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ACOG Practice Bulletin NO. 56. American College of Obstetricians and Gynecologists

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... Lower-extremity lymphedema is a late effect experienced by some gynecologic cancer survivors, especially those treated with surgery or radiation involving the pelvic or inguinal lymph nodes [49] . Onset may occur immediately after therapy or be delayed many years [50] . ...
... Therapies which may help survivors suffering from lymphedema include: Lymphedema hosiery, manual massage, compression bandages, or consultation with a lymphedema therapist. Severe cases may require hospitalization and intravenous antibiotics [49,[51][52][53] . Lymphedema therapists may be located on the Lymphology Association of North America's website, http://www.cltlana ...
... Despite this, there is currently no agreed upon diagnostic criteria for FGR. The American College of Obstetricians and Gynecologists (ACOG) defines FGR as an estimated fetal weight less than the 10 th centile [40]. The Royal College of Obstetricians and Gynaecologists (RCOG) uses fetal abdominal circumference (AC) or estimated fetal weight (EFW) <10 th centile to diagnose a FGR fetus [41] . ...
... More recently, early FGR has been defined by a consensus committe of international fetal medicine experts with solitary parameters ither EFW <3 rd centile, AC <3 rd centile or absent umbilical artery end diastolic flow [43]. In its latest practice bulletin the ACOG acknowledges the fact that terminology for classifying fetuses and newborns who have failed to achieve normal weight is incon- sistent [40]. Indeed, the acronyms SGA and FGR are often used interchangeably. ...
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Fetal growth restriction (FGR) diagnosed before 32 weeks is identified by fetal smallness associated with Doppler abnormalities and is associated with significant perinatal morbidity and mortality and maternal complications. Recent studies have provided new insights into pathophysiology, management options and postnatal outcomes of FGR. In this paper we review the available evidence regarding diagnosis, management and prognosis of fetuses diagnosed with FGR before 32 weeks of gestation.
... Prematurity by even a single week increases the risk of morbidity and mortality [5] , suggesting that late preterm infants (LPIs) are physiologically and metabolically immature. The ACOG guidelines state that delivery before 39 weeks of GA should only be undertaken when there is an accepted medical or obstetric complication, or if fetal lung maturity has been documented [6,7]. ACOG states that the indications for induction of labor are not absolute but should take into account maternal and fetal conditions, GA, cervical status, and other factors. ...
... In such circumstances, GA criteria, or fetal lung maturity should be established. However, it is important to bear in mind that a mature fetal lung test result before 39 weeks of gestation, in the absence of appropriate clinical circumstances, is not an indication for delivery [6]. ...
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Late preterm births have been on the increase. Though the reasons for the increase in late preterm births are unclear, non-medically indicated inductions and cesarean sections seem to be the significant preventable contributors. Late preterm infants are typically healthier than very preterm infants, but compared to term infants they are at significantly increased risk of both short and long term morbidity and mortality. In the short term they have increased rates of feeding difficulties, hypoglycemia, jaundice, temperature instability, apnea, respiratory distress and sepsis evaluation compared to term infants. Emerging data also suggest a higher rate of long-term neurodevelopmental, social, and medical morbidity. Therefore, if elective induction of labor or cesarean section at late preterm gestation (34–36 weeks of gestational age) is considered for either maternal or fetal indications, the risk and benefits should be carefully examined. The family and physician should discuss that elective delivery of late preterm infants is not recommended unless absolutely indicated. Due to a considerably higher risk of morbidity and mortality, developing and testing new paradigms of obstetric and fetal management for pregnancies with potential for late preterm delivery are a logical objective. For example, strategies to enhance fetal physiologic maturation when late preterm delivery is unavoidable need to be explored.
... Studies comparing LMP to ultrasound dating have been typically reported in high-income countries where the resources exist for screening most women [5][6][7]; however, some have also been done in LMIC [8, 9]. Crown-rump length (CRL) measured in the first trimester provides the most accurate estimate of date of delivery, as supported by the American College of Obstetricians and Gynecologists [10]. Early ultrasound exams have a lower prediction error than those conducted later and may be of particular importance in settings with high rates of fetal growth restriction [5]. ...
... Other studies validated LMP in specific populations, such as very preterm [8], and may not be comparable to the current study. First trimester CRL, as used in this study, is considered the best measurement for gestational age deter- mination [10], as it is both accurate and precise, predicting 94 % of delivery dates within 14 days [22]. Other research also shows early pregnancy CRL to be the best at estimating gestational age among ultrasound measures of fetal size [22, 23], presumably because measurements at this time should be before any discernable growth restriction that could impact gestational age estimation. ...
