Biomedical subjects
Publications and source records attributed to T F Baskett.
The origin of Naegele's rule to calculate the expected date of confinement is reviewed. It is possible that the rule has been misinterpreted, resulting in an earlier estimated date of delivery with implications for induction of labour for post dates pregnancy.
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OBJECTIVE: To compare two techniques of irrigation flow control with regard to risk of absorption of uterine irrigation fluid during operative hysteroscopy. METHODS: We compared two techniques of uterine irrigation fluid outflow management-passive gravity outflow and direct connection of the outflow to wall suction-in a randomized controlled trial involving 40 women undergoing hysteroscopic endometrial ablation. The amount of fluid absorbed by each subject was calculated, as were operating time, uterine size, and endometrial pharmacologic preparation. Endometrial thickness and operator view were graded visually by the surgeon. RESULTS: The median (range) amount of irrigation fluid absorbed was 450 mL (0-2300) in the group in which passive gravity outflow was used and 0 mL (700 mL excess outflow to 300 mL absorption) in the group in which direct connection of the outflow to wall suction was used (P < .001). None of the other variables that might have influenced uterine irrigation fluid absorption (operating time, uterine size, pharmacologic endometrial preparation, or endometrial thickness) differed between the two groups. CONCLUSION: Connecting the outflow of the uterine irrigation system to wall suction is a simple and effective method of reducing the risk of fluid absorption during endometrial ablation.
OBJECTIVE: To determine the level of near-miss maternal mortality and morbidity due to severe obstetrical complications or maternal disease in a tertiary maternity hospital. DESIGN: Retrospective review. SETTING: A free-standing maternity hospital delivering 5500 infants per year. METHODS: The information coded in the perinatal database concerning women who had required transfer for critical care to a general hospital was reviewed for the 14 year period 1980 to 1993. The complications necessitating transfer and the specialised consultants and services required were noted. RESULTS: Over 14 years there were 76,119 women delivered with two maternal deaths (2.6/100,000). Fifty-five women required transfer for critical care (0.7/1000). The main reasons for transfer were hypertensive disease (25%), haemorrhage (22%) and sepsis (15%). Transfer to an intensive care unit was required by 80%, and the remainder were transferred to specialised medical or surgical units. Twenty different specialist groups were consulted. The 55 patients spent 280 days in critical care and 464 days hospital after-care (mean 13 days, range 3-92). CONCLUSION: A review of near-miss maternal mortality helps delineate the continuing threats to maternal health and the type of support services most commonly required.
OBJECTIVE: To assess the efficacy of lignocaine spray during outpatient hysteroscopy in reducing the need for additional anesthesia and reducing the discomfort of the procedure. DESIGN: A randomized double-blind, placebo-controlled trial. SETTING: An undergraduate university teaching hospital in London. PATIENT(S): One hundred twenty patients undergoing outpatient hysteroscopy. INTERVENTION(S): Application of lignocaine spray to the cervix, cervical canal, and uterine cavity during outpatient hysteroscopy. MAIN OUTCOME MEASURE(S): The need to use additional anesthesia and the pain experienced at various steps of the procedure. RESULT(S): Women treated with active spray experienced significantly less pain when the cervix was grasped with a tenaculum at the start of hysteroscopy. There were no other significant differences in the outcome of hysteroscopy between the placebo and lignocaine groups, although there was a significant reduction in the use of additional anesthesia in both groups compared with historical controls. CONCLUSION(S): Lignocaine spray has beneficial effects on cervical but not uterine sensation. Pretreatment with either lignocaine or placebo seems to reduce the need for additional intracervical anesthesia during hysteroscopy.
OBJECTIVE: To evaluate a simplified protocol for pessary management. METHODS: Women with symptomatic pelvic organ prolapse who opted for pessaries were enrolled in a prospective simplified protocol for pessary management. After the initial pessary fitting, they were seen at 2 weeks for reexamination and thereafter at 3- to 6-month intervals. RESULTS: One hundred ten women (mean age 65 years) were enrolled, and 81 (74%) of them were fitted successfully with a pessary. Life-table analysis showed that 66% of those who used a pessary for more than 1 month were still users after 12 months and 53% were still users after 36 months. The severity of pelvic prolapse did not predict the likelihood of pessary failure except in cases of complete vaginal eversion. Patients complaining of stress incontinence were less likely to have a successful pessary fitting and more likely to opt for surgery. Current hormone use and substantial perineal support do not predict greater likelihood of pessary fitting success. No serious complications from using the pessary were observed in the study sample. CONCLUSION: Stringent guidelines calling for frequent pelvic examinations during pessary use can be relaxed safely. Pessaries can be offered as a safe long-term option for the management of pelvic prolapse.
