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PubMed2006

Audit of the influence of body mass index on the performance of epidural analgesia in labour and the subsequent mode of delivery.

OBJECTIVE: To assess the influence of body mass index (BMI) on the performance of epidural analgesia in labour and the subsequent mode of delivery. DESIGN: A retrospective audit of prospectively collected quality assurance data. SETTING: The delivery suite of Leeds General Infirmary, Leeds, UK. This is a 4500-delivery teaching hospital unit. POPULATION: All women receiving epidural analgesia during labour in our unit between April 1997 and December 2005. METHODS: Epidural recipients were divided into BMI groups according to World Health Organization (WHO) categories and compared for indices of epidural performance and mode of delivery. MAIN OUTCOME MEASURES: Midwife and patient satisfaction scores with epidural analgesia, epidural resite rates, and mode of delivery. RESULTS: Data from 13 299 epidural recipients were analysed. Using WHO definitions, 22.8% were of normal body mass, 41.9% were overweight, 31.9% obese, and 3.4% morbidly obese. Epidurals were more likely to fail as BMI increased, as judged by midwife satisfaction scores (P < 0.001) and epidural resite rates (P < 0.01). This trend was not seen for maternal satisfaction scores using the WHO BMI categories. However, if women with BMI below 30 kg/m2 were grouped together, a significant trend was found (P < 0.01). BMI had no influence on vaginal instrumental deliveries, but caesarean section rates rose from 11.5% in women of normal BMI to 29.2% in the morbidly obese women (P < 0.001). CONCLUSIONS: Obesity increases the incidence of analgesic failure and the need for resite of epidurals. The caesarean section rate among epidural recipients increases dramatically as BMI rises.

Adolescent↗
PubMed2005

Impact of pregnancy on the function of transplanted kidneys.

INTRODUCTION: This study reviewed the course of pregnancies in terms of impact on renal function and delivery-related data among women who received kidney transplants in our unit. METHODS: We reviewed the medical records of women transplanted between 1982 and 2002 who became pregnant. We recorded the data of medical, obstetrical, and transplant-related complications, plasma creatinine levels, and blood pressures at baseline, delivery, and 12 months after delivery. RESULTS: Thirty women had 37 pregnancies. Immunosuppressive protocols included cyclosporine, ketoconazole, azathioprine, and prednisone in 22 patients or azathioprine and prednisone in 15. Renal function decreased significantly: mean creatinine levels at baseline, delivery, and after 1 year were: 1.19 +/- 0.38 mg/dL; 1.44 +/- 0.70 mg/dL; and 1.38 +/- 0.53 mg/dL, respectively (P = .023 and P = .004 vs baseline respectively). Systolic and diastolic blood pressures at delivery were higher than at baseline (134 +/- 19 and 86 +/- 14 mm Hg vs 126 +/- 21 and 79 +/- 13 mm Hg (P = .029 and P = .053, respectively). These values normalized 1 year later (128 +/- 21 and 80 +/- 16). Decreased use of antihypertensive drugs were the cause of poor blood pressure control (1.8 +/- 1.3 vs 0.9 +/- 0.7, P < .01). Blood pressure control improved following delivery. The most frequent complications were preeclampsia (18.9%), intrahepatic cholestasis (13.5%), and urinary tract infections (13.5%). There were five rejection episodes. Seven miscarriages took place and one mole. Eleven pregnancies were uncomplicated. CONCLUSION: Renal transplantation is the best treatment for fertile women with end-stage renal disease who want to become pregnant. However, pregnancy is risky for the mother, fetus, newborn, and allograft.

Blood Pressure↗
PubMed2003

[Factors associated with HIV risk perception among hospital postpartum women].

