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BMJ Open Mar 2019Obstetric anal sphincter injury (OASIS) occurs in 5%-7% of normal deliveries and increases with vacuum extraction (VE) to 12%-14% in nulliparous women in Sweden....
Lateral episiotomy versus no episiotomy to reduce obstetric anal sphincter injury in vacuum-assisted delivery in nulliparous women: study protocol on a randomised controlled trial.
INTRODUCTION
Obstetric anal sphincter injury (OASIS) occurs in 5%-7% of normal deliveries and increases with vacuum extraction (VE) to 12%-14% in nulliparous women in Sweden. Lateral/mediolateral episiotomy may reduce the prevalence of OASIS at VE in nulliparous women. The current use of episiotomy is restrictive. The protective effect and consequences are uncertain. This trial will investigate if lateral episiotomy can reduce the prevalence of OASIS and assess short-term and long-term effects.
METHODS AND ANALYSIS
This is a multicentre randomised controlled trial of lateral episiotomy versus no episiotomy in nulliparous women with a singleton, live fetus, after gestational week 34+0 with indication for VE. A lateral episiotomy of 4 cm is cut at crowning, 1-3 cm from the midline, at a 60° angle. The primary outcome is OASIS by clinical diagnosis analysed according to intention to treat. To demonstrate a 50% reduction in OASIS prevalence (from 12.4% to 6.2%), 710 women will be randomised at a 1:1 ratio. Secondary outcomes are pain, blood loss, other perineal injuries, perineal complications, Apgar score, cord pH and neonatal complications. Web-based questionnaires at baseline, 2 months, 1 and 5 years will be used to assess pain, incontinence, prolapse, sexual function, quality of life and childbirth experience. A subset of women will receive follow-up by pelvic floor sonography and pelvic examination. Mode of delivery and recurrence of OASIS/episiotomy in subsequent pregnancies will be assessed at 5 and 10 years using register data.
ETHICS AND DISSEMINATION
The trial is open for enrolment. The trial has received ethical approval from the Regional Ethical Review Board of Stockholm and full funding from the Swedish Research Council. Women are interested in participation. The predominant restrictive view on episiotomy may limit recruitment. Results are of global interest and will be disseminated in peer-reviewed journals and at international congresses.
TRIAL REGISTRATION NUMBER
NCT02643108; Pre-results.
Topics: Anal Canal; Episiotomy; Female; Humans; Obstetric Labor Complications; Perineum; Pregnancy; Pregnancy Outcome; Randomized Controlled Trials as Topic; Risk Factors; Vacuum Extraction, Obstetrical
PubMed: 30872546
DOI: 10.1136/bmjopen-2018-025050 -
BMC Pregnancy and Childbirth Mar 2023Robert's uterus is a rare congenital anomaly, characterized as an asymmetric septate uterus that has a blind hemicavity with unilateral menstrual fluid retention and a... (Review)
Review
BACKGROUND
Robert's uterus is a rare congenital anomaly, characterized as an asymmetric septate uterus that has a blind hemicavity with unilateral menstrual fluid retention and a unicornuate hemicavity connecting to the cervix unimpededly. Patients with Robert's uterus generally present with menstrual disorders and dysmenorrhea, and some may have reproductive problems as well, including infertility, recurrent miscarriage, preterm labor and obstetric complications. In this case, we describe a successful pregnancy implanted on the obstructed hemicavity and delivered a liveborn girl. Meanwhile, we highlight diagnostic and therapeutic difficulties in patients with atypical symptoms of Robert's uterus.
CASE PRESENTATION
A 30-year-old Chinese primigravida sought for emergency treatment at 26 weeks and 2 days of gestation because of preterm premature rupture of membranes (PPROM). At the age of 19, the patient was misdiagnosed with hyperprolactinemia and pituitary microadenoma for showing symptom of hypomenorrhea and was suspected to have a uterine septum in the first trimester. She was diagnosed with Robert's uterus at 22 weeks of gestation by repetitious prenatal transvaginal ultrasonography, which was subsequently confirmed by magnetic resonance imaging. At 26 weeks and 3 days of gestation, the patient was suspected to have oligohydramnion, irregular uterine contraction, and umbilical cord prolapse, and she expressed a strong will of saving the baby. Emergency cesarean delivery was performed and a small hole, together with several weak spots, was found at the lower and back wall of the septum of the patient. The treatment was effective and both the mother and the infant, who had an extremely low birth weight, were discharged in good health conditions.
