell lesions in the cavernosum of treated animals. In vitro pharmacological studies on CC strips from both groups of test animals demonstrated a profound accentuation of the contractile responses to noradrenaline and histamine and attenuation of relaxant response to acetylcholine. However, in contrast to single-egg treated group, which demonstrated a reduction in the relaxant response to electrical field stimulation (EFS), there was a marked and statistically significant potentiation of this nitrergic transmission, in the two-eggs group. Prior incubation of CC strips of normolipidaemic rabbits (n-7) with lysolecithin, reproduced similar exaggerated response to EFS. Therefore, from the results of our study, it is concluded that oxidised LDL or its major amphiphile lysolecithin, at some critical level or beyond, may be capable of reverting at least some of the adverse effects of hypercholesterolaemia on erectile function, through its mediating effect on nitrergic transmission.
Acetylcholine↗
Factors influencing recruitment and retention of academic staff in South-East Asia.
South-East Asia has a number of developing and developed countries. The economic standings of these countries are different and influence the number of staff in each academic department. The quantum of clinical work they are expected to perform and the remuneration vary enormously. The retirement age, facilities for research and criteria for promotion are different. The health care delivery system, the financial status and outlook of the universities also differ. These factors operate differently in the South-East Asian countries and determine the recruitment and retention of academic staff.
Asia, Southeastern↗
Psychosocial support or active management of labour or both to improve the outcome of labour.
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Female↗