Fetal echocardiography: are we getting it right?

Objective To determine the diagnostic accuracy of prenatal fetal echocardiography. Methods The study was a retrospective chart review of 190 consecutive patients over a 3-year period from November 1998 to February 2002 of all women referred to the Maternal Fetal Medicine unit, Mater Mothers Hospital, for fetal echocardiography. The prenatal diagnosis was compared with the postnatal diagnosis made by postnatal echocardiography, surgical findings or post-mortem. The accuracy of prenatal diagnosis was described on a predetermined 4-point scale. Results Of the 89 patients, for whom complete diagnostic follow-up was available, there was complete agreement between the prenatal and postnatal diagnosis in 63 cases, minor discrepancies in 25 cases and major disagreement in 1 case. Conclusions In experienced hands, fetal echocardiography is accurate and allows medical staff and patients information in order manage a pregnancy appropriately. Copyright (C) 2004 John Wiley Sons, Ltd.

Determining the fetal scalp lactate level that indicates the need for intervention in labour

Background: Fetal scalp lactate testing has been shown to be as useful as pH with added benefits. One remaining question is What level of lactate should trigger intervention in the first stage of labour?' Aims: This study aimed to establish the lactate level in the first stage of labour that indicates the need for intervention to ensure satisfactory outcomes for both babies and mothers. Methods: A prospective study at Mater Mothers' Hospital, Brisbane, Australia, a tertiary referral centre. One hundred and forty women in labour, with non-reassuring fetal heart rate traces, were tested using fetal blood scalp sampling of 5 mu L of capillary blood tested on an Accusport (Boeringer, Mannheim, East Sussex, UK) lactate meter. Decision to intervene in labour was based on clinical assessment plus a predetermined cut off. Main outcome measures were APGAR scores, cord arterial pH, meconium stained liquor and Intensive Care Nursery admission. Results: Two-graph receiver operating characteristic (TG-ROC) analysis showed optimal specificity, and sensitivity for predicting adverse neonatal outcomes was a scalp lactate level above 4.2 mmol/L. Conclusions: Fetal blood sampling remains the standard for further investigating-non-reassuring cardiotocograph (CTG) traces. Even so, it is a poor predictor of fetal outcomes. Scalp lactate has been shown to be at least as good a predictor as scalp pH, with the advantages of being easier, cheaper and with a lower rate of technical failure. Our study, found that a cut off fetal scalp lactate level of 4.2 mmol/L, in combination with an assessment of the entire clinical picture, is a useful tool in identifying those women who need intervention.

Prevalence of rectocele in young nulliparous women

Background: It is generally assumed that fascial defects in the rectovaginal septum are the result of childbirth. However, rectoceles do occur in women who have never delivered vaginally. Aims: To determine the incidence of rectocele in a cohort of asymptomatic, young nulliparous women. Methods: Observational cohort study on 178 nulliparous caucasian women (aged 18-24) recruited for a twin study of pelvic floor dysfunction. All women were interviewed and examined by translabial ultrasound, supine and after voiding. In 52 women, 3D imaging was obtained and 171 datasets were complete and available for analysis. Ultrasound findings were reviewed for rectovaginal septal integrity by an assessor blinded against interview and demographic data for rectovaginal septal integrity. Results: A discontinuity of the anterior rectal wall with extrusion of rectal mucosa or contents (depth of ! 10 mm) was observed in 21/171 (12%). The depth of this herniation ranged from 10 to 25 mm and was filled with stool (n = 10) or rectal mucosa (n = 11). Defects were associated with a higher BMI (P = 0.049), with the complaint of constipation (P = 0.049) and non-significantly with straining at stool (P = 0.09). Descent of the ampulla to beyond the level of the symphysis pubis without fascial defect, that is, significant perineal relaxation, was observed in 23/171 (13%). Conclusions: Twelve percent of 171 young nulligravid caucasian women showed a defect of the rectovaginal septum. Associations were observed with higher body mass index and a history of constipation. It is hypothesised that in some women defects of the rectovaginal septum and perineal hypermobility may be congenital in nature.

