Biomedical subjects
Publications and source records attributed to A Bisits.
We present a case of renal abscess with perinephric and paranephric extension. Ultrasonography showed an intrarenal lesion. The extension into the perinephric and paranephric space was better defined on MRI.
OBJECTIVE: This study was undertaken to assess the effectiveness of glyceryl trinitrate (GTN) patches in comparison with beta2 sympathomimetics (beta2) for the treatment of preterm labor. STUDY DESIGN: A multicenter, multinational, randomized controlled trial was conducted in tertiary referral teaching hospitals. Women in threatened preterm labor with positive fetal fibronectin or ruptured membranes between 24 and 35 weeks' gestation were recruited and randomly assigned to either beta2 or GTN with rescue beta2 tocolysis if moderate-to-strong contractions persisted at 2 hours. Obstetric and neonatal outcomes were assessed. RESULTS: Two hundred thirty-eight women were recruited and randomly assigned, 117 to beta2 and 121 to GTN. On a strict intention-to-treat basis, there was no significant difference in the time to delivery using Kaplan-Meier curves (P = .451). At 2 hours, 27% of women receiving beta2 had moderate or stronger contractions compared with 53% in the GTN group (P < .001). This led to 35% of women in the GTN group receiving rescue treatment. If delivery or requirement for beta2 rescue are regarded as treatment failure, then a significant difference was observed between the 2 arms (P = .0032). There were no significant differences in neonatal outcomes. CONCLUSION: GTN is a less efficacious tocolytic compared with ss2 sympathomimetics.
Explore the source record for details and available documents.
OBJECTIVE: Fetal fibronectin bedside testing has been proposed as a diagnostic tool for the accurate diagnosis of preterm labor. The study objective was to determine whether the introduction of routine fetal fibronectin bedside testing affected costs and transfer rates from referral district hospitals to a tertiary obstetric hospital, as well as direct admissions to a tertiary referral hospital. STUDY DESIGN: We performed an 18-month prospective audit of fetal fibronectin use in 9 referral hospitals and one university maternal-fetal medicine unit. Data collected were delivery details and cervical dilatation at admission. Cost savings in terms of transport costs for patients with a negative fetal fibronectin result who were not transferred or admitted to the tertiary center were calculated for interhospital transfer (road ambulance or fixed-wing retrieval). RESULTS: One hundred fifty-one patients had a presumptive diagnosis of threatened preterm labor. Forty-five patients had a positive fetal fibronectin result and 106 had a negative fetal fibronectin result (3 with cervical dilatation >/=3 cm). Eleven (24%) patients with a positive fetal fibronectin result were delivered within 7 days, and 5 (5%) with a negative fetal fibronectin result were delivered within 7 days. One patient was delivered at 34 weeks, and the remaining patients were delivered at or after 36 weeks' gestation. All 3 patients with negative fetal fibronectin results with cervical dilatation of >/=3 cm were delivered within 5 days, leaving 2 (1.9%) patients (with closed cervices and negative fetal fibronectin results) being delivered 5 days after the fetal fibronectin testing. Ninety percent of the patients admitted to a referral hospital with threatened preterm labor who had a negative fetal fibronectin result were not transferred; thus an unnecessary transfer was avoided, with cost savings ranging from $30,297 for road and fixed-wing transport. CONCLUSION: A negative fetal fibronectin result is not helpful if cervical dilatation is present, and these patients should be treated as having a high risk of preterm delivery. The use of a fetal fibronectin test was associated with a 90% reduction in maternal transfer and can substantially reduce the costs and inconvenience associated with unnecessary transfer.
