Objective To explore the attitudes of obstetricians to performe a caesarean section on maternal request in the absence of medical indication.
Design Cluster sampling cross‐sectional survey.
Setting ... Neonatal Intensive Care Unit (NICU) associated maternity units in eight European countries.
Population Obstetricians with at least 6 months clinical experience.
Methods NICU‐associated maternity units were chosen by census in Luxembourg, Netherlands and Sweden and by geographically stratified random sampling in France, Germany, Italy, Spain and UK. An anonymous, self‐administered questionnaire was used for data collection.
Main outcome measures Obstetricians’ willingness to perform a caesarean section on maternal request.
Results One hundred and five units and 1530 obstetricians participated in the study (response rates of 70 and 77%, respectively). Compliance with a hypothetical woman’s request for elective caesarean section simply because it was ‘her choice’ was lowest in Spain (15%), France (19%) and Netherlands (22%); highest in Germany (75%) and UK (79%) and intermediate in the remaining countries. Using weighted multivariate logistic regression, country of practice (P < 0.001), fear of litigation (P= 0.004) and working in a university‐affiliated hospital (P= 0.001) were associated with physicians’ likelihood to agree to patient’s request. The subset of female doctors with children was less likely to agree (OR 0.29, 95% CI 0.20–0.42).
Conclusions The differences in obstetricians’ attitudes are not founded on concrete medical evidence. Cultural factors, legal liability and variables linked to the specific perinatal care organisation of the various countries play a role. Greater emphasis should be placed on understanding the motivation, values and fears underlying a woman’s request for elective caesarean delivery.
Aetiology of preterm labour: bacterial vaginosis Guaschino, S; De Seta, F; Piccoli, M ...
BJOG : an international journal of obstetrics and gynaecology,
December 2006, 2006-Dec, 2006-12-00, 20061201, Letnik:
113, Številka:
s3
Journal Article
Recenzirano
Bacterial vaginosis (BV) is a common condition characterised by a polymicrobial disorder, with an overgrowth of several anaerobic or facultative bacteria and with a reduction or absence of ...lactobacillus colonisation. The prevalence of BV ranges from 4 to 64%, depending on the racial, geographic and clinical characteristics of the study population. In asymptomatic women, the prevalence varies from 12 to 25%, and similar percentages are observed in pregnant women. Although BV is associated with several adverse outcomes, such as upper genital tract infections, pelvic inflammatory disease, endometritis, preterm birth and low birthweight, many basic questions regarding the pathogenesis of BV remain unanswered. Mucosal immune system activation may represent a critical determinant of adverse consequences associated with BV. An unequal risk for BV acquisition and\or recurrence could derive from different mucosal immune host abilities and\or capability of invading microbes to produce factors that inactivate the local immune response. BV is associated with a two‐fold increased risk of preterm birth, with the greatest risk when BV is present before 16 weeks of gestation (odds ratio = 7.55). This may indicate a critical period during early gestation when BV‐related organisms can gain access to the upper genital tract and set the stage for spontaneous preterm labour later in gestation. The results of treatment trials for pregnant women with BV have been heterogeneous, with anywhere from an 80% reduction to a two‐fold increase in preterm birth among women who received treatment. For this reason, in current clinical practice significant controversy surrounds determining not only who and when to screen but also who and how to treat. Recent evidence shows that individual genetic backgrounds can affect chemokine production. This is an interesting area for future research and could lead to trials of treatment only for women genetically predisposed to preterm birth.
Endometrial carcinoma (EC) is the leading female genital tract malignancy in industrialized countries. It will become an important public health problem in the coming years in the USA and Europe, ...where its incidence is increasing, and next‐generation interventions should include periodical screening in high‐risk women. In this review, we discuss the importance to gynaecologists of detecting women at high risk and offering an adequate screening programme. Screening for EC is particularly challenging and there is currently no proven programme for the surveillance of women estimated to be at an increased risk of developing this form of cancer. The data in the literature, including this and previous issues of Cytopathology, and personal experience suggest that endometrial liquid‐based cytology (LBC) might play an essential role in a screening policy for EC. LBC may enable practitioners to reduce age‐adjusted mortality for women at high risk for EC.