Postoperative analgesic requirements - total laparoscopic hysterectomy versus vaginal hysterectomy

Background: There is limited information available on the requirement for postoperative analgesic drugs in patients submitted to total laparoscopic hysterectomy (TLH) compared with patients undergoing vaginal hysterectomy (VH). Aim: To compare the postoperative analgesic requirements in patients who underwent a TLH with patients who had a VH. Methods: Chart review of 53 patients who had TLH and 47 who had VH and were seen postoperatively by an acute pain management service in order to assess postoperative analgesic requirements. Patient controlled analgesia (PCA) was part of the standard protocol for postoperative pain management. Analgesic requirement was recorded as the mean doses of morphine and number of days that patients used non-steroidal anti-inflammatory drugs (NSAIDs), oxycodone and tramadol. Results: The requirement for total morphine was approximately half the dose in patients who had a TLH (10.8 +/- 12.6 mg) compared with patients who had a VH (19.4 +/- 21.9 mg) (P 0.017). The length of use of NSAIDs was significantly reduced in patients who had undergone a TLH (2.0 +/- 0.95 days) as compared with patients who had a VH (2.85 +/- 1.1 days) (P < 0.0001). Conclusions: Patients submitted to TLH require less postoperative analgesic drugs when compared with patients who had VH. Prospective randomised trials are warranted to compare analgesic requirements between patients submitted to TLH and VH.

Clinicians' evaluations of fetal oximetry sensor placement in a multicentre randomised trial (the FOREMOST trial)

Background: Fetal pulse oximetry (FPO) may improve the assessment of the fetal well-being in labour. Reports of health-care provider's evaluations of new technology are important in the overall evaluation of that technology. Aims: To determine doctors' and midwives' perceptions of their experience placing FPO sensors. Methods: We surveyed clinicians (midwives and doctors) following placement of a FPO sensor during the FOREMOST trial (multicentre randomised trial of fetal pulse oximetry). Clinicians rated ease of sensor placement (poor, fair, good and excellent). Potential influences on ease of sensor placement (staff category, prior experience in Birth Suite, prior experience in placing sensors, epidural analgesia, cervical dilatation and fetal station) were examined by ordinal regression. Results: There were 281 surveys returned for the 294 sensor placement attempts (response rate 96%). Sensors were placed by midwives (29%), research midwives (48%), registrars (22%) and obstetricians (1%). The majority of clinicians had 1 or more years' Birth Suite experience, had placed six or more sensors previously, and rated ease of sensor placement as good. Advancing fetal station (P < 0.001) and the presence of epidural analgesia prior to sensor placement (P = 0.029) predicted improved ease of sensor placement. Having a clinician placing a sensor for the first time predicted a lower rating for ease of sensor placement (P = 0.001), compared to having placed one or more sensors previously. Conclusions: Clinicians with varying levels of Birth Suite experience successfully placed fetal oxygen saturation sensors, with the majority rating ease of sensor placement as good.

Vitamin A supplementation for breastfeeding mothers (Protocol)

This is the protocol for a review and there is no abstract. The objectives are as follows: To assess the effects of vitamin A supplementation, alone or in combination with other micronutrients (e.g. iron, folic acid, vitamin E), in mothers during the postpartum period, on maternal and infant health. Specific objectives are to compare the effects of vitamin A supplementation (alone or in combination with other micronutrients) with placebo or no supplementation on: 1. the duration and occurrence of maternal morbidity (xerophthalmia, infection) or illness symptoms (night blindness, fever, nausea, vomiting); 2. the duration and occurrence of neonatal or infant morbidity (respiratory tract infection, diarrhea, measles) or illness symptoms (fever, nausea, vomiting); 3. maternal serum retinol concentration; 4. infant serum retinol concentration; 5. breast milk retinol concentration; and 6. maternal satisfaction.

A medical management of interstitial ectopic pregnancy: A 5-year clinical study

Background: Medical treatment of the rare interstitial ectopic pregnancy with methotrexate has been considered an alternative to surgical resection. Aim: To determine the treatment success rate with a single-dose intravenous methotrexate/folinic acid regimen and to identify predictors of treatment outcome. Methods: A 5-year audit (April 2000-August 2005) was carried out, collecting clinical imaging data and serum beta-human chorionic gonadotrophin (beta-hCG). Time taken for complete beta-hCG resolution was recorded, and a negative beta-hCG result was used as an endpoint of successful outcome. Results: Of the 13 cases, two required urgent surgery for rupture on presentation. In the remaining 11 cases, intravenous methotrexate (300 mg) was used, with oral folinic acid rescue (15 mg x 4 doses). There were no side-effects. Complete beta-hCG resolution was achieved in 10 of the 11 medically treated cases (91% success rate), requiring 21-129 days. Successful outcome was seen with initial beta-hCG level as high as 106 634 IU/L and gestation sac as large as 6 cm and a live fetus. Conclusion: The methotrexate/folinic acid regimen used as a one-dose treatment is safe and effective for unruptured interstitial pregnancy, with no side-effects and the advantage of avoiding invasive surgery. Subsequent tubal patency and reproductive function are yet to be ascertained.