Obstetrics

Methods Three hundred and twenty-eight IUGR fetuses (abdominal circumference < 5th percentile, elevated umbilical artery (UA) pulsatility index (PI)) had concurrent surveillance with UA, middle cerebral artery (MCA) and ductus venosus (DV) Doppler ultrasonography and BPS (fetal tone, movement, breathing, maximal amniotic fluid pocket and fetal heart rate). Patients were stratified into three groups according to their Doppler examination: (1) abnormal UA alone; (2) brain sparing (MCA-PI > 2 SD below mean for gestational age); and (3) abnormal DV (PI > 2 SD above the mean for gestational age) and BPS groups: (1) normal (> 6/10);

Purpose: To evaluate the efficiency of transvaginal ultrasound in the early diagnosis of ovarian cancer. Methods: Screening transvaginal ultrasound has been annually performed during the last 2 years in asymptomatic women without familial history of ovarian cancer. When abnormalities were detected, the procedure was repeated after 4-6 weeks. If the findings disappeared, the study was repeated after 1 year. If the abnormality persisted, study was complemented with tumor markers, computed tomography and laparoscopic surgery. The findings were compared with a control group of women in whom ovarian transvaginal ultrasonography was formally indicated. Results: A total of 26007 transvaginal ultrasound were performed: 8813 (33.8%) belonged to the screening group and 17194 (66.2%) to the control group. In 14 patients of the screening group, a malignant tumor was diagnosed and histologically confirmed. The mean age of these patients was 45 years old (SD 12). Eleven of these tumors were stage I (seven Ia, and four Ic), two stage IIIc and one was a metastatic melanoma in both ovaries. Six lesions were borderline tumors (five serous and one mucinous). In the control group, 27 ovarian cancers were diagnosed in patients with a mean age of 48 years (SD 17). In this group, 11 tumors were in stage I, and six were borderline. Conclusions: Although consensus about the benefits of using transvaginal ultrasound as a screening procedure is not conclusive, our data reveals that tumors detected in patients screened with transvaginal ultrasound are in earlier stages when compared with those diagnosed in the control group. No differences were found in age and number of borderline tumors between both groups. Additional studies are needed to support this preliminary findings.

A recent finding of the Confidential Enquiry on Maternal and Child Health (CEMACH) 1 was that maternal mortality is associated with risk factors such as increased maternal age (>35 years), obesity [body mass index (BMI) > 30], late booking and social disadvantage. In the 3-year period from April 2002, there were 10 maternal deaths at Northwick Park Hospital (NPH); due to this excessive number, the unit was investigated by the Health Care Commision 2 and placed under 'special measures' by the Department of Health until October 2006.

Summary. During the second pregnancy of 56 Swedish women resulting in a term birth, energy intake and physical activity were measured for 3 days at weeks 17 and 33. The values were related to maternal lean body mass, pregnancy weight gain, maternal fat accretion and infant birth-weight by multiple linear regression analyses. A significant regression coefficient was found for energy intake at week 17 on maternal fat accretion. Energy intake was not significantly correlated with infant birthweight, not even when physical activity and maternal lean body mass were taken into account. Thus in a well-nourished Swedish population, energy intake is positively related to maternal fat accretion but not to the birthweight of term infants.

We describe a case in which in-utero diagnosis of an esophageal atresia with a tracheo-esophageal fistula in the third trimester followed the finding of an increased nuchal translucency in the first trimester and suggest a mechanism by which these two findings might be associated.

Many world religions prescribe the practice of fasting—
abstaining from food and drink—and all cite situations in which individuals are exempt. Muslim women who breastfeed may observe the religious practice of fasting
during the Holy month of Ramadan, for 29 or 30 days. In Islam, this is called siyam, the refraining from food, drink, and sexual relations from just before dawn until the point of
sunset during Ramadan (Al Masri, 1997/1949). In this paper,  we offer a way to navigate the decision-making process to ascertain if siyam is negatively affecting the breastfeeding woman or infant, and propose some clinical management options.

