Perineal trauma at the time of vaginal delivery is common, and when the anal sphincter is included, these injuries can be associated with additional morbidity including incontinence, pelvic pain, and ...sexual dysfunction.
The aim of this systematic review with meta-analysis was to evaluate whether a hands-on technique during vaginal delivery results in less incidence of perineal trauma than a hands-off technique.
Electronic databases were searched from their inception until June 2018. No restrictions for language or geographic location were applied. The reference lists of identified articles were examined to identify studies not captured by electronic searches. Randomized controlled trials comparing a hands-on technique of perineal support during vaginal delivery (i.e. intervention group) with a hands-off technique (i.e. control group) were included in the meta-analysis. Hands-on was defined as involving one hand on the fetal head, applying pressure to control expulsion, with the other hand applying pressure on the maternal perineum. The primary outcome was severe perineal trauma, defined as either third- or fourth-degree lacerations. The meta-analysis was performed using the random effects model of DerSimonian and Laird, to produce summary treatment effects in terms of relative risk (RR) with 95% confidence interval (CI).
Five trials, including 7287 women, were analyzed. All studies included singleton gestations with cephalic presentation at term undergoing spontaneous vaginal delivery. Women randomized to the hands-on technique had similar incidence of severe perineal trauma (1.5 versus 1.3%; RR 2.00, 95% CI 0.56-7.15). There was no significant between-group difference in the incidence of intact perineum, first-, second- and fourth-degree laceration. Hands-on technique was associated with increased risk of third-degree lacerations (2.6 versus 0.7%; RR 3.41, 95% CI 1.39-8.37) and of episiotomy (13.6 versus 9.8%, RR 1.59, 95% CI 1.14-2.22) compared to the hands-off technique.
Hands-on technique during spontaneous vaginal delivery of singleton gestations results in similar incidence of several perineal traumas compared to a hands-off technique. The incidence of third-degree lacerations and of episiotomy increases with the hands-on technique. Key Message A hands-on technique during vaginal delivery results in similar incidence of severe lacerations compared to hands-off.
Introduction
The National Institute of Child Health and Human Development, American College of Obstetricians and Gynecologists, and Society for Maternal‐Fetal Medicine have emphasized the need to ...promote vaginal delivery and have offered recommendations to safely prevent primary cesarean delivery. However, there has been limited discussion regarding management of intravenous fluids and other aspects of labor management that may influence mode of delivery. Therefore the aim of our study was to determine whether an intravenous fluid rate of 250 vs. 125 mL/h is associated with a difference in cesarean delivery rate.
Material and methods
Searches were performed in MEDLINE, OVID, Scopus, ClinicalTrials.gov, the PROSPERO International Prospective Register of Systematic Reviews, Embase, Web of Science, and the Cochrane Library for randomized controlled trials. We included all randomized controlled trials comparing intravenous fluid rates of 250 vs. 125 mL/h in nulliparous women in spontaneous labor at term with singleton pregnancies at ≥36 weeks. Studies were included regardless of the type of intravenous fluids used and regardless of whether oral intake was restricted during labor. Studies including multiparous women or women whose labor was induced were excluded. The primary outcome was the incidence of cesarean delivery. We planned to assess a subgroup analysis according to type of fluids used and according to restriction of oral fluid intake.
Results
Seven trials including 1215 nulliparous women in spontaneous labor at term were analyzed; 593 (48.8%) in the 250 mL/h group, and 622 (51.2%) in the 125 mL/h group. Five studies used lactated Ringer's solution, one used normal saline in dextrose water, and in one study it was unclear which intravenous fluid was used. Women who received intravenous fluids at 250 mL/h had a significantly lower incidence of cesarean delivery for any indication (12.5 vs. 18.1%; RR 0.70, 95% CI 0.53–0.92; seven studies, 1215 participants; I2 = 0%) and for dystocia (4.9 vs. 7.7%; RR 0.60, 95% CI 0.38–0.97; five studies, 1093 participants; I2 = 18%), a significantly shorter mean duration of labor of about one hour (mean difference −64.38 min, 95% CI −121.88 to −6.88; six studies, 1155 participants; I2 = 83%) and a significantly shorter mean length of second stage of labor (mean difference −2.80 min, 95% CI −4.49 to −1.10; 899 participants; I2 = 22%) compared with those who received intravenous fluid at 125 mL/h. No differences were found in the other secondary outcomes. There were no maternal or perinatal deaths and only one woman, in the 125 mL/h group, developed pulmonary edema. The findings persisted regardless of the type of intravenous fluid used. No significant reduction in the incidence of cesarean delivery was demonstrated in women with unrestricted oral intake; however, this was limited to only two studies evaluating 254 women.