OBJECTIVE: To assess factors associated with perception of HIV infection risk among postpartum women admitted to charitable maternity hospitals. METHODS: The study sample comprised 384 postpartum women admitted to two charitable maternity hospitals in the city of São Paulo, Brazil. Data collection was carried out from January to March 2000. All women were interviewed 12 hours after delivery and data was collected on sociodemographics, STD/AIDS knowledge and attitudes (independent variables) and cultural issues (dependent variables), and "whether she considered herself at risk for HIV infection" (dependent variable). Statistical analysis was performed using Chi-square test and multiple logistic regression. RESULTS: Nearly 29% of postpartum women considered themselves at risk for HIV infection. They were single, had prior STD and believed "married men enjoy himself in the same way as single men do". Prevention and health maintenance behaviors were also identified. CONCLUSIONS: Women's knowledge on AIDS seems to affect their individual risk perception. Future HIV/AIDS prevention campaigns should be focused on increasing couples and adolescents' involvement.

Adolescent↗
PubMed2005

Crash emergency cesarean section: decision-to-delivery interval under 30 min and its effect on Apgar and umbilical artery pH.

PURPOSE: The objective of this study was to investigate the effect of decision-to-delivery interval of crash emergency cesarean section on Apgar and umbilical artery pH in a level-3 university hospital. MATERIALS AND METHODS: In a retrospective analysis, all women undergoing "crash" emergency cesarean section were evaluated. Emergency cesarean sections were performed in the delivery room. Data relating to indication, Apgar score, arterial cord pH, and time intervals between decision-to-deliver and actual delivery were collected retrospectively. RESULTS: All 109 crash emergency cesarean sections were performed within a decision-to-delivery time of 30 min. The median (with 10-90th percentile) time was 10 min (5-19). Thirty-three (30.3%) of the emergency cesarean sections had a gestational age below 32 weeks and 60 (55%) below 37 weeks. An abnormal fetal heart rate pattern was noted in most of the cases (91%). Prolapsed cord (21%) and placental abruption (20%) were the most frequent reasons for emergency cesarean section but in one-fourth (25.7%) no morphological reason could be identified. Very short decision-to-delivery times below 20 min were inversely correlated to fetal outcome, i.e., lower umbilical blood pH and Apgar scores (P < 0.01). CONCLUSION: The 30-min standard for the decision-to-delivery time interval set by Anglo-American countries may be a feasible guideline at least for level-3 hospitals. The 20-min interval set by the German Society of Gynecology and Obstetrics could not be achieved in all cases. The positive effect of very short intervals on neonatal outcome still needs to be proven.

Apgar Score↗
PubMed2006

A randomized controlled trial of acupuncture for initiation of labor in nulliparous women.

OBJECTIVE: To evaluate the utility of outpatient acupuncture for labor stimulation. METHODS: Nulliparous women at 39 4/7 weeks or greater with a singleton gestation and Bishop score of less than 7 were randomized to usual medical care (control group) versus usual care and three outpatient acupuncture treatments (acupuncture group). Each treatment consisted of eight needles applied to bilateral points LI4, SP6, UB31, and UB32. The primary outcome was time elapsed from the time of randomization to delivery. Secondary outcomes included rates of cesarean section and induction of labor. Medical records were abstracted for maternal demographic, medical, and delivery outcome data. A priori sample size calculation revealed that 56 women were required to detect a 72-hour difference in delivery time with a power of 83% and an alpha of 0.05. Student's t-test, Chi-square, and Kaplan-Meier statistics were used to compare groups. RESULTS: Fifty-six women were randomized and completed the study procedures. Race, age, gestational age, and cervical Bishop score were similar in both groups. Mean time to delivery occurred 21 hours sooner in the acupuncture group, but this difference did not reach statistical significance (p = 0.36). Compared to controls, women in the acupuncture group tended to be more likely to labor spontaneously (70% vs. 50%, p = 0.12) and less likely to deliver by cesarean section (39% vs. 17%, p = 0.07). Of women who were not induced, those in the acupuncture group were more likely to be delivered than the controls at any point after enrollment (p = 0.05). CONCLUSION: Acupuncture is well tolerated among term nulliparous women and holds promise in reducing interventions that occur in post-term pregnancies.

Acupuncture Therapy↗
PubMed1999

Diamond-shaped optical fiber delivery system.