The quality of both the programs and the literature that describe these programs has varied considerably. The purposes of this study were to evaluate the published literature that described computer-assisted instruction in medical education and to assess the quality of evidence for its implementation, with particular emphasis on obstetrics and gynecology. STUDY DESIGN: Reports published between 1988 and 2000 on computer-assisted instruction in medical education were identified through a search of MEDLINE and Educational Resource Identification Center and a review of the bibliographies of the articles that were identified. Studies were selected if they included a description of computer-assisted instruction in medical education, regardless of the type of computer program. Data were extracted with a content analysis of 210 reports. The reports were categorized according to study design (comparative, prospective, descriptive, review, or editorial), type of computer-assisted instruction, medical specialty, and measures of effectiveness. RESULTS: Computer-assisted instruction programs included online technologies, CD-ROMs, video laser disks, multimedia work stations, virtual reality, and simulation testing. Studies were identified in all medical specialties, with a preponderance in internal medicine, general surgery, radiology, obstetrics and gynecology, pediatrics, and pathology. Ninety-six percent of the articles described a favorable impact of computer-assisted instruction in medical education, regardless of the quality of the evidence. Of the 210 reports that were identified, 60% were noncomparative, descriptive reports of new techniques in computer-assisted instruction, and 15% and 14% were reviews and editorials, respectively, of existing technology. Eleven percent of studies were comparative and included some form of assessment of the effectiveness of the computer program. These assessments included pre-and posttesting and questionnaires to score program quality, perceptions of the medical students and/or residents regarding the program, and impact on learning. In one half of these comparative studies, computer-assisted instruction was compared with traditional modes of teaching, such as text and lectures. Six studies compared performance before and after the computer-assisted instruction. Improvements were shown in 5 of the studies. In the remainder of the studies, computer-assisted instruction appeared to result in similar test performance. Despite study design or outcome, most articles described enthusiastic endorsement of the programs by the participants, including medical students, residents, and practicing physicians. Only 1 study included cost analysis. Thirteen of the articles were in obstetrics and gynecology. CONCLUSION: Computer-assisted instruction has assumed to have an increasing role in medical education. In spite of enthusiastic endorsement and continued improvements in software, few studies of good design clearly demonstrate improvement in medical education over traditional modalities. There are no comparative studies in obstetrics and gynecology that demonstrate a clear-cut advantage. Future studies of computer-assisted instruction that include comparisons and cost assessments to gauge their effectiveness over traditional methods may better define their precise role.

To determine whether obstetric handoff quality differs morning versus evening, weekend versus weekday, or based on provider type. Using the American College of Obstetricians and Gynecologists (ACOG) handoff guidelines, we developed an observational tool to assess whether handoffs included its 8 recommended elements. We observed handoffs between attending obstetricians, Obstetrics and Gynecology residents, labor and delivery nurses, and certified nurse midwives. Observation times included a balance of morning, evening, weekdays, and weekends. Participants were blinded to the study objectives. We defined high-quality handoffs as those that included 7 of the 8 recommended ACOG elements. A total of 425 inpatient handoffs were observed: 233 (55%) were morning handoffs and 189 (45%) were evening; 251 (59%) were on weekdays and 171 (41%) on weekends. Of the handoffs observed, 201 (48%) were presented by residents, 139 (33%) by nurses, 56 (13%) by attending obstetricians, and 26 (6%) by mid...

The anaesthetist plays a key role in the management of high-risk pregnancies, and must be a member of the multidisciplinary team that is required to care for the critically ill obstetric patient. Anaesthetists are trained in advanced life support and resuscitation. They are experienced in the management of the critically ill, and provide anaesthesia, sedation and pain management. The obstetric anaesthetist should undertake education of medical and midwifery staff in the early recognition, monitoring and treatment of the sick mother, resuscitation training, running 'skills drills' for emergency simulations, risk management and audit of maternal morbidity on the labour ward. To date, there is little evidence to inform the anaesthetic management of the critically ill obstetric patient; most recommendations and guidelines are based on the management of non-obstetric, critically ill patients. Management must be adapted to encompass the physiological changes of pregnancy. Evidence-based guidelines on management of the critically ill woman with specific obstetric conditions are also lacking.

A case of high-grade endometrial stromal sarcoma, confi ned into an intrauterine polypoid growth, in a woman with a history of breast cancer who was treated with adjuvant tamoxifen. Based on the fi ndings, a high-grade endometrial stromal sarcoma was diagnosed. The patient underwent a total hysterectomy and bilateral salpingo-oophorectomy with multiple omental biopsies. Pathological examination on multiple uterine sections showed the absence of residual tumor cells in the uterus. The endometrium showed patterns of glandular cystic hyperplasia. After 14 months of follow-up, the patient is well and free of disease. In deciding if tamoxifen therapy is warranted, all potentially life-threatening adverse events associated with tamoxifen should be considered, including endometrial adenocarcinoma or uterine sarcoma.