OBJECTIVE: To determine the role of outpatient diagnostic hysteroscopy in patients with abnormal uterine bleeding (AUB) on hormone replacement therapy (HRT) and to contrast this with a control group of women presenting with postmenopausal bleeding. DESIGN: Comparative observational study. SETTING: Outpatient hysteroscopy clinic in a university hospital. PATIENTS: Three hundred ten patients undergoing outpatient hysteroscopy. INTERVENTIONS: Outpatient diagnostic hysteroscopy with endometrial biopsy when indicated. MAIN OUTCOME MEASURES: Hysteroscopic findings, need for cervical dilatation and local anaesthesia, correlation between hysteroscopy and histologic diagnosis. RESULTS: There were 157 (7.1%) patients with AUB on HRT and another 153 (6.9%) with postmenopausal bleeding out of 2,203 outpatient hysteroscopies. Hysteroscopy was successful in 97% and 92% of patients, respectively, and intrauterine pathology was diagnosed in 46.7% and 39.7% of these cases. Functional endometrium was noted significantly more often with HRT and endometrial atrophy with postmenopausal bleeding. Overall, local anesthesia was used in 126 (40.6%) and shown to be associated significantly with the need for cervical dilatation. Endometrial biopsy was attempted in 125 (80%) and 119 (78%) patients in the study and control groups, but was unsuccessful significantly more often with postmenopausal bleeding (38.7%) versus 16%). There were six cases of endometrial carcinoma, all in the control group. CONCLUSION: There is a high incidence of intrauterine abnormalities in women with menstrual symptoms while taking HRT, but the pathology differed from those with postmenopausal bleeding. As focal lesions are found commonly in such patients, their detection by diagnostic hysteroscopy should improve compliance with HRT as it would allow individualization of treatment.
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OBJECTIVE: To assess the antecedents of shoulder dystocia, the risk of recurrence, and the perinatal morbidity associated with the different maneuvers used for its management. METHODS: We conducted a 10-year (1980-1989) retrospective case record review of all instances of shoulder dystocia in a teaching maternity hospital. RESULTS: There were 254 cases of shoulder dystocia in 40,518 vaginal cephalic deliveries (0.6%), with 33 cases (13.0%) of brachial plexus palsy and 13 fractures (5.1%). There were no perinatal deaths attributable to shoulder dystocia. The risk of shoulder dystocia was increased with prolonged pregnancy (threefold), prolonged second stage of labor (threefold), mid-forceps deliveries (tenfold), and increasing birth weight. Of the maneuvers used to deal with shoulder dystocia, strong downward traction on the head was significantly correlated with brachial plexus palsy compared with other individual methods of delivering the shoulders. There was only one case of recurrent shoulder dystocia in 80 women having 93 cephalic vaginal deliveries after their original delivery coded with shoulder dystocia. CONCLUSION: Shoulder dystocia is not a reliably predictable event in labor. Although the risk of shoulder dystocia is increased with prolonged pregnancy, prolonged second stage of labor, increasing birth weight, and mid-forcepts delivery, the majority of cases occur without these risk factors. Strong downward traction on the head is associated with the greatest degree of neonatal trauma, whereas McRoberts maneuver has the least. The risk of recurrent shoulder dystocia is low.
To ascertain the perinatal mortality and morbidity in the second twin as related to its presentation and method of delivery, we reviewed the data on 578 sets of twins delivered from 1980 to 1987 and included 397 sets in whom both twins were greater than or equal to 1000 gm, without lethal anomalies, and in whom the first twin presented as a vertex. The perinatal outcome comparing twin A (all vertex) with twin B (vertex or nonvertex) with cesarean section or vaginal delivery was analyzed. No statistically significant difference in perinatal mortality or morbidity was found in comparing the nonvertex second twin delivered vaginally or by cesarean section. The one perinatal death and significant perinatal morbidity occurred in infants weighing less than 1500 gm or at less than 32 weeks' gestational age. It is concluded that vaginal delivery, irrespective of the position of the second twin, is valid in selected cases as long as fetal weight is greater than 1500 gm and the gestational age is greater than or equal to 32 weeks.
The Rh Programme of Nova Scotia was established in 1964 for the prevention and treatment of Rh(D) alloimmunization. The program's effectiveness in preventing the condition has been established previously. Because of increasing budget restraint in health care we decided to examine the cost-effectiveness of the program by comparing the cost of prevention (office administration fees, program staff salaries and the price of Rh immune globulin) with the cost of health care services required in addition to standard obstetric procedures and neonatal care in 80 cases of Rh(D) alloimmunization treated from 1982 to 1986. Neonatal intensive care accounted for 80.1% of the additional health care expenses; an extra 512 hospital days for such care constituted 65.7% of the total treatment expense. The cost per case prevented ($1495) was 2.7 times less than the cost per case treated ($3986).
