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PubMed1999

Obstetric complications and the risk of schizophrenia: a longitudinal study of a national birth cohort.

BACKGROUND: Numerous epidemiological studies found an increased risk of schizophrenia among persons exposed to various obstetric complications. The underlying mechanisms are unknown. OBJECTIVE: To study specific risk factors, as well as sets of risk factors, representing 3 different etiologic mechanisms: (1) malnutrition during fetal life; (2) extreme prematurity; and (3) hypoxia or ischemia. METHODS: In this longitudinal cohort study, information in the National Birth Register was linked to the National Inpatient Register. We followed up 507516 children born between 1973 and 1977 with regard to a diagnosis of schizophrenia between 1987 and 1995 (238 cases). By record linkage, we also had access to data on psychiatric illness in the mother. Occurrence of schizophrenia was measured by the Mantel-Haenszel test and logistic regression. RESULTS: A number of specific risk factors were associated with an increased risk of schizophrenia. The relative risk (95% confidence interval) for preeclampsia was 2.5 (1.4-4.5); vacuum extraction, 1.7 (1.1-2.6); and malformations, 2.4 (1.2-5.1). In logistic regression models, we found that indicators of all 3 etiologic mechanisms were associated with increased point estimates of schizophrenia, although at lower risk levels. Preeclampsia, an indicator of fetal malnutrition, was the only risk factor with statistically significant increased risk after control for all potentially confounding factors. CONCLUSION: This study supports the theory of an association between obstetric complications and schizophrenia. Although preeclampsia was the strongest individual risk factor, there was evidence of increased risk associated with all 3 etiologic mechanisms.

Adult↗
PubMed1989

Nonaggressive obstetric management. An option for some fetal anomalies during the third trimester.

Nonaggressive obstetric management was used in 13 cases of anomalous fetuses during the third trimester. Criteria that define these anomalies are (1) a very high probability of a correct diagnosis and (2) either (a) a very high probability of death as an outcome of the anomaly diagnosed or (b) a very high probability of severe and irreversible deficit of cognitive developmental capacity as a result of the anomaly diagnosed. On the basis of two approaches to obstetric ethics, we defend the legitimacy of nonaggressive management of third-trimester pregnancies complicated by fetal anomalies that meet these criteria.

Beneficence↗
PubMed1991

Obstetrics and malpractice. Evidence on the performance of a selective no-fault system.

Most malpractice litigation in obstetrics could be replaced with an alternative insurance system based on "accelerated-compensation events," which are classes of medical injuries determined in advance by medical experts to be readily identifiable, normally preventable with good care, and nondistorting of medical decision making. This professionally derived system would help prevent injury and improve the resolution of injuries. Prior work on accelerated-compensation events was largely conceptual, so to study the likely effects of accelerated-compensation events, we applied the events to a large database of obstetrical malpractice claims. Results refute prior criticisms. Accelerated-compensation events (1) are definitely feasible to develop and apply, (2) would probably cover two thirds of currently paid claims and three quarters of indemnity dollars, (3) would likely involve substantial savings in time and expense per case, and (4) would probably not introduce an unmanageable number of large new claims.

Defensive Medicine↗
PubMed2006

Methods of repair for obstetric anal sphincter injury.