To assess the indications, use, and yield of fetal echocardiography. Methods: We reviewed our 8-year experience with fetal echocardiography at a large health maintenance organization in northern California to assess "the yield of abnormal findings for each indi~:ation and the accuracy of prenatal cardiac diagnosis. The study included 915 fetuses undergoing fetal echocardiography between 18-38 weeks' gestation because of accepted indications. All live-born infants had the presence or absence of congenital heart disease (CHD) confirmed postnatally. Results: Family history of CHD led to 34% of all fetal echocardiography studies, with a detection rate of 0.7%. Maternal diabetes mellitus accounted for 28% of all studies, with a detection rate of 1.2%. Exposure of mothers to a potential teratogen led to 48 studies, but no abnormalities were detected. Only 4% of fetal echocardiograms were obtained because of a suspected heart defect noted on a screening obstetric sonogram; this indication had a detection rate of 68% and yielded by far the most cases of severe CHD. Based on the expected occurrence rate of severe CHD in our closed referral system, only about 15% were referred for fetal echocardiography and detected prenatally. Conclusion: Basing fetal echocardiography referral on risk factors misses most clinically significant detectable CHD.

The information reflects emerging clinical and scientific advances as of the date issued, is subject to change, and should not be construed as dictating an exclusive course of treatment or procedure. Variations in practice may be warranted based on the needs of the individual patient, resources, and limitations unique to the institution or type of practice.

Introduction: Childbirth is a personal and individual journey that is different for every woman. Perception of the birth experience is thought to be influenced by many factors, the most significant of which may be the type of delivery. Normal vaginal delivery (NVD) is a natural process and cesarean section (CS) an operative process for child birth. Awareness regarding mode of delivery have a very important role for the future wellbeing of mother and child both. Objectives: To assess the awareness regarding normal vaginal delivery among pregnant women attending the out patients department (OPD) of an Upazilla Health Complex. Materials and Methods: This descriptive cross-sectional study was conducted at Kaliganj Upazilla Health Complex, Gazipur from January to March 2018 among 300 pregnant women. Age range of the patients was 15-40 years and selected purposively who were willing to attend and having no major complications. Data were collected by face to face interview with structured ...

BACKGROUND AND OBJECTIVES Advanced maternity care training in family medicine is highly variable at both the residency and fellowship levels. Declining numbers of family physicians providing maternity care services may exacerbate disparities in access to maternal and child care, especially in rural and other underserved communities. Accreditation of maternity care fellowships and board certification may be one potential avenue to address this trend. This study sought to understand the perceptions and beliefs of key family medicine stakeholders in advanced maternity care regarding the formalization of maternity care training through fellowship accreditation and the creation of a certificate of added qualification (CAQ). METHODS In 2014 and 2015, the authors conducted semi-structured interviews with 51 key stakeholders in family medicine maternity care. Transcribed interviews were coded using an iterative process to identify themes and patterns until saturation was reached. RESULTS Pa...

Objective  To document the frequency and causes of maternal mortality and severe (near-miss) morbidity in metropolitan La Paz, Bolivia.Design  Facility-based cross-sectional study.Setting  Four maternity hospitals in La Paz and El Alto, Bolivia, where free maternal health care is provided through a government-subsidised programme.Population  All maternal deaths and women with near-miss morbidity.Methods  Inclusion of near-miss using clinical and management-based criteria.Main outcome measures  Maternal mortality ratio (MMR), severe morbidity ratio (SMR), mortality indices and proportion of near-miss cases at hospital admission.Results  MMR was 187/100 000 live births and SMR was 50/1000 live births, with a relatively low mortality index of 3.6%. Severe haemorrhage and severe hypertensive disorders were the main causes of near-miss, with 26% of severe haemorrhages occurring in early pregnancy. Sepsis was the most common cause of death. The majority of near-miss cases (74%) were in cr...

A concrete and useful way to create an action plan for improving the quality of maternity care in the United States is to start with a view of the desired result, a common definition and a shared vision for a high-quality, high-value maternity care system. In this paper, we present a long-term vision for the future of maternity care in the United States. We present overarching values and principles and specific attributes of a high-performing maternity care system. We put forth the ''2020 Vision for a High-Quality, High-Value Maternity Care System'' to serve as a positive starting place for a fruitful collaborative process to develop specific action steps for broad-based maternity care system improvement.

Maternal plasma levels of cortiocotrophin-releasing factor (CRF) have been measured in abnormal pregnancy states to assess their potential as biochemical markers for at-risk pregnancies. CRF levels were not significantly altered in patients with hydatidiform mole, polyhydramnios or diabetes. CRF levels were elevated in pregnancies complicated by accidental antepartum haemorrhage at 28 weeks (P<O.03) but not for the rest of the third trimester. In twin pregnancies CRF levels were significantly raised throughout the third trimester (28-32 weeks, P<O.Ol; 34-36 weeks, P<O.OOl). In patients with pregnancy-induced hypertension (28 weeks, P<O.OOl; 32-36 weeks, P<O-OOl; and 3&4O weeks, P<O-Ol), preterm labour and premature rupture of the membranes (28 weeks, P<O.O04; 30-32 weeks, P<O.002; and 34-36 weeks, P<@OOl), CRF levels were significantly raised and in some patients levels were elevated 11 weeks before the onset of signs or symptoms. These observations raise the possibility that maternal CRF measurement may be of use as a predictive indicator of certain at-risk pregnancies.