Conclusions
Our findings provide evidence that the duration of labor in low‐risk nulliparous women may be shortened by a policy of intravenous fluids at a rate of 250 mL/h rather than 125 mL/h. A rate of 250 mL/h seems to be associated with a reduction in the incidence of cesarean delivery compared to 125 mL/h. The number needed to treat to prevent one cesarean delivery is 18 women. Our data support increased hydration among nulliparous women in labor when oral intake is restricted. Further study is needed regarding risks and benefits of increased hydration among women with unrestricted oral intake, those undergoing induction of labor, and those with medical comorbidities.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
The coronavirus disease 2019 pandemic has had an impact on healthcare systems around the world with 3 million people contracting the disease and 208,000 cases resulting in death as of this writing. ...Information regarding coronavirus infection in pregnancy is still limited.
This study aimed to describe the clinical course of severe and critical coronavirus disease 2019 in hospitalized pregnant women with positive laboratory testing for severe acute respiratory syndrome coronavirus 2.
This is a cohort study of pregnant women with severe or critical coronavirus disease 2019 hospitalized at 12 US institutions between March 5, 2020, and April 20, 2020. Severe disease was defined according to published criteria as patient-reported dyspnea, respiratory rate >30 per minute, blood oxygen saturation ≤93% on room air, ratio of partial pressure of arterial oxygen to the fraction of inspired oxygen <300 mm Hg, or lung infiltrates >50% within 24–48 hours on chest imaging. Critical disease was defined as respiratory failure, septic shock, or multiple organ dysfunction or failure. Women were excluded from the study if they had presumed coronavirus disease 2019, but laboratory testing was negative. The primary outcome was median duration from hospital admission to discharge. Secondary outcomes included need for supplemental oxygen, intubation, cardiomyopathy, cardiac arrest, death, and timing of delivery. The clinical courses are described by the median disease day on which these outcomes occurred after the onset of symptoms. Treatment and neonatal outcomes are also reported.
Of 64 hospitalized pregnant women with coronavirus disease 2019, 44 (69%) had severe disease, and 20 (31%) had critical disease. The following preexisting comorbidities were observed: 25% had a pulmonary condition, 17% had cardiac disease, and the mean body mass index was 34 kg/m2. Gestational age was at a mean of 29±6 weeks at symptom onset and a mean of 30±6 weeks at hospital admission, with a median disease day 7 since first symptoms. Most women (81%) were treated with hydroxychloroquine; 7% of women with severe disease and 65% of women with critical disease received remdesivir. All women with critical disease received either prophylactic or therapeutic anticoagulation during their admission. The median duration of hospital stay was 6 days (6 days severe group and 10.5 days critical group; P=.01). Intubation was usually performed around day 9 on patients who required it, and peak respiratory support for women with severe disease was performed on day 8. In women with critical disease, prone positioning was required in 20% of cases, the rate of acute respiratory distress syndrome was 70%, and reintubation was necessary in 20%. There was 1 case of maternal cardiac arrest, but there were no cases of cardiomyopathy or maternal death. Thirty-two of 64 (50%) women with coronavirus disease 2019 in this cohort delivered during their hospitalization (34% severe group and 85% critical group). Furthermore, 15 of 17 (88%) pregnant women with critical coronavirus disease 2019 delivered preterm during their disease course, with 16 of 17 (94%) pregnant women giving birth through cesarean delivery; overall, 15 of 20 (75%) women with critical disease delivered preterm. There were no stillbirths or neonatal deaths or cases of vertical transmission.
In pregnant women with severe or critical coronavirus disease 2019, admission into the hospital typically occurred about 7 days after symptom onset, and the duration of hospitalization was 6 days (6 severe group vs 12 critical group). Women with critical disease had a high rate of acute respiratory distress syndrome, and there was 1 case of cardiac arrest, but there were no cases of cardiomyopathy or maternal mortality. Hospitalization of pregnant women with severe or critical coronavirus disease 2019 resulted in delivery during the clinical course of the disease in 50% of this cohort, usually in the third trimester. There were no perinatal deaths in this cohort.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Type 1 von Willebrand disease (VWD) is the most common subtype of VWD, comprising 75% of VWD patients. We provide a systematic review of type 1 VWD in pregnancy. Our objective was to evaluate the ...rate of postpartum hemorrhage (PPH) in patients with known type 1 VWD. The primary outcome was rate of PPH. Primary PPH was defined as a cumulative blood loss ≥1,000 mL, or blood loss accompanied by signs and symptoms of hypovolemia within 24 hours postpartum or requiring blood products. Secondary PPH was defined as significant bleeding 24 hours to 12 weeks postpartum. Relevant articles published in English pertaining to VWD and pregnancy were identified without any time or study limitations. Seven articles (
= 144 pregnancies) met inclusion criteria. The rate of primary PPH was 4/144 (2.8%). The secondary PPH rate was reported in four studies, and occurred in 7/48 pregnancies (14.6%), ranging from 2 to 19 days postpartum. In conclusion, according to this systematic review, the frequency of primary PPH in pregnancies with known type 1 VWD is 2.8%. This is similar to the overall PPH rates of 3% reported in the literature. Although the sample size was small, secondary PPH occurred in almost 15% of pregnancies, while in the overall obstetrical population this occurs in approximately 1% of cases. Patients with known type 1 VWD may not be at increased risk of primary PPH, though they appear to bear increased risk of secondary PPH.