BACKGROUND: Anal sphincter injury during childbirth - obstetric anal sphincter injuries (OASIS) - is associated with significant maternal morbidity including perineal pain, dyspareunia and anal incontinence. Anal incontinence affects women psychologically and physically. Many do not seek medical attention because of embarrassment. The two recognised methods for the repair of damaged external anal sphincter (EAS): are end-to-end (approximation) repair and overlap repair. OBJECTIVES: To compare the effectiveness of overlap repair versus end-to-end repair following OASIS in reducing subsequent anal incontinence, perineal pain, dyspareunia and improving quality of life. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 January 2006), MEDLINE (January 1966 to 31 January 2006), EMBASE (January 1974 to 31 January 2006), SciSearch (January 1974 to 31 January 2006) and conference proceedings of obstetrics and gynaecology, surgery and coloproctology. SELECTION CRITERIA: Randomised controlled trials comparing different techniques of immediate primary repair of EAS following OASIS. DATA COLLECTION AND ANALYSIS: Trial quality was assessed independently by all authors. MAIN RESULTS: Three eligible trials, of grade A quality, involving 279 women, were included. There was considerable heterogeneity in the outcome measures, time points and reported results. Meta-analyses showed that there was no statistically significant difference in perineal pain (relative risk (RR) 0.08, 95% confidence interval (CI) 0.00 to 1.45, one trial, 52 women), dyspareunia (RR 0.62, 95% CI 0.11 to 3.39, one trial, 52 women), flatus incontinence (RR 0.93, 95% CI 0.26 to 3.31, one trial, 52 women) and faecal incontinence (RR 0.07, 95% CI 0.00 to 1.21, one trial, 52 women) between the two repair techniques at 12 months but showed a statistically significantly lower incidence in faecal urgency (RR 0.12, 95% CI 0.02 to 0.86, one trial, 52 women) and lower anal incontinence score (weighted mean difference -1.70, 95% CI -3.03 to -0.37) in the overlap group. Overlap technique was also associated with a statistically significant lower risk of deterioration of anal incontinence symptoms over 12 months (RR 0.26, 95% CI 0.09 to 0.79, one trial, 41 women). There was no significant difference in quality of life. AUTHORS' CONCLUSIONS: The limited data available show that compared to immediate primary end-to-end repair of OASIS, early primary overlap repair appears to be associated with lower risks for faecal urgency and anal incontinence symptoms. As the experience of the surgeon is not addressed in the three studies reviewed, it woudl be inappropriate to recommend one type of repair in favour of another.

Anal Canal↗
PubMedDate not supplied

Obstetric neuropraxia in the Nigerian African.

The results of a prospective study of 34 Nigerian women with obstetric neuropraxia (puerperal paresis of the lower limbs) seen at the University College Hospital, Ibadan, are presented. The height of 29 (84%) was under 62 in (1.58 m). All were younger than 45, and 41% (14) were primiparous. Lumbosacral plexus injury with a foot-drop was the most frequent presenting feature (88%), bilateral involvement was observed in 13 patients (38%), femoral neuropathy was observed in nine (26%) and the ankle tendon jerks were absent in 35%. Spastic paraparesis was not uncommon (15%). Results of electromyographic examination and determinations of conduction velocities were consistent with proximal neuropraxia of the lumbasacral trunk in many of them (88%). The presentation of the fetus was cephalic in 97% of the women. The major predisposing factor was prolonged labor. Among the complications associated with the neuropraxia were hydroureters above the pelvic brim and vesico- and rectovaginal fistulae. Perinatal mortality was high particularly with labor of more than 18 hours. Recovery from the neuropraxia was complete for 76% of the patients. It is concluded that direct pressure on the lumbosacral plexus and nerve trunks by the presenting fetal part is the major factor in the pathogenesis of obstetric neuropraxia encountered in Nigerians.

Adult↗
PubMed1979

Applications of real-time ultrasound in obstetrics: the linear and dynamically focused phased arrays.

Real-time ultrasound is a dynamic imaging technique that allows in utero orientation to the fetus. It permits rapid and efficient examination of fetal anatomy and provides a dynamic assessment of fetal well-being. The energy dissipation can be comparable to that in conventional ultrasonic B-mode scanning. We have used both linear and dynamically focused phased arrays for fetal examinations in conjunction with conventional gray scale B-mode scanners. The sophisticated phased-array real-time systems have demonstrated higher resolution and an improved gray scale as compared with the linear arrays. Applications of real-time ultrasound in obstetrics are discussed, and appropriate clinical examples are cited that illustrate the value of the technique for study of both normal and abnormal fetal development. We believe that this technique is the most sensitive method of detecting intrauterine fetal demise. The relative advantages and disadvantages of linear and dynamically focused phased arrays in obstetric evaluation are considered.