OBJECTIVE: Many women who have preterm labor have abnormally high plasma concentrations of the placental peptide corticotropin-releasing hormone and the fetal product alpha-fetoprotein in early pregnancy. This study was designed to evaluate the ability of these biochemical tests and a clinical risk factor score to prospectively discriminate pregnancies at high risk for preterm delivery. STUDY DESIGN: Eight hundred sixty women were studied prospectively from the early second trimester until delivery. A risk factor score for preterm delivery was calculated from the clinical history and maternal plasma corticotropin-releasing hormone and alpha-fetoprotein concentrations were measured by radioimmunoassay between 17 and 30 weeks' gestation. The risk factor score, corticotropin-releasing hormone concentration, and alpha-fetoprotein concentration for each woman were expressed as individual odds or likelihood ratios for preterm delivery and as a combined risk estimate derived from the 3 tests. RESULTS: Sixty women had preterm deliveries (n = 37 spontaneous labor, n = 23 planned deliveries), and these women had significantly higher concentrations of corticotropin-releasing hormone (median 1.92 multiples of the median) and alpha-fetoprotein (median 1.32 multiples of the median) than did women with term deliveries (median 1.00 multiples of the median, P <.001 for both tests), with these abnormalities being evident from early in the second trimester. The risk factor score was >/=10 in 28% of women with preterm delivery and 7% of women with term delivery. The combination of all 3 markers resulted in a higher detection rate and a higher positive predictive value than the risk factor score, corticotropin-releasing hormone concentration, or alpha-fetoprotein concentration alone, correctly discriminating 37% of women who would have preterm deliveries with a false-positive rate of 5%. The positive predictive value was also 37% (odds of being affected given a positive result were 1:1.7). CONCLUSIONS: The combination of measurement of maternal plasma corticotropin-releasing hormone and alpha-fetoprotein concentrations in the second trimester with risk factor scoring provides a more accurate indicator of the risk of preterm delivery than does risk factor scoring alone. This method of risk assessment may therefore be of use in targeting prevention strategies.
OBJECTIVE: We assessed the ability of maternal plasma corticotropin-releasing hormone measurements to predict preterm delivery in the setting of a pilot study comparing transdermal glyceryl trinitrate with standard beta-mimetic therapy for preterm labor and to determine the effect of these tocolytics on maternal plasma corticotropin-releasing hormone concentrations. STUDY DESIGN: Twenty-six consecutive patients with preterm labor were randomized to tocolytic treatment with transdermal glyceryl trinitrate (n=13) or intravenous albuterol (n=13). RESULTS: Plasma corticotropin-releasing hormone immunoreactivity levels were higher in women who were delivered within 7 days (41.4+/-13.5 pmol/L) than in those continuing to term (14.2+/-2.4 pmol/L, p=0.011) and were not altered by treatment. Two women in each of the treatment groups delivered within 7 days of the initiation of treatment, two women in the glyceryl trinitrate group were changed to albuterol because of persistence of contractions. Glyceryl trinitrate treatment was associated with significantly fewer maternal side effects. Neither treatment altered umbilical artery Doppler ultrasonographic findings. CONCLUSION: Transdermal glyceryl trinitrate is better tolerated than intravenous albuterol but may be no more efficacious than albuterol for the treatment of preterm labor. Biologic markers such as plasma corticotropin-releasing hormone levels may be an important method of identifying women at high risk of preterm delivery.
The objective of this study was to evaluate a pocket Doppler device (Multi Dopplex II) for the waveform analysis of umbilical artery systolic/diastolic (S/D) ratios and resistance index (RI). A prospective, paired study was undertaken in a perinatal ultrasound unit in a tertiary referral hospital. Forty-three high-risk pregnant women beyond 16 weeks' gestation had fetal umbilical artery flow velocity waveforms recorded with both Multi Dopplex II and duplex Doppler devices and the waveform analyses were calculated. The Multi Dopplex II falsely indicated absent diastolic flow in two cases and failed to produce a flow velocity waveform in the presence of maternal obesity, polyhydramnios and some cases of anterior placenta (n = 8). As well as this, the limits of agreement overall for both S/D ratio and RI were wide (for S/D ratio, -1.6 to 2.2 and for RI, -0.20 to 0.20). Even though the levels of agreement were better for the third trimester (for S/D ratio, -0.8 to 1.1 and for RI, -0.10 to 0.20), we concluded that the limits of agreement were too wide for clinical use.