Summary
In our study we examined the early complement components in patients with bacterial vaginosis (BV), vulvovaginal candidiasis (VVC) and in healthy controls. The levels of C1q, mannose‐binding ...lectin (MBL) and C3 were measured by ELISA in the cervicovaginal lavage (CVL) from gynaecological patients and controls. No significant differences were observed in the levels of these proteins in the three study groups. Immunofluorescence analysis of the clue cells and Candida hyphae from BV and VVC patients for surface‐bound complement components showed the presence of C3, while C1q was undetectable. MBL was revealed on clue cells but not on Candida. Binding of MBL to Candida, grown or cytocentrifuged from the CVL of VVC patients, was found to be pH dependent and occurred between pH 4·5 and pH 5·5. In conclusion, we demonstrated that MBL and C3 present in the vaginal cavity act as recognition molecules for infectious agents that colonize the cervicovaginal mucosa. Our finding that MBL, but not C1q, binds to bacteria and fungi in vagina suggests that the lectin and classical pathways of complement activation may play a different role in immune defence in the female genital tract.
BACKGROUND: Apoptosis plays an important role in regulating spermatogenesis. However, the biological significance of apoptosis in ejaculated sperm is not yet clear. This study set out to investigate ...how apoptosis correlates with semen quality and the presence of seminal leukocytes. METHODS: Fifty-seven semen samples from the male partners of infertile couples were classified as normal or abnormal according to World Health Organization guidelines. Flow cytometry was used to evaluate sperm populations and seminal leukocytes. Preliminary flow cytometry analysis using 6-carboxyfluoresceindiacetate (6-CFDA), which identifies live cells, and propidium iodide (PI), which stains only dead cells, was performed in order to pinpoint the sperm region accurately. Having thus gated the sperm population, bivariate Annexin V/PI analysis was then carried out in order to measure the percentage of apoptotic and necrotic sperm and the apoptotic index (the ratio between apoptotic:live sperm). Leukocytes were counted by the standard peroxidase test and by flow cytometry using monoclonal antibody (mAb) anti-CD45 or anti-CD53. RESULTS: No significant differences in the apoptotic index and the percentage of live and apoptotic sperm were detected between the subjects with normal and abnormal semen. A significant inverse correlation between sperm concentration and the apoptotic index was observed only in the normal sperm group. There was no correlation between the concentration of leukocytes, detected either by peroxidase or by mAb anti-CD45 or anti-CD53, either with the percentage of apoptotic sperm or with the apoptotic index. In contrast, the ratio between CD45 positive leukocytes and sperm showed a significant correlation with the apoptotic index. A weaker correlation was found when leukocytes were counted by peroxidase, while no correlation was observed using mAb anti-CD53. CONCLUSIONS: Sperm apoptosis did not seem to be correlated with semen quality. In the absence of genito-urinary infection, one of the main functions of seminal leukocytes is probably to provide for the removal of apoptotic sperm.
Approximately three-quarters of all women will experience an episode of vulvovaginal candidosis at least once in their life and 5-10% of them will have more than one attack. Women suffering from ...three to four attacks within 12 months will be diagnosed with recurrent vulvovaginal candidosis (RVVC). This review covers the large number of proposed aetiological factors for RVVC. The diagnosis of the condition made by conventional means by health providers is often false and is also often misdiagnosed by the affected woman herself. The review covers various methods of diagnosing RVVC and the current knowledge on potential pathogenetic mechanisms proposed for genital candida infections. Treatment of RVVC, including local and systemic antimicrobial therapy and behaviour modification to decrease the risk of recurrences, are discussed. Recent knowledge on drug resistance in candida is also included.
Update on Chlamydia trachomatis GUASCHINO, S.; DE SETA, F.
Annals of the New York Academy of Sciences,
01/2000, Letnik:
900, Številka:
1
Journal Article
Recenzirano
: Chlamydia trachomatis is one the most important sexually transmitted diseases; it can cause serious sequelae despite the absence of symptoms in some people. It's estimated that about 25% of women ...who have acute salpingitis become infertile, and chlamydial infection is the commonest cause. The introduction of screening programs for its detection are still a topic of discussion. The literature shows that the total cost of examination and treatment of complications known to be associated with genital chlamydial infection (PID, chronic pelvic pain, tubal factor infertility) is generally higher than the total cost of a large‐scale Chlamydia screening program. The selection of a diagnostic test for detection of chlamydial genital infection depends on availability, local expertise, and prevalence of Chlamydia trachomatis in the test population. Cell culture is too expensive in nonendemic regions, so the use of non‐culture techniques is very attractive. PCR (polymerase chain reaction) and LCR (ligase chain reaction) are actually the two most commonly used alternatives to conventional methods for detecting STD agents. In fact, PCR and LCR have proved useful for detection of Chlamydia trachomatis in cervical and urethral samples both in symptomatic and asymptomatic women. Recently, testing of first‐void urine (FVU) specimens with these techniques has shown that the amplification tests are as sensitive as tests with endocervical swab cultures.