OBJECTIVE: Physicians who use laser systems are looking for new fiberoptic delivery systems with better performance. We searched for a delivery system with high power and with a tip of high durability that may be reused many times. SUMMARY BACKGROUND DATA: The delivery systems currently found on the market can burn and break easily. The surgeon may either finish the surgery with a damaged delivery system, or have to switch to a new one during surgery, thus increasing the inconvenience and cost of the surgery. METHODS: Distal tips of fibers used with Nd:YAG and diode lasers have been shaped and polished according to their specific function, including excision, vaporization, and coagulation of tissue. RESULTS: We have developed several prototypes of optical fiber delivery systems, and in particular, we have developed a prototype of a delivery system, called the Diamond-Shaped Optical Fiber Delivery System, or Diamond. By making the tip of an optical fiber diamond shaped, we are able to obtain greater mechanical resistance than that of other delivery systems that were tested in our laboratory. In the Colorectal Unit, we applied it in surgical procedures such as perianal fistulectomy, hemorrhoidectomy, and excision of condilomata acuminata and pilonidal cyst and sinuses. During cutting and coagulating, the system performed well with no technical problems. CONCLUSIONS: A new delivery system (Diamond) gave satisfactory performance during surgical operations. Its main component, the diamond-shaped distal end, provided high durability and was reused many times, thus improving the quality of operations and reducing expenses greatly.

Biophysical Phenomena↗
PubMed2006

Costs of newborn care in California: a population-based study.

OBJECTIVE: We sought to describe the current costs of newborn care by using population-based data, which includes linked vital statistics and hospital records for both mothers and infants. These data allow costs to be reported by episode of care (birth), instead of by hospitalization. METHODS: Data for this study were obtained from the linked 2000 California birth cohort data. These data (n = 518,704), provided by the California Office of Statewide Health Planning and Development (OSHPD), contain infant vital statistics data (birth and death certificate data) linked to infant and maternal hospital discharge summaries. In addition to the infant and maternal hospital discharge summaries associated with delivery, these data include discharge summaries for all infant hospital-to-hospital transfers and maternal prenatal hospitalizations. The linkage algorithm that is used by OSHPD in creating the linked cohort data file is highly accurate. More than 99% of the maternal and infant discharge abstracts were linked successfully with the birth certificates. These data were also linked successfully with the infant discharge abstracts from the receiving hospital for 99% of the infants who were transferred to another hospital. The hospital discharge records were the source of the hospital charges and length-of-stay information summarized in this study. Hospital costs were estimated by adjusting charges by hospital-specific ratios of costs to charges obtained from the OSHPD Hospital Financial Reporting data. Costs, lengths of stay, and mortality were summarized by birth weight groups, gestational age, cost categories, and types of admissions. RESULTS: Low birth weight (LBW) and very low birth weight (VLBW) infants had significantly longer hospital stays and accounted for a significantly higher proportion of total hospital costs. The average hospital stay for LBW infants ranged from 6.2 to 68.1 days, whereas the average hospital stay for infants who weighed >2500 g at birth was 2.3 days. Overall, VLBW infants accounted for 0.9% of cases but 35.7% of costs, whereas LBW infants accounted for 5.9% of cases but 56.6% of total hospital costs. Although total maternal and infant costs were similar (approximately 1.6 billion dollars), the distribution of maternal costs was much less skewed. For infants, 5% of infants accounted for 76% of total infant hospital costs. Conversely, the most expensive 3% of deliveries accounted for only 17% of total maternal costs. CONCLUSIONS: The very smallest infants make up a hugely disproportionate share of costs; more than half of all neonatal costs are incurred by LBW or premature infants. Maternal costs are similar in magnitude to newborn costs, but they are much less skewed than for infants. Preventing premature deliveries could yield very large cost savings, in addition to saving lives.

California↗
PubMed2002

Current evaluation and future needs of a mental health data linkage system in a remote region: a Canadian experience.

Linking client data across care sectors and agencies is becoming essential to ensure continuity of care, evaluation, and planning of mental health services delivery. The Data Linkage System (DLS), a record-linked, client-based, mental health database in northwestern Ontario, was established in response to this need. It is a voluntary system currently used by 30 of 40 mental health programs. The study surveyed program administrators to determine the system's utilization, perceived value, and future needs regarding data collection. The survey results delineated the perceived usefulness of the DLS in a remote region. The findings will provide direction for continued development of the DLS.