CONCLUSIONS
Pregnancy in the blind cavity of Robert's uterus with living neonates is incredibly rare. In our case, the favorable outcome may result from the unusual hole found at the septum, which may play a role in communicating amniotic fluid between the two hemicavities so to keep the neonate alive. we highlight the importance of early diagnosis and pre-pregnancy treatment of this uterine malformation, and the timely termination of pregnancy, for improving birth quality and reducing mortality.
Topics: Adult; Female; Humans; Infant, Newborn; Pregnancy; Dysmenorrhea; Infertility; Pelvis; Urogenital Abnormalities; Uterus; Fetal Membranes, Premature Rupture; Magnetic Resonance Imaging; Ultrasonography
PubMed: 36978042
DOI: 10.1186/s12884-023-05541-5 -
Journal of Rehabilitation Medicine.... 2019To assess and describe the involvement of all speech subsystems, including respiration, phonation, articulation, resonance, and prosody, in an individual with cervical...
OBJECTIVE
To assess and describe the involvement of all speech subsystems, including respiration, phonation, articulation, resonance, and prosody, in an individual with cervical spinal cord injury.
METHODS
Detailed speech and voice assessment was performed that included Frenchay Dysarthria Assessment, cranial nerve examination, voice (per-ceptual and instrumental) and nasometric evalua-tion, and intelligibility and communicative effecti-veness.
RESULTS
Impaired respiratory and phonatory con-trol correlated with the physical impairment of C4 and C5 prolapsed intervertebral disc. Cranial nerve examination indicated nerve IX and XI pathology. Phonatory deficits such as imprecise consonants and mild sibilant distortions were apparent. Voice analysis revealed a hoarse, breathy voice with re-duced loudness and no problems with resonance. Reading and speaking rate was reduced, and over-all a mild reduction in communicative effectiveness was perceived.
CONCLUSION
Assessment of the speech subsystems produced a comprehensive picture of the patient's condition and impairments in one or more areas was identified. Treatment options to improve speech outcomes were provided.
PubMed: 33884123
DOI: 10.2340/20030711-1000022 -
Journal of Clinical Medicine Research Aug 2009This study is aimed to determine the clinical and radiological corellations of adult patients with Spinal Cord Injury Without Radiographic Abnormalities (SCIWORA).
BACKGROUND
This study is aimed to determine the clinical and radiological corellations of adult patients with Spinal Cord Injury Without Radiographic Abnormalities (SCIWORA).
METHODS
The study population consisted of all adult patients with suspected cervical spine injury. SCIWORA was defined as the presence of either no injury or a neural injury on Magnetic Resonance Imaging (MRI) in the absence of radiographic or Computed Tomographic (CT) Scan findings suggestive of trauma in patients with neurological deficit. Purely extra neural compressive lesions were excluded from the study.
RESULTS
Twelve of ninety seven (12.4%) patients had a neural injury on MRI with normal radiographs and CT scan. These included cord contusion in five cases, cord edema in five cases and cord hemorrhage in two cases. Ten patients were managed conservatively and two patients with disc prolapse were managed surgically. All patients showed at least one ASIA Impairment Scale (AIS) grade improvement and three patients (25%) recovered completely.
CONCLUSIONS
Parenchymal spinal cord injury is the single most important determinant in the long term outcome of adult SCIWORA patients. Cord hemorrhage has the worst prognosis and cord edema has the best. Longitudinal signal extension and associated extra neural injuries are also associated with poorer outcomes. Cases with purely neural injuries can be managed conservatively, but associated extra neural injuries, especially disc prolapse and ligamentous instability, warrant surgical management.
KEYWORDS
Post Traumatic Myelopathy; Spinal Cord Trauma; Computed tomography; Magnetic resonance imaging; SCIWORA.
PubMed: 22493651
DOI: 10.4021/jocmr2009.08.1256 -
BMJ Open Jun 2021This study aimed to evaluate the success rate of vaginal delivery, the reasons for unplanned caesarean delivery, the rate of umbilical cord prolapse and the risk of...
OBJECTIVE
This study aimed to evaluate the success rate of vaginal delivery, the reasons for unplanned caesarean delivery, the rate of umbilical cord prolapse and the risk of umbilical cord prolapse in twin deliveries.
DESIGN
Retrospective cohort study.
SETTING
Single institution.