Objective To compare semi-quantitative visual and automated methods of urine testing with fully quantitative point of care urinalysis for the detection of significant proteinuria (0.3 g/24 hours) in pregnancy complicated by hypertension. Design A prospective comparative study.

Objectives: Family delivery is an important aspect of modern obstetrics. The aim of this study was to estimate the phenomenon of family delivery from the standpoint of participating and non-participating fathers. Study design: Two types of questionnaires were used in the study. Five hundred and five men were divided into two groups: (A) delivery participants and (B) delivery non-participants. Results: The participants were significantly younger than non-participants. Better educated men dominated in group ''A'', whereas men with trade education were the majority in group ''B''. Low birth classes attendance among women in group ''B'' was noticed. All men in group ''B'' knew about the possibility of taking part in the delivery. Almost 100% of participants declared their satisfaction with family delivery. For non-participants, wife and media were the main source of knowledge, while for participants it was the medical staff and labor schools. Conclusions: Family labor is commonly accepted by both partners and is generally connected with positive emotions. This phenomenon is generally approved by couples with higher economical status. Family labor resignation, common among pairs with lower economical status, is caused generally by fear and lack of proper knowledge. Health care providers, through labor schools and outpatients visits, should concentrate on getting to couples, whose attitude towards family labor is negative. Educational programs and popular press articles should be prepared more thoroughly, focusing on the whole population of potential fathers. #

Objective: The purpose of this research was to evaluate the discrimination and calibration of mortality prediction of Simplified Acute Physiology Score 2, Simplified Acute Physiology Score 3, Mortality Probability Model II, and Mortality Probability Model III in peripartum women. Design: A retrospective cohort study.

The association of pulmonary sequestration and nonimmune fetal hydrops reportedly carries a very poor prognosis for survival. We describe three newborns with good outcomes despite the diagnosis of pulmonary sequestration; two cases were associated with hydrops fetalis and one with isolated fetal ascites. Two neonates with severe hydrops fetalis had pulmonary sequestration diagnosed postnatally. A third infant presented early in gestation with marked fetal ascites that regressed spontaneously before delivery; this infant also had pulmonary sequestration. Despite severe respiratory insufficiency requiring aggressive management, all three infants survived after surgical resection of the sequestered lung mass. These cases demonstrate the difficulties associated with antenatal counseling regarding long-term prognosis for infants with nonimmune hydrops and pulmonary sequestration. With optimal care in a tertiary perinatal center, a less pessimistic outlook than previously described in the literature may be appropriate.

charges, and unbilled procedures are published. Department faculty are asked to work at least 30-hour days, often with little sleep during the night, despite studies on fatigue and medical errors of residents younger than faculty. Residents are asked to collude by writing delivery notes that include the phrase "attending is present," even if he or she technically may not have been in the room for fetal delivery. The hidden curriculum here is the department emphasis, not on good patient care or resident education and oversight, but on payment. Does this not plant the seeds for "a little cheating" in future practice, like upcoding, treatment choice based on reimbursement, and ultimately, fraudulent billing for unperformed services?

Contemporary training in obstetrics and gynecology requires a delicate balance between teaching principles of basic science and clinical care and the technical skills required either in the delivery room or in surgical suites. 1 To accomplish this paradigm requires instruction not only in the core skills, such as basic suturing techniques, but also in a distinctive and new set of abilities not required in times past, ranging from interpretation of ultrasound images to advanced endoscopic surgery. However, changes in the clinical skill set are only part of the contemporary educational needs in our specialty. Changes in social awareness and the medicolegal environment demand competency in counseling and communication. 2 These issues require increasing emphasis on the development of communication and interpersonal skills in training programs. Circumstances in which unique communication skills are essential range from routine preoperative counseling and interviewing to more acute care situations that require intervention such as domestic violence. These newer needs require increasingly sophisticated formats and teaching tools to adequately train medical students and residents in the art of communication and interviewing. Technologies such as virtual reality (VR) that immerse participants into theoretical 3-dimensional (3-D) worlds, offer the opportunity for simulation of and interaction in any circumstance. Virtual reality constitutes a 3-D interface that puts an interacting subject in active exchange with a world recreated by computer programs. In this setting, the interaction is no longer unidirectional but bidirectional: a subject becomes not merely a passive observer of pictures in a text but can actively modify a 3-D virtual world. 3 Environments may be designed to simulate any interaction, whether personal or mechanical.