Abdomen↗
PubMedDate not supplied

Portable obstetrical ultrasound calculation and analysis using an inexpensive laptop microcomputer and simple basic program.

This paper describes the use of a commercially available inexpensive portable laptop microcomputer and a simple user-friendly software package that allows rapid, portable obstetrical ultrasound calculation in the reading room, delivery suite, office setting, or over the telephone. The program is written in BASIC and may be modified by the user. The programming philosophy is described and a variety of BASIC subroutines and formulae useful to the obstetrical sonologist are listed. All fetal parameter formulae are referenced.

Costs and Cost Analysis↗
PubMed1991

Quantification of training in obstetrical ultrasound: a study of family practice residents.

This study was done to determine how rapidly physicians in training could become competent in performing obstetrical ultrasound for the purposes of routine evaluations (i.e., the standard examination as defined by AIUM). The scan measurements and results of organ surveys of 12 family medicine residents were compared with the results obtained by faculty members experienced in obstetrical ultrasound. Residents rapidly became proficient in biometry. The mean menstrual age calculated from BPD, AC, HC, and FL differed from faculty values by 0.381 weeks after residents had performed 40 supervised scans. Organ survey success rates demonstrated similar high concordance between resident and faculty scans.

Faculty, Medical↗
PubMed2004

Oberlin's ulnar nerve transfer to the biceps motor nerve in obstetric brachial plexus palsy: indications, and good and bad results.

We present 7 children with obstetric brachial plexus palsy treated by transferring two motor fascicles out of the ulnar nerve to the biceps nerve. Three were male, and 4 were female. The left-side brachial plexus was affected in 4 patients, and the right side in 3 patients. All children had vaginal delivery; two of them presented with shoulder dystocia. The average birth weight was 4300 g (range, 3620-5500 g). Average age at time of operation was 16 months (range, 11-24 months). The indication for the operation was absent active elbow flexion with active shoulder abduction against gravity in 4 cases, and no biceps function and bad shoulder function in 3 cases. Oberlin's ulnar nerve transfer was done in 4 cases without brachial plexus exploration in those children with good shoulder function, and exploration of the brachial plexus was performed in the other 3 cases with bad shoulder function. The average follow-up was 19 months (range, 13-30 months). Five children had biceps muscle >or=M(3) with active elbow flexion against gravity, and 2 children had biceps muscle <M(3). We recommend Oberlin's ulnar nerve transfer for upper-type obstetric brachial plexus palsy in 1). breech delivery with avulsion of C5 and C6 nerve roots,) late presentation with good recovery of shoulder function, and 3). neuroma-in-continuity of the upper trunk with intraoperative good nerve conduction for the shoulder muscles, the same as preoperative good shoulder function but with no biceps action.

Brachial Plexus Neuropathies↗
PubMed2006

Secondary reanimation procedures in late obstetrical brachial plexus palsy patients.

The varying degrees of spontaneous reinnervation that occur in untreated obstetrical brachial plexus palsy leave characteristic deformities of the shoulder, elbow, forearm, wrist, and hand. Common sequelae are internal rotation and adduction deformity of the shoulder, elbow flexion contractures, forearm supination deformity, and lack of wrist extension and finger flexion. Early microsurgical reconstruction of the affected plexus leads to a more rewarding overall function of the upper arm, but residual deformities might appear later which are similar, although less serious, than those observed in untreated cases. Secondary procedures of the shoulder, elbow, forearm, and hand will improve the appearance and function of the upper extremity in late cases of obstetrical brachial plexus. Careful preoperative planning is mandatory and a multistage approach should be applied, depending on the type of palsy and the age of the patient.