The use of single-dose intramuscular methotrexate for the primary treatment of ectopic pregnancy is increasing in frequency in many countries. We performed a systematic review of all available studies and case reports of intramuscular methotrexate to examine the therapeutic efficacy, side-effects and complication rates of this new treatment approach. The pooled data show a successful resolution rate of 71% (95% confidence interval 58% to 81%) after a single dose of intramuscular methotrexate and 84% (95% confidence interval 77% to 90%) after 1 or 2 doses. Side-effects were experienced by 24% (95% confidence interval 9% to 47%) of patients and 10% (95% confidence interval 7% to 14%) had a ruptured ectopic pregnancy. The pooled data show that single-dose intramuscular methotrexate is associated with a high failure rate. Follow-up is prolonged and there is a significant incidence of minor side-effects. Serious complications and side-effects have occurred. The use of intramuscular methotrexate should be confined to clinical trials until more evidence is obtained to support its more widespread use.
There is a widespread belief that salpingostomy is the treatment of choice for ectopic pregnancy. The ability to treat most ectopic pregnancies via a laparoscopic approach has been a major advance in gynaecological surgery. Despite the well publicized benefits of laparoscopy over laparotomy only 50% of patients with ectopic pregnancies in Australia presently benefit from this surgical advance. Although it is clear that laparoscopic treatments are preferable to laparotomy there is no consensus on whether salpingectomy or salpingostomy should be performed, despite over 40 years of research since the introduction of conservative tubal treatment. A systematic review of laparoscopic surgical treatment is needed and could be incorporated into the Cochrane Collaboration. A prospective clinical study, with long-term follow-up, needs to be performed to evaluate fertility prognosis and complications after laparoscopic salpingectomy versus salpingostomy.
We report the existence of a 'placental clock', which is active from an early stage in human pregnancy and determines the length of gestation and the timing of parturition and delivery. Using a prospective, longitudinal cohort study of 485 pregnant women we have demonstrated that placental secretion of corticotropin-releasing hormone (CRH) is a marker of this process and that measurement of the maternal plasma CRH concentration as early as 16-20 weeks of gestation identifies groups of women who are destined to experience normal term, preterm or post-term delivery. Further, we report that the exponential rise in maternal plasma CRH concentrations with advancing pregnancy is associated with a concomitant fall in concentrations of the specific CRH binding protein in late pregnancy, leading to a rapid increase in circulating levels of bioavailable CRH at a time that coincides with the onset of parturition, suggesting that CRH may act directly as a trigger for parturition in humans.
Female sterilization as an interval, postabortal or postpartum procedure, is one of the most widely employed contraceptive techniques on a global basis. The short-term complications of sterilization, which include intra- and extrauterine pregnancies, are well researched and documented. The figures for long-term complications, including ectopic pregnancy, are much less reliable as the follow-up rates diminish as time passes after sterilization. Three cases of tubal pregnancy that occurred long after interval sterilization are presented as a warning against the assumption that long-term complications cannot occur.
The objective of this report was to undertake an overview of the clinical utility of umbilical Doppler ultrasound in the management of high-risk pregnancies. The study is designed as a formal meta-analysis of 6 randomised trial reports selected by predetermined criteria and was performed at the Division of Reproductive Medicine, Newcastle University, Australia. A total of 6 randomised controlled trials amounted to 2,102 patients in the experimental (Doppler) group and 2,133 patients in the control group. All patients had high-risk pregnancies. The management of pregnancies with Doppler was compared to those with standard obstetric management (i.e. excluding Doppler). Main outcome measures were perinatal mortality in the form of intrauterine deaths as well as obstetric performance indicators including caesarean section, elective delivery, fetal distress in labour, antenatal admissions and admissions to Neonatal Intensive Care Unit. The meta-analysis shows a significant reduction in perinatal mortality in the groups in which Doppler was used. Typical odds ratio was 0.5 [95% confidence intervals (CI) 0.34, 0.73]. The specific reduction in perinatal mortality occurred in intrauterine deaths in otherwise normally formed fetuses. The typical odds ratio was 0.54 with 95% CI 0.32, 0.89. This meta-analysis shows a significant reduction in overall perinatal mortality, specifically in the form of intrauterine deaths in otherwise normally formed babies.