Community Mental Health Services↗
PubMed1995

Cardiac enzymes in patients undergoing caesarean section.

Some of the changes reported in the ECG of parturients undergoing Caesarean section are suggestive of myocardial ischaemia. This study determined serum CK total and the isoenzyme CK-MB levels in 21 patients during and after Caesarean section under epidural anaesthesia. Twenty patients complained of chest pain, discomfort and pressure, while 12 had ST segmental depression. Although the total CK activity in ten patients was elevated, CK-MB activity in all patients was negative. The electrocardiographic changes were rate-related and occurred at the time pressure was placed upon the upper abdomen and lower thoracic cage by the surgeon to facilitate Caesarean delivery. The data from this study demonstrate that no myocardial injury as measured by CK-MB activity occurs in parturients undergoing Caesarean delivery despite the complaint of chest pain, discomfort and pressure, and ST changes in the ECG.

Abdomen↗
PubMed2002

Kinetics of the pregnancy-induced humoral and cellular immune response against the paternal HLA class I antigens of the child.

Pregnancy can prime the maternal humoral immune response against paternal human leukocyte antigens (HLA) of the child. Previous studies have reported that formation of antibodies against inherited paternal HLA is associated with the presence of primed cytotoxic T lymphocytes (CTLs) specific for these antigens. Recently, we reported that primed CTLs can persist for more than 10 years after pregnancy even if the antibodies have disappeared. In the present study we studied the kinetics of the pregnancy induced immune response of the T-cell and B-cell compartment. In 12 women, who had specific antibodies against the paternal HLA antigens of the child (child mismatch) at the time of delivery, we analyzed the CTLp frequencies against the paternal HLA antigens from the time of delivery up to 2 years after. The contribution of primed CTLs to these CTLp frequencies was tested by limiting dilution analysis in the absence and presence of monoclonal antibodies specific for CD8. In contrast to naïve CTLs, primed CTLs are resistant to CD8 antibodies. Disappearance of the antibodies was not associated with a decrease of the number of CTLp directed against the paternal antigens, towards which the antibodies were originally directed. However, in women where the antibodies disappeared, a decrease of primed child mismatch specific CTLs was found, whereas in women where the antibodies persist, the population of primed CTLs remained stable up to 2 years after delivery. Our data suggest a functional correlation between the T-cell and B-cell allorepertoire. Although the kinetics do not run completely in parallel, disappearance of the anti-HLA antibodies in the first 2 years after delivery is related with a decrease of primed child mismatch specific CTLs. These data may be relevant for transplantation of female recipients with historical, pregnancy-induced HLA alloantibodies.

Antibody Affinity↗
PubMed2002

A randomized trial of intrapartum analgesia in women with severe preeclampsia.

OBJECTIVE: To estimate whether the cesarean delivery rate differs between women with severe preeclampsia who receive intrapartum epidural analgesia versus patient-controlled intravenous opioid analgesia. METHODS: Women with severe preeclampsia at at least 24 weeks' gestation were randomly assigned to receive either intrapartum epidural (n = 56) versus patient-controlled intravenous opioid analgesia (n = 60), and each was administered by a standardized protocol. The sample size was selected to have 80% power to detect at least a 50% difference in the predicted intergroup cesarean delivery rates. Data were analyzed by intent to treat. RESULTS: Selected maternal characteristics and neonatal outcomes were similar in the two groups. The cesarean delivery rates in the epidural group (18%) and the patient-controlled analgesia group (12%) were similar (P =.35). Women who received epidural analgesia were more likely to require ephedrine for the treatment of hypotension (9% versus 0%, P =.02), but their infants were less likely to require naloxone at delivery (9% versus 54%, P <.001). Epidural analgesia provided significantly better pain relief as determined by a visual analogue intrapartum pain score (P <.001) and a postpartum pain management survey (P =.002). CONCLUSION: Compared with patient-controlled intravenous opioid analgesia, intrapartum epidural analgesia did not significantly increase the cesarean delivery rate in women with severe preeclampsia at our level III center, and it provided superior pain relief.