Arm↗
PubMed2006

The extent of endosonographic anal sphincter defects after primary repair of obstetric sphincter tears increases over time and is related to anal incontinence.

OBJECTIVE: To describe and classify endosonographic obstetric sphincter defects at 1 week, 3 months and 1 year after primary repair, and to relate the endosonographic results to anal sphincter pressure and to symptoms of anal incontinence over time. METHODS: Forty-one women who had suffered a third- or fourth-degree perineal tear at delivery underwent anal endosonography and anal manometry 1 week, 3 months and 1 year after primary suture of the tear. The extent of the endosonographic defects was described using defect scores ranging from 0 (no defect) to 16 (maximal defect), the score taking into account the location and the longitudinal and circumferential extent of the defect. The women answered a questionnaire with regard to bowel function 1 and 4 years after delivery, the degree of incontinence being expressed as a Wexner score. RESULTS: Some 90% (37/41) of the women had endosonographic defects at 1 week, 3 months and 1 year. The endosonographic defect scores increased significantly between the first and second examinations and then remained unchanged. At 1 year there was a negative correlation between endosonographic sphincter defect score and sphincter pressure. At 1 and 4 years, 54% (22/41) and 61% (25/41) of the women, respectively, had a Wexner score >/= 1. There was a positive correlation between the endosonographic sphincter defect score at 1 week, 3 months and 1 year and the Wexner incontinence score at 1 and 4 years. The endosonographic sphincter defect score at 1 week was the variable that was most predictive of the Wexner score at 4 years (r = 0.48, P = 0.002). CONCLUSION: The higher the endosonographic sphincter defect score after primary repair of an obstetric sphincter tear the lower the sphincter pressure and the higher the risk of anal incontinence.

Adult↗
PubMed2003

Endoanal sonography in assessment of fecal incontinence following obstetric trauma.

OBJECTIVES: Fecal incontinence is a common, incapacitating and largely unrecognized medical problem and can be caused by various factors. Obstetric trauma is the most common cause of fecal incontinence secondary to trauma. We aimed to analyze the role of endoanal ultrasound in assessment of this type of fecal incontinence, and report the functional results of surgical treatment. METHODS: We reviewed the records of all 22 patients with fecal incontinence secondary to obstetric trauma who were evaluated by endoanal ultrasound and underwent surgical management in our department from April to 1997 to April 2002. Pre- and postoperative evaluation of the degree of incontinence was done using the incontinence score of Jorge and Wexner. RESULTS: The patients had a median age of 43 (range, 29-68) years. All had vaginal deliveries, five of which (22.7%) were instrumental. Most of the patients had total fecal incontinence (solids) with preoperative incontinence score values of 15-20 (median, 18). Endoanal ultrasound confirmed structural defects in the anterior external anal sphincter alone in 16 (72.7%) patients, and both anterior external and internal sphincter defects in six (27.3%) patients. A thinned perineal body was present in all patients. All patients received surgical treatment with overlapping sphincteroplasty and there was improvement of continence in 19 (86.4%) patients with postoperative incontinence score values between 4 and 0 (median, 2). CONCLUSIONS: Endoanal sonography is an accurate method for assessing sphincter anatomy, delineating both internal and external anal sphincters. Surgical treatment of sphincter defects is associated with good outcome.

Adult↗
PubMed2003

Results of endosonographic imaging of the anal sphincter 2-7 days after primary repair of third- or fourth-degree obstetric sphincter tears.