PARTICIPANTS
This study included 455 women pregnant with twins (307 dichorionic and 148 monochorionic) who attempted vaginal delivery from January 2009 to August 2018. The following criteria were considered for vaginal delivery: diamniotic twins, cephalic presentation of the first twin, no history of uterine scar, no other indications for caesarean delivery, no major structural abnormality in either twin and no fetal aneuploidy.
RESULTS
The rate of vaginal delivery of both twins was 89.5% (407 of 455), caesarean delivery of both twins was 7.7% (35 of 455) and caesarean delivery of only the second twin was 2.9% (13 of 455). The major reasons for unplanned caesarean delivery were arrest of labour and non-reassuring fetal heart rate pattern. The rate of umbilical cord prolapse in the second twin was 1.8% (8 of 455). Multivariate analysis revealed that abnormal umbilical cord insertion in the second twin (velamentous or marginal) was the only significant factor for umbilical cord prolapse in the second twin (OR, 5.05, 95% CI 1.139 to 22.472, p=0.033).
CONCLUSIONS
Abnormal umbilical cord insertion in the second twin (velamentous or marginal) was a significant factor for umbilical cord prolapse during delivery. Antenatal assessment of the second twin's umbilical cord insertion using ultrasonography would be beneficial.
Topics: Delivery, Obstetric; Female; Humans; Pregnancy; Prolapse; Retrospective Studies; Twins; Umbilical Cord
PubMed: 34135046
DOI: 10.1136/bmjopen-2020-046616 -
Chinese Medical Journal Oct 2017Preterm premature rupture of membrane (PPROM) can lead to serious consequences such as intrauterine infection, prolapse of the umbilical cord, and neonatal respiratory...
BACKGROUND
Preterm premature rupture of membrane (PPROM) can lead to serious consequences such as intrauterine infection, prolapse of the umbilical cord, and neonatal respiratory distress syndrome. Genital infection is a very important risk which closely related with PPROM. The preliminary study only made qualitative research on genital infection, but there was no deep and clear judgment about the effects of pathogenic bacteria. This study was to analyze the association of infections with PPROM in pregnant women in Shaanxi, China, and to establish Bayesian stepwise discriminant analysis to predict the incidence of PPROM.
METHODS
In training group, the 112 pregnant women with PPROM were enrolled in the case subgroup, and 108 normal pregnant women in the control subgroup using an unmatched case-control method. The sociodemographic characteristics of these participants were collected by face-to-face interviews. Vaginal excretions from each participant were sampled at 28-36+6 weeks of pregnancy using a sterile swab. DNA corresponding to Chlamydia trachomatis (CT), Ureaplasma urealyticum (UU), Candida albicans, group B streptococci (GBS), herpes simplex virus-1 (HSV-1), and HSV-2 were detected in each participant by real-time polymerase chain reaction. A model of Bayesian discriminant analysis was established and then verified by a multicenter validation group that included 500 participants in the case subgroup and 500 participants in the control subgroup from five different hospitals in the Shaanxi province, respectively.
RESULTS
The sociological characteristics were not significantly different between the case and control subgroups in both training and validation groups (all P > 0.05). In training group, the infection rates of UU (11.6% vs. 3.7%), CT (17.0% vs. 5.6%), and GBS (22.3% vs. 6.5%) showed statistically different between the case and control subgroups (all P < 0.05), log-transformed quantification of UU, CT, GBS, and HSV-2 showed statistically different between the case and control subgroups (P < 0.05). All etiological agents were introduced into the Bayesian stepwise discriminant model showed that UU, CT, and GBS infections were the main contributors to PPROM, with coefficients of 0.441, 3.347, and 4.126, respectively. The accuracy rates of the Bayesian stepwise discriminant analysis between the case and control subgroup were 84.1% and 86.8% in the training and validation groups, respectively.
CONCLUSIONS
This study established a Bayesian stepwise discriminant model to predict the incidence of PPROM. The UU, CT, and GBS infections were discriminant factors for PPROM according to a Bayesian stepwise discriminant analysis. This model could provide a new method for the early predicting of PPROM in pregnant women.
Topics: Adult; Bayes Theorem; Case-Control Studies; Discriminant Analysis; Female; Fetal Membranes, Premature Rupture; Humans; Pregnancy; Real-Time Polymerase Chain Reaction; Risk Factors; Young Adult
PubMed: 29052561
DOI: 10.4103/0366-6999.216396 -
Taiwanese Journal of Obstetrics &... Sep 2012To investigate the incidence, management, and perinatal and long-term outcomes of term pregnancies with umbilical cord prolapse (UCP) at Mackay Memorial Hospital,...