Early detection is an essential component of cancer management. Unfortunately, visual examination can often be unreliable, and many settings lack the financial capital and infrastructure to operate ...PET, CT, and MRI systems. Moreover, the infrastructure and expense associated with surgical biopsy and microscopy are a challenge to establishing cancer screening/early detection programs in low-resource settings. Improvements in performance and declining costs have led to the availability of optoelectronic components, which can be used to develop low-cost diagnostic imaging devices for use at the point-of-care. Here, we demonstrate a fiber-optic fluorescence microscope using a consumer-grade camera for in vivo cellular imaging.
The fiber-optic fluorescence microscope includes an LED light, an objective lens, a fiber-optic bundle, and a consumer-grade digital camera. The system was used to image an oral cancer cell line labeled with 0.01% proflavine. A human tissue specimen was imaged following surgical resection, enabling dysplastic and cancerous regions to be evaluated. The oral mucosa of a healthy human subject was imaged in vivo, following topical application of 0.01% proflavine.
The fiber-optic microscope resolved individual nuclei in all specimens and tissues imaged. This capability allowed qualitative and quantitative differences between normal and precancerous or cancerous tissues to be identified. The optical efficiency of the system permitted imaging of the human oral mucosa in real time.
Our results indicate this device as a useful tool to assist in the identification of early neoplastic changes in epithelial tissues. This portable, inexpensive unit may be particularly appropriate for use at the point-of-care in low-resource settings.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Abstract Emerging data suggest intraventricular hemorrhage (IVH) of the preterm neonate is a complex disorder with contributions from both the environment and the genome. Environmental analyses ...suggest factors mediating both cerebral blood flow and angiogenesis contribute to IVH, while candidate gene studies report variants in angiogenesis, inflammation, and vascular pathways. Gene-by-environment interactions demonstrate the interaction between the environment and the genome, and a non-replicated genome-wide association study suggests that both environmental and genetic factors contribute to the risk for severe IVH in very low-birth weight preterm neonates.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Injection drug use (IDU) is a known, but infrequent risk factor on candidemia; however, the opioid epidemic and increases in IDU may be changing the epidemiology of candidemia.
Active ...population-based surveillance for candidemia was conducted in selected US counties. Cases of candidemia were categorized as IDU cases if IDU was indicated in the medical records in the 12 months prior to the date of initial culture.
During 2017, 1191 candidemia cases were identified in patients aged >12 years (incidence: 6.9 per 100 000 population); 128 (10.7%) had IDU history, and this proportion was especially high (34.6%) in patients with candidemia aged 19-44. Patients with candidemia and IDU history were younger than those without (median age, 35 vs 63 years; P < .001). Candidemia cases involving recent IDU were less likely to have typical risk factors including malignancy (7.0% vs 29.4%; relative risk RR, 0.2 95% confidence interval {CI}, .1-.5), abdominal surgery (3.9% vs 17.5%; RR, 0.2 95% CI, .09-.5), and total parenteral nutrition (3.9% vs 22.5%; RR, 0.2 95% CI, .07-.4). Candidemia cases with IDU occurred more commonly in smokers (68.8% vs 18.5%; RR, 3.7 95% CI, 3.1-4.4), those with hepatitis C (54.7% vs 6.4%; RR, 8.5 95% CI, 6.5-11.3), and in people who were homeless (13.3% vs 0.8%; RR, 15.7 95% CI, 7.1-34.5).
Clinicians should consider injection drug use as a risk factor in patients with candidemia who lack typical candidemia risk factors, especially in those with who are 19-44 years of age and have community-associated candidemia.
If detected early, oral cancer is eminently curable. However, survival rates for oral cancer patients remain low, largely due to late-stage diagnosis and subsequent difficulty of treatment. To ...improve clinicians' ability to detect early disease and to treat advanced cancers, we developed a multimodal optical imaging system (MMIS) to evaluate tissue in situ, at macroscopic and microscopic scales. The MMIS was used to measure 100 anatomic sites in 30 patients, correctly classifying 98% of pathologically confirmed normal tissue sites, and 95% of sites graded as moderate dysplasia, severe dysplasia, or cancer. When used alone, MMIS classification accuracy was 35% for sites determined by pathology as mild dysplasia. However, MMIS measurements correlated with expression of candidate molecular markers in 87% of sites with mild dysplasia. These findings support the ability of noninvasive multimodal optical imaging to accurately identify neoplastic tissue and premalignant lesions. This in turn may have considerable impact on detection and treatment of patients with oral cancer and other epithelial malignancies.
1038 Type 1 von willebrand disease in pregnancy Pierce-Williams, Rebecca; Makhamreh, Mona M.; Blakey-Cheung, Sophia ...
American journal of obstetrics and gynecology,
February 2021, 2021-02-00, Volume:
224, Issue:
2
Journal Article
Peer reviewed
Open access
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
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