OBJECTIVES: To describe the endosonographic image of the anal sphincter 2-7 days after delivery in women who had undergone a primary repair of an obstetric sphincter tear. METHODS: Forty-eight women who had suffered a third- or fourth-degree sphincter tear at delivery and had undergone primary sphincter repair were examined with endoanal sonography 2-7 days after delivery. A score from 0 to 16 was used to describe the extent of the endosonographic defects, a score of 0 indicating no defect and a score of 16 a defect > 180 degrees involving the whole length and depth of the sphincter. Clinical information was retrieved from the delivery and operation records after the analysis of the ultrasound images and the classification of the sonographic defects had been completed. RESULTS: Clinically, 34 (71%) women had a partial third-degree tear, 11 (23%) had a total third-degree tear, and three (6%) had a fourth-degree tear. Forty-three (90%; 95% CI, 77-97%) women had sonographic defects, all hypoechoic. Twenty-three (54%) sonographic defects were confined to the proximal part of the anal canal and involved less than half of the length of the anal canal. Thirty (63%) defects were confined to the external sphincter. Five of nine women (56%) with an endosonographic sphincter defect score >/= 8 had undergone primary sphincter repair by a doctor in training vs. 9 of 39 women (23%) with an endosonographic sphincter score < 8 (P = 0.05), despite the fact that 86% (12/14) of the tears sutured by doctors in training were clinically partial third-degree tears vs. 65% (22/34) of those sutured by specialists (P = 0.15). Five (15%) of 34 women with a clinical partial third-degree tear had an endosonographic sphincter score >/= 8 vs. four (29%) of 14 with a clinical total third- or fourth-degree sphincter tear (P = 0.26). CONCLUSIONS: Most women (90%) with a clinical third- or fourth-degree obstetric sphincter tear have endosonographic sphincter defects if they are examined 2-7 days after primary repair. The extent of the endosonographic defects seems to be determined mainly by the surgical experience of the doctor performing the repair, and not by the clinical degree of the tear.

Anal Canal↗
PubMedDate not supplied

Cesarean section rates by type of maternity unit and level of obstetric care: an area-based study in central Italy.

BACKGROUND: The rate of cesarean section in the Lazio region of Italy is one of the highest in the Western world, 26.5%. In order to evaluate the effects of nonmedical factors on cesarean section, we examined its relationship to the characteristics of maternity units in the region. METHODS: We collected data from the birth certificates of 91,557 infants born to women residing in Lazio in 1988-1989 and classified all maternity units in the region by method of financing (public, semiprivate with arrangements with the national health service, and completely private) and level of obstetric care (unclassified and levels I,II, and III). The rates of cesarean section were examined for primiparous and multiparous women, taking into account birthweight, gestational age, fetal presentation, maternal age, and day of delivery. RESULTS: The adjusted odds ratio for cesarean section (with public units of level I taken as reference) was 1.06 (primiparous) and 1.22 (multiparous) for semiprivate maternity units and 1.59 (primiparous) and 1.52 (multiparous) for private units; it increased to 1.59 (primiparous) and 1.61 (multiparous) for unclassified semiprivate units and to 2.06 (primiparous) and 1.87 (multiparous) for unclassified private units. CONCLUSIONS: The rate of cesarean section was associated in the Lazio region with private payment for hospital care and with inadequate level of obstetric care. The latter factor is of particular concern and should be investigated elsewhere.

Adult↗
PubMed1984

The aetiological relationship between congenital torticollis and obstetrical paralysis.

A statistical study was done to determine the incidence of congenital torticollis. The aetiological relationship between torticollis and obstetrical paralysis was analysed in an attempt to clarify the possible cause of torticollis. There were forty-three cases of torticollis in the 2,160 babies delivered at the Otsu Red Cross Hospital from 1978 to 1981. The overall incidence of torticollis was 1.9%; 1.2% in cephalic presentations, 6.5% in double breech presentations, 4.2% in footling presentations and 34.0% in single (frank) breech presentations. In addition, forty-three cases of obstetrical paralysis treated in Kyoto University Hospital from 1961 to 1981 were reviewed. Torticollis was found in 26% of the cephalic presentations (6 out of 23) and in 80% of the breech presentations (16 out of 20) respectively. These findings suggest that a foetal posture with both the knees and the cervical spine extended seems to be closely related to the development of torticollis, which indicates that a direct cause may be stretching of the sternocleidomastoid muscle during delivery.