BACKGROUND: It has recently been suggested that recombinant FSH administration may result in an increased risk of venous thrombosis. An open‐label, randomized, controlled trial was carried out to ...compare the impact of urinary and recombinant FSH on haemostasis. METHODS: Fifty infertile women were randomized, using a random number generator on a personal computer, to receive either highly purified urinary FSH (u‐hFSH) or recombinant human FSH (r‐hFSH); a starting dose of 150 IU. Human chorionic gonadotrophin 10000 IU was administered once there was at least one follicle ≥18 mm. The luteal phase was supported with progesterone 50 mg/day for at least 15 days. Fifty normally menstruating women were recruited as controls. Repeated measurements of estradiol, progesterone, prothrombin time (PT) expressed as INR, activated partial thromboplastin time (APTT) ratio, fibrinogen (FBG), factor VIII (FVIII), normalized activated protein C ratio (nAPC ratio), antithrombin III activity (AT), protein C activity (PC), protein S activity (PS), tissue‐type plasminogen activator antigen (t‐PA), type 1 plasminogen activator inhibitor (PAI), prothrombin fragments 1+2 (F1+2), were performed during both hyperstimulated and natural cycles, and at onset of the following menstruation or at 8 weeks of pregnancy. RESULTS: At the end of gonadotrophin administration PT INR increased in the u‐hFSH group, while AT and t‐PA significantly decreased. In the patients treated with r‐hFSH, only F1+2 significantly decreased. No significant changes were observed in the control group. In the luteal phase FBG increased significantly in all groups. In the u‐hFSH group no other significant changes were noted compared to pre‐ovulatory values, while compared to baseline values AT, PS and t‐PA significantly decreased. In the r‐hFSH group during the luteal phase PT INR significantly decreased, but did not differ from baseline levels. Other parameters such as FBG, FVIII, t‐PA, rose significantly, but only FVIII and FBG values were significantly higher than baseline levels. In the women who became pregnant a significant increase in t‐PA and a significant decrease in PS at the midluteal phase were observed. After one month all the haemostatic parameters returned to baseline value if pregnancy failed to occur, while in the pregnant women a significant increase in FVIII and a significant decrease in PS were observed. CONCLUSIONS: Ovarian stimulation with recombinant FSH does not influence coagulation and fibrinolysis significantly, as already reported for urinary gonadotrophins. The moderate changes induced by both treatments are no longer detectable after 4 weeks.
The goals of antibacterial prophylaxis during obstetric/gynaecological surgery are similar to those of prophylaxis during intra-abdominal surgery. The vaginal flora consists of many aerobic and ...anaerobic organisms, is dominated by peroxide-producing lactobacilli, and is non-pathogenic under normal conditions. Destabilization of the vaginal ecosystem, as in bacterial vaginosis (BV), causes a massive increase in the ratio of anaerobes to aerobes and is associated with a large increase in the risk of infection. The surgical procedures at most risk of postoperative infection are vaginal, abdominal and radical hysterectomy and caesarean section. Both the American College of Obstetricians and Gynecologists and the American Society of Health-System Pharmacists have recommended single-dose prophylactic protocols using a variety of agents (penicillins, cephalosporins and clindamycin). However, it remains doubtful whether prophylaxis is used widely. In Italy, such prophylaxis has proved less effective in women with BV. Accordingly, patients with confirmed BV are given topical clindamycin for 7 days leading up to surgery, in addition to the usual prophylactic regimen. Caesarean delivery carries a 5- to 20-fold greater risk of infection that normal vaginal delivery. A meta-analysis of 66 clinical studies has shown that any prophylactic regimen is effective in reducing postoperative complications. The use of prophylaxis in patients undergoing a low-risk caesarean section remain controversial.
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