Although many factors influence fetal movements, maternal perception of gross fetal movement appears to be an accurate reflection of fetal activity. Observation in humans and studies in animals indicate that the compromised fetus reduces its oxygen requirements by reducing activity. This fact has enabled perceived fetal movement to become a useful adjunctive test of fetal asphyxia in high-risk pregnancy. Its application to low-risk pregnancy has many attractions, particularly as approximately 50 per cent of stillbirths occur without obvious cause in normal pregnancies. Although studies suggest that such application would be beneficial, questions about acceptability, the burden of further testing precipitated by reports of diminished movement, and the perinatal implications of unwarranted early intervention need to be clarified before the universal application of fetal movement counting protocols can be recommended.
With improved neonatal care, biophysical assessment to detect fetal asphyxia is used increasingly at an earlier gestational age. We have tested five fetal biophysical variables: nonstress test, fetal breathing movements, fetal movements, fetal tone, and amniotic fluid volume 11,012 times in 5582 singleton fetuses in whom there was a normal perinatal outcome. The nonstress test and fetal breathing movements were more likely to be abnormal at 26 to 33 weeks' gestation compared with 34 to 41 weeks. The nonstress test, fetal breathing movements, fetal tone, and amniotic fluid volume were more likely to be abnormal at 42 to 44 weeks' gestation compared with 37 to 41 weeks. Fetal biophysical tests should be interpreted in relation to gestational age.
Antepartum assessment of 5034 high-risk pregnancies to predict perinatal death included five biophysical variables (nonstress test, fetal breathing movements, fetal movements, fetal tone, and amniotic fluid volume) which combined to form a biophysical profile score. We assessed 4148 fetuses within seven days of delivery. The ability of each variable to predict perinatal death was expressed as the likelihood ratio, which incorporates sensitivity and specificity into one number. The predictive ability was most accurate with fetal movement (likelihood ratio 48.1) and the combined biophysical profile score (likelihood ratio 51.0). The biophysical profile score was more likely to predict perinatal death due to asphyxia (seven of eight) than lethal anomaly (six of 19). The overall perinatal mortality was 7.6 per 1000 total births. The perinatal mortality rate was 1.0 for a normal biophysical profile score, 31.3 for an equivocal score, and 200.0 for an abnormal score. The false-negative rate for the biophysical profile score was 0.7 per 1000.
A program to reduce the incidence of erythroblastosis fetalis was started in Nova Scotia in 1964. Up to the end of 1984, 120 fetuses received 247 intrauterine transfusions. The survival rate was 45.6% in the first 10 years of the program and 66.7% in the next 11 years. For fetuses at or over 26 weeks' gestation the figures were 51.5% and 73.7% respectively. Postpartum prevention was started in 1968, with administration of Rh immune globulin (RhIG) to Rh-negative unimmunized women within 72 hours after the birth of an Rh-positive infant. Antepartum prevention, started in 1979, consisted of administration of RhIG at 28 weeks' gestation to Rh-negative unimmunized women. The effectiveness of the prevention program was evaluated by enumerating the known cases of Rh(D) alloimmunization in the province from 1982 to 1984: 55 cases were identified, a rate of 1.5 per 1000 births instead of the expected rate of about 10 per 1000.
Eighty patients with a Bishop score of less than or equal to 4 were randomly administered vaginal triacetin gel containing placebo or prostaglandin E2 in 1, 2, and 3 mg doses. Twelve to sixteen hours later, those not in labor underwent oxytocin induction. Increasing doses of prostaglandin were effective in ripening the cervix, and the higher doses were associated with significant success in inducing labor.
An 8-year (1975-1982) study of 26 cases of nonimmune fetal hydrops revealed the main causes to be: anomalies (11/26), tachyarrhythmias (4/26), and twin-to-twin transfusion (4/26). The perinatal mortality was 19/26 (76%). Based on this series, and a review of the literature, a plan for the antenatal diagnosis and management of these cases is outlined.
The application of the fetal biophysical profile score in the management of 2,400 high-risk pregnancies was assessed. The negative predictive value for normal perinatal outcome was not improved compared to single variable tests. The positive predictive value for abnormal perinatal outcome was improved. The overall perinatal mortality in 2,485 fetuses was 9.2 per 1,000. In the 1,980 fetuses with a normal biophysical profile score within 7 days of delivery, excluding lethal anomalies, the perinatal mortality was 1 per 1,000. Fetal movement counting is supported as the most valid and appropriate test for universal fetal screening.