Breech Presentation↗
PubMed1990

Obstetric fecal incontinence. Role of pelvic floor denervation and results of delayed sphincter repair.

During the last five years, 37 patients with fecal incontinence because of childbirth have been investigated. Ages varied from 22 to 62 years and duration of symptoms from 0.3 to 26 years. Anal manometry was performed in all patients and electromyography was performed in 24 patients. Thirty patients underwent delayed sphincter repair. In all patients, a dehiscence was found anteriorly, bridged by scar tissue. Continence was restored in 25 patients (83 percent). Electromyography was performed postoperatively in patients who remained incontinent and who demonstrated severe denervation. All these patients had undergone previous sphincter repair. In seven patients, there were no signs of obstetric injury. Electromyography demonstrated severe denervation, but sphincter mapping did not demonstrate muscle discontinuity. Continence improved in four patients within one year as a result of reinnervation demonstrated by electromyography. The authors conclude that fecal incontinence after childbirth may be due to either obstetric rupture or denervation. Both disorders may coexist. Delayed sphincter repair gives excellent results provided that denervation is not present. Preoperative assessment with electromyography is mandatory.

Adult↗
PubMed1990

Manometric assessment of patients with obstetric injuries and fecal incontinence.

Anorectal manometry was performed with a multilumen continuously perfused catheter in nine women with fecal incontinence after vaginal delivery. All patients had a third-degree or fourth-degree perineal laceration. The median age was 30 (range, 24 to 38) years. Anal manometry revealed low resting and squeeze pressures with a mean pressure of 28.7 +/- 5.3 mm Hg (normal, 60 to 80 mm Hg) and 42.5 +/- 5.9 mm Hg (normal, 100 to 150 mm Hg), respectively. Seven of nine patients had specific anterior quadrant defects demonstrated by cross-sectional analysis of the sphincter. In addition, five patients had evidence of global defects of the sphincter or relatively low pressures in other portions of the sphincter. Follow-up manometric data were obtained in four patients after reconstruction of the sphincter and demonstrated a mean improvement of resting and squeeze pressures of 5.1 mm Hg and 16.0 mm Hg, respectively. Although specific anterior defects may be expected with the history of obstetric trauma, the presence of global defects of the sphincter was unexpected and may support the role of injury to the innervation of the musculature of the pelvic floor as a contributing cause of fecal incontinence after childbirth. Anal manometry provides a quantitative assessment of sphincter function and dysfunction and is an important part of the preoperative assessment of patients with fecal incontinence from obstetric injuries.

Adult↗
PubMed1999

Long-term cost of fecal incontinence secondary to obstetric injuries.

INTRODUCTION: Anal incontinence is eight times more frequent in females than in males because of injuries sustained at childbirth. The aim of the present study was to determine the long-term costs associated with anal incontinence related to obstetric injuries. METHODS: Sixty-three patients with anal incontinence caused by obstetric sphincter injuries answered questionnaires regarding previous treatments, symptoms, and use of protective products. Of the patients, 31 were treated surgically, 11 with biofeedback, 6 with a combination of surgery and biofeedback, and 15 conservatively. Treatments and their respective costs were obtained from patient records, patient questionnaires, billing database, and Health Care Financing Administration's 1996 inpatient database. Costs were expressed in 1996 dollars. RESULTS: The mean incontinence score changed from 26 at evaluation to 16 at follow-up (P < 0.001). The average cost per patient was $17,166. Evaluation and follow-up charges totaled $65,412, and physiologic assessment accounted for 64 percent of these costs. Treatment charges totaled $559,341, and physician charges accounted for 18 percent of these charges. CONCLUSIONS: Fecal incontinence after childbirth results in substantial economic costs, and treatment is not always successful. New treatment modalities, such as artificial bowel sphincter or dynamic graciloplasty, should be assessed to determine their cost-effectiveness.

Adult↗