OBJECTIVE
To investigate the incidence, management, and perinatal and long-term outcomes of term pregnancies with umbilical cord prolapse (UCP) at Mackay Memorial Hospital, Taipei, from 1998 to 2007.
MATERIALS AND METHODS
For this retrospective study, we reviewed the charts, searched a computerized birth database, and contacted the families by telephone to acquire additional follow-up information.
RESULTS
A total of 40 cases of UCP were identified among 40,827 term deliveries, an incidence of 0.1%. Twenty-six cases (65%) were delivered by emergency cesarean section (CS). Of the neonates, 18 had an Apgar score of <7 at 1 minute, 10 of these scores being sustained at 5 minutes after birth, and three infants finally died. Eleven UCPs occurred at the vaginal delivery of a second twin, and nine with malpresentation. All of the infants who had good perinatal outcomes also had good long-term outcomes. Poor perinatal outcomes occurred in cases where there was a delayed diagnosis, or an inability to carry out an emergency CS or a prompt vaginal delivery.
CONCLUSION
Early detection of UCP and expeditious delivery are crucial to good perinatal outcomes. An emergency CS remains the mainstream management. Multiparous women whose cervixes are nearly fully dilated and who are expecting babies relatively smaller than their elder brothers or sisters born vaginally may still have vaginal deliveries managed by well-experienced birth teams, with good perinatal outcomes. Otherwise, vaginal delivery is not recommended and CS is the wiser choice.
Topics: Adult; Apgar Score; Cesarean Section; Extraction, Obstetrical; Female; Fetal Distress; Follow-Up Studies; Humans; Incidence; Infant, Newborn; Intensive Care, Neonatal; Male; Obstetric Labor Complications; Pregnancy; Prolapse; Retrospective Studies; Risk Factors; Taiwan; Term Birth; Treatment Outcome; Umbilical Cord
PubMed: 23040920
DOI: 10.1016/j.tjog.2012.07.010 -
Malawi Medical Journal : the Journal of... Mar 2021Preventing prolongation of the decision-to-delivery interval (DDI) for emergency caesarean delivery (CD) remains central to improving perinatal health. This study...
BACKGROUND
Preventing prolongation of the decision-to-delivery interval (DDI) for emergency caesarean delivery (CD) remains central to improving perinatal health. This study evaluated the effects of the DDI on perinatal outcome following emergency CD.
METHODS
A prospective cross-sectional study involving 205 consenting women who had emergency CD at a tertiary hospital in Nigeria was conducted. The time-motion documentation of events from decision to delivery was documented; the outcome measures were perinatal morbidity (neonatal resuscitation, 5-minute Apgar score, neonatal intensive admission) and mortality. Data analysis was performed with IBM SPSS Statistics version 20.0, and <0.05 was considered significant.
RESULTS
The overall mean DDI was 233.99±132.61 minutes (range 44-725 minutes); the mean DDI was shortest for cord prolapse (86.25±86.25 minutes) and was shorter for booked participants compared with unbooked participants (207.19±13.88 minutes vs 249.25±12.05 minutes; =0.030) and for general anaesthesia compared with spinal anaesthesia (219.48±128.60 minutes vs 236.19±133.42 minutes; =0.543). All neonatal parameters were significantly worse for unbooked women compared with booked women, including perinatal mortality (10.8% vs 1.3%; =0.012). Neonatal morbidity increased with DDI for clinical indications, UK National Institute of Health and Care Excellence (NICE) and Robson classification for CDs; perinatal mortality was 73.2 per 1000 live births, all were category 1 CDs and all except one occurred with DDI greater than 90 minutes. Severe preeclampsia/eclampsia, obstructed labour and placenta praevia tolerated DDI greater than 90 minutes compared with abruptio placentae and umbilical cord prolapse. However, logistic regression showed no statistical correlation between the DDI and neonatal outcomes.
CONCLUSION
Perinatal morbidity and mortality increased with DDI relative to the clinical urgency but perinatal deaths were increased with DDI greater than 90 minutes. For no category of emergency CD should the DDI exceed 90 minutes, while patient and institutional factors should be addressed to reduce the DDI.
Topics: Adult; Apgar Score; Cesarean Section; Cross-Sectional Studies; Decision Making; Emergency Treatment; Female; Humans; Infant, Newborn; Nigeria; Perinatal Mortality; Physicians; Pregnancy; Pregnancy Outcome; Prospective Studies; Time Factors
PubMed: 34422231
DOI: 10.4314/mmj.v33i1.5 -
The Journal of Maternal-fetal &... Dec 2024In the present study, we sought to identify risk factors for umbilical cord prolapse (UCP) and adapt the multidisciplinary team (MDT) first-aid simulation training for...