Adult↗
PubMed1979

[Indications for induction of labour beyond full term (author's transl)].

Reported in this paper are diagnosis, therapy, and results in the context of suspicion of overdue pregnancy of cases recorded between 1974 and 1977. The presumed data of delivery rather than the calculated date is taken for reference. That approach has been taken against the background of a high-accuracy determination scale which, in turn, is based on complete case history data and current findings. The intention has been widest possible limitation of the probability of having deliveries overdue by 14 days. Such overdue deliveries were reduced to 240 in 13,172 pregnancies (1.82 per cent) by using this approach. In that context, an unambiguous differentiation was made between testing for possible labour onset and induction of labour, the latter being defined as strictly indicated obstetric action for the unlimited purpose of complete childbirth. Absence of possible labour onset, 14 days beyond term, was an indication for induction of labour in 188 women. Peripartal and real perinatal mortality (one malformation) was zero in 240 cases. Acidosis, but not in advanced stage, was recorded from five per cent of the newborns. The risk now can be more conveniently calculated. In other words, it is more systematically taken in unavoidable cases, an aspect meeting not only the demand on efficient obstetric action but legal requirements, as well.

Female↗
PubMed1994

Preformulation studies with melanotan-II: a potential skin cancer chemopreventive peptide.

Melanotan-II (1) is a cyclic heptapeptide analogue of alpha-melanocyte-stimulating hormone (alpha-MSH) which tans the skin and is currently being evaluated for the prevention of sunlight-induced skin cancers. The dissociation constants of 1 were determined using potentiometric titration and ultraviolet spectrophotometry. The pKa1 (histidine) and pKa2 (arginine) were estimated to be 6.54 and 11.72, respectively. The apparent partition coefficient (PC) was measured at three pH values using both n-octanol and isooctane as the nonpolar phase. The PC(octanol) and delta log PC at pH 7.35 were 2.82 and 1.05, respectively. These data, together with the observance of a bioavailability of 4.6% in the rat, indicate that 1 may be a suitable candidate for oral delivery. The data presented here are useful in developing an appropriate dosage form for 1.

Amino Acid Sequence↗
PubMed1998

Systemic oxygen extraction during incremental exercise in patients with severe chronic obstructive pulmonary disease.

To determine if decreased systemic oxygen (O2) extraction contributes to the exercise limit in severe chronic obstructive pulmonary disease (COPD), 40 consecutive incremental cycle ergometer exercise tests performed by such patients, from which a "log-log" lactate threshold (LT) was identified, were compared to those of 8 patients with left ventricular failure (LVF) and 10 normal controls. Pulmonary gas exchange and minute ventilation were measured continuously and arterial blood gas tensions, pH, and lactate concentrations were sampled each minute. Cardiac output (Qc) was measured by first-pass radionuclide ventriculography. The systemic O2 extraction ratio (O2ER) was calculated as arterial - mixed venous O2 content difference (CaO2 - CvO2)/CaO2. Peak exercise O2 uptake (VO2peak) was markedly reduced in both COPD and LVF [41 (3) and 42 (3)% predicted, respectively], compared to controls [89 (2)% predicted, P < 0.0001 for each]. Similarly, the LT occurred at a low percentage of predicted maximal oxygen consumption in both COPD and LVF [25 (2) and 27 (3)%] compared to normals [46 (3)%, P < 0.0001 for each]. The systemic O2ER at peak exercise was severely reduced in COPD [0.36 (0.02)] compared to the other groups [P < 0.0001 for each], for whom it was nearly identical [0.58 (0.03) vs 0.63 (0.04), LVF vs control, P > 0.05]. In the COPD group, an early LT correlated with reduced systemic O2ER at peak exercise (r = 0.64, P < 0.0001), but not with any index of systemic O2 delivery. These data suggest that lactic acidemia during exercise in patients with severe COPD is better related to abnormal systemic O2 extraction than to its delivery and contributes to the exercise limit.

Acidosis, Lactic↗
PubMed1998

Maternal anthropometric factors and risk of primary cesarean delivery.

OBJECTIVES: This study examined absolute and proportional gestational weight gain and prepregnancy body mass index as predictors of primary cesarean delivery. METHODS: Data were derived from a prospective study of pregnancy outcome risk factors in 2301 women in greater New Haven, Conn, who had singleton deliveries by primary cesarean (n = 312) or vaginal delivery (n = 1989) and for whom height, prepregnancy weight, and weight gain were available. Women were divided into 4 body mass index groups (underweight, low average, high average, and obese) and further subdivided into 8 groups according to median proportional or absolute weight gain. RESULTS: Risk of cesarean delivery increased with increasing body mass index and gestational weight gain greater than the median for one's body mass index. Proportional weight gain was more predictive of cesarean delivery than absolute weight gain. Underweight women gaining more than 27.8% of their prepregnancy weight had a 2-fold adjusted relative risk of cesarean delivery. CONCLUSIONS: Proportional weight gain is an important predictor of cesarean delivery for underweight women; high body mass index is also predictive of increased risk.

Adult↗
PubMed1990

Private midwives: a new approach to family planning service delivery in Ghana.

Data on 134 private sector midwives who were educated and trained in family planning service delivery by the Ghana Registered Midwives' Association (GRMA) showed that, for most, the course was the first they had received since qualifying as a midwife. Four out of five of the new family planning clients served by these midwives were first time contraceptive users. Approximately 9% of the clients were men, most of whom requested condoms. While delivering women is still the main function of the maternity homes, it is clear that family planning services have come to represent an important element of the health care the midwives provide. A follow-up study of family planning acceptors found extremely encouraging continuation rates. In addition, a survey of the women that the midwives had delivered showed that the contraceptive prevalence rate among these women was higher than the national rate. Providing family planning services through private sector midwives has been shown to be a very successful approach in Ghana, and one that has the potential to become a pillar of the nation's overall family planning delivery programme. As several other countries in Africa also have active private sector health networks, this approach holds promise far beyond its initial success in Ghana.

Adolescent↗
PubMedDate not supplied

Relationship between endocervical canal length between 15-24 weeks gestation and obstetric history.

The object was to determine whether there is a correlation between the obstetric history and the ultrasonographically determined endocervical canal length between 15 and 24 weeks gestation. A retrospective cohort study was performed in singleton pregnancies of multigravidas with normal and abnormal obstetric histories. They underwent sonographic evaluation for the determination of the endocervical canal length between 15 and 24 weeks gestation. The shortest endocervical canal length measurements between 15 and 20 weeks and also between 21 and 24 weeks of gestation were recorded. An ultrasound diagnosis of cervical incompetence was defined as progressive shortening of the endocervical canal length to <2 cm or a single endocervical canal length measurement <2 cm. A multivariable general linear regression model was used to correlate the relationship between endocervical canal lengths at 15-20 weeks and 21-24 weeks gestation in the current pregnancy with the earliest gestational age at delivery of prior pregnancies. Chi-square test was used to determine the relationship between the development of an ultrasound diagnosis of cervical incompetence and the earliest gestational age at delivery of prior pregnancies. A total of 155 pregnancies were studied. The number of women according to the obstetric history categories were: 57 had delivered <24 weeks, 12 between 24 and 26 weeks, 16 between 27 and 32 weeks, 16 between 33 and 36 weeks, and 54 delivered > or =37 weeks. There was a significant correlation between the endocervical canal length measurements between 15-20 (P < 0.0001) weeks and 21-24 weeks (P < 0.0001) in the studied pregnancy and the earliest gestational age at delivery of prior pregnancies. A significant relationship between the ultrasound diagnosis of cervical incompetence and the obstetric history category (P = 0.0026) was observed. There were 36 cases of ultrasound diagnosed cervical incompetence with 91.7% (33/36) occurring in women who had a prior <27 weeks' gestation delivery. These data provide further evidence that cervical incompetence is a relative condition and not an "all or none" phenomenon. In addition, women with a prior delivery <30 weeks gestation should be followed with second trimester serial cervical sonography to rule out cervical incompetence.

Adult↗