OBJECTIVE
In the present study, we sought to identify risk factors for umbilical cord prolapse (UCP) and adapt the multidisciplinary team (MDT) first-aid simulation training for UCP patients. We evaluated the usefulness of the MDT first-aid simulation by comparing delivery outcomes for UCP patients before and after its implementation.
MATERIAL AND METHODS
A retrospective review was conducted on 149 UCP cases (48 overt and 101 occult) and 298 control deliveries that occurred at the Third Affiliated Hospital of Sun Yat-sen University from January 1998 to December 2022. Patient data were compared between the groups. One-way analysis of variance (ANOVA) was used for means comparison, and the chi-square test was used for categorical data. Univariate and multivariate logistic regression analyses were performed to identify factors significantly associated with UCP.
RESULTS
Overt UCP was strongly associated with all adverse delivery outcomes. Both univariate and multivariate analyses identified multiparity, breech presentation, polyhydramnios, and low birth weight as independent risk factors for overt UCP (all odds ratios [OR] > 1; all < 0.05). Preterm labor and abnormal placental cord insertion were identified as independent risk factors for occult UCP (all OR > 1; all < 0.05). After 2014, when obstetrical staff received MDT first-aid simulation training, patients with overt UCP experienced shorter decision-to-delivery intervals due to more timely cesarean sections. They also had higher Apgar scores at 1, 5, and 10 min, and lower admission rates to the neonatal intensive care unit compared to patients before 2014 (all < 0.05).
CONCLUSION
MDT first-aid simulation training for overt UCP can improve neonatal outcomes. However, medical simulation training efforts should initially focus on the early identification of risk factors for both overt and occult UCP.
Topics: Humans; Female; Prolapse; Retrospective Studies; Pregnancy; Risk Factors; Simulation Training; Umbilical Cord; Infant, Newborn; Adult; Patient Care Team; Case-Control Studies; Pregnancy Outcome; Obstetric Labor Complications
PubMed: 38735870
DOI: 10.1080/14767058.2024.2352088 -
Stem Cell Research & Therapy Jul 2021Current surgical therapies for pelvic organ prolapse (POP) do not repair weak vaginal tissue and just provide support; these therapies may trigger severe complications....
BACKGROUND
Current surgical therapies for pelvic organ prolapse (POP) do not repair weak vaginal tissue and just provide support; these therapies may trigger severe complications. Stem cell-based regenerative therapy, due to its ability to reconstruct damaged tissue, may be a promising therapeutic strategy for POP. The objective of this study is to evaluate whether mesenchymal stem cell (MSC) therapy can repair weak vaginal tissue in an ovariectomized rhesus macaque model.
METHODS
A bilateral ovariectomy model was established in rhesus macaques to induce menopause-related vaginal injury. Ten bilaterally ovariectomized rhesus macaques were divided into two groups (n=5/group): the saline group and the MSC group. Three months after ovariectomy, saline or MSCs were injected in situ into the injured vaginal wall. The vaginal tissue was harvested 12 weeks after injection for histological and biochemical analyses to evaluate changes of extracellular matrix, microvascular density, and smooth muscle in the vaginal tissue. Biomechanical properties of the vaginal tissue were assessed by uniaxial tensile testing. Data analysis was performed with unpaired Student's t test or Mann-Whitney.
RESULTS
Twelve weeks after MSC transplantation, histological and biochemical analyses revealed that the content of collagen I, elastin, and microvascular density in the lamina propria of the vagina increased significantly in the MSC group compared with the saline group. And the fraction of smooth muscle in the muscularis of vagina increased significantly in the MSC group. In addition, MSC transplantation improved the biomechanical properties of the vagina by enhancing the elastic modulus.
CONCLUSION
Vaginal MSC transplantation could repair the weak vaginal tissue by promoting extracellular matrix ingrowth, neovascularization, and smooth muscle formation and improve the biomechanical properties of the vagina, providing a new prospective treatment for POP.
Topics: Animals; Elastin; Female; Humans; Macaca mulatta; Mesenchymal Stem Cell Transplantation; Pelvic Organ Prolapse; Prospective Studies
PubMed: 34266489
DOI: 10.1186/s13287-021-02488-2