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Background The best method of gestational age assessment is by ultrasound in the first trimester; however, this method is impractical in large field trials in rural areas. Our objective was to assess the validity of gestational age estimated from prospectively collected date of last menstrual period (LMP) using crown-rump length (CRL) measured in early pregnancy by ultrasound. Methods As part of a large, cluster-randomized, controlled trial in rural Bangladesh, we collected dates of LMP by recall and as marked on a calendar every 5 weeks in women likely to become pregnant. Among those with a urine-test confirmed pregnancy, a subset with gestational age of <15 weeks (n = 353) were enrolled for ultrasound follow-up to measure CRL. We compared interview-assessed LMP with CRL gestational age estimates and classification of preterm, term, and post-term births. ResultsLMP-based gestational age was higher than CRL by a mean (SD) of 2.8 (10.7) days; differences varied by maternal education and preterm birth (P < 0.05). Lin’s concordance correlation coefficient was good at ultrasound [0.63 (95 % CI 0.56, 0.69)] and at birth [0.77 (95 % CI 0.73, 0.81)]. Validity of classifying preterm birth was high but post-term was lower, with specificity of 96 and 89 % and sensitivity of 86 and 67 %, respectively. Results were similar by parity. Conclusions Prospectively collected LMP provided a valid estimate of gestational age and preterm birth in a rural, low-income setting and may be a suitable alternative to ultrasound in programmatic settings and large field trials. Trial registrationClinicalTrials.gov NCT00860470
... With the advent of chromosomal microarray analysis, geneticists can now identify a larger number of well-defined genetic syndromes. In a 2012 NICHD multicenter trial comparing prenatal chromosomal microarray analysis to prenatal microscopic karyotype, CMA was able to detect all clinically significant aneuploidies and unbalanced translocations diagnosed with karyotyping [22]. The American Congress of Obstetricians and Gynecologists (ACOG) recommends chromosomal microarray analysis as the next step in management when an ultrasound reveals one or more major fetal abnormalities, especially after a negative karyotype analysis [22]. ...
... In a 2012 NICHD multicenter trial comparing prenatal chromosomal microarray analysis to prenatal microscopic karyotype, CMA was able to detect all clinically significant aneuploidies and unbalanced translocations diagnosed with karyotyping [22]. The American Congress of Obstetricians and Gynecologists (ACOG) recommends chromosomal microarray analysis as the next step in management when an ultrasound reveals one or more major fetal abnormalities, especially after a negative karyotype analysis [22]. CMA can detect aneuploidy as well as submicrosomal abnormalities that are too small to be detected by conventional karyotype. ...
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Partial trisomy of the 10q region was originally reported in 1979 [1]. For 25 years, the diagnosis was made microscopically based on large, visible insertions in the region identified by karyotype analysis. Previous case reports have included both unbalanced translocations and large duplications/insertions in the 10q region [2]. Probands with partial trisomy 10q syndrome often have an abnormal phenotype that may include developmental delay [3-5], craniofacial abnormalities [3, 5], talipes (clubfoot) [2], microcephaly [2-4], or congenital heart disease [2-6]. Prenatal diagnoses by karyotype have been made following ultrasound diagnosis of sacrococcygeal teratoma [7], renal pyelectasis [3, 8-10], and other fetal abnormalities [4]. In this case, we report the first prenatal diagnosis of partial trisomy 10q (10q22.3-10q23.2) with a normal karyotype and an abnormal chromosomal microarray analysis (CMA). This is the smallest copy number variant (CNV) (7.5 Mb) in the 10q22.3-10q23.2 regions yet reported.
... Induction of labor is among the most common obstetric interventions in order to achieve a vaginal delivery when the benefits of expeditious delivery outweigh the potential risk of continuing pregnancy [9]. The present study is an attempt to compare the neonatal outcome associated with induction of labour versus planned SVD in a low-risk obstetric population. ...
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The main objectives were to study selected neonatal morbidities and outcomes in relation to induced labour versus spontaneous vaginal delivery in a low risk obstetric population. Methods: This was a prospective, comparative study that was conducted in Omdurman maternity hospital in Sudan, 400 babies were included in the study divided equally between induced and spontaneous vaginal delivery. Data was collected using a specifically designed questionnaire including maternal and neonatal data. Chi square test was used to study the correlation between neonatal outcome and type of delivery. P value was set at 0.05 level of significance. Results: The main results showed significant association between induction of delivery and the following maternal variables: age, level of education, parity and frequency of antenatal care visits (P values respectively .027, .02, .003, .012). With regards to neonatal outcome, the study revealed significant association between type of delivery and low Apgar score (P= 0.001) with more babies in the spontaneous vaginal delivery group having low Apgar score however the study didn’t reveal any significant differences in neonatal outcome with regards to gender, birth weight, need for resuscitation and neonatal mortality (P values respectively .071, .077, .062, .562). Conclusion: The study showed significant difference in Apgar score between the two groups, being lower in the spontaneous vaginal delivery group but didn’t reveal any significant differences in neonatal outcome with regards to gender, birth weight, need for resuscitation and neonatal mortality.
... The overall prevalence of anaemia in this study was 20.9%, while iron deficiency anaemia was at 10.3%, indicating that about half of the anaemia was due to iron deficiency. Other causes of anaemia in young women include heavy menstruation for longer than five days, abnormal uterine bleeding, (such as from fibroids) [14] and pregnancy. [15] The prevalence of anaemia found in young non-pregnant women (20.9%) appears higher than the WHO estimate for non-pregnant women in Thailand at 18%. [16] However, there is a lower prevalence of iron deficiency anaemia compared to young adolescent girls from Indonesia (21.8%) [17] . Similarly, women of reproductive age in northwest Vietna ...
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Objective: To assess the prevalence of iron deficiency, anaemia and iron deficiency anaemia (IDA) in women aged 20-40 years and its association with iron intake. Methods: A total of 388 women were recruited from universities and work sites in Kuala Lumpur and its suburbs. The subjects comprised 135 Malays, 130 Chinese and 123 Indians. Dietary intake was estimated using a single 24-hour food recall and a semi-quantitative food frequency questionnaire. Haemoglobin (Hb), haematocrit (hct), mean corpuscular volume (MCV) and serum ferritin were determined. Results: The prevalence of anaemia (Hb <12g/dL) was 20.9%, being highest among the Indians (26.4%) and lowest among the Malays (16.4%). About 10.3% of the women showed iron deficiency anaemia (IDA) (Hb <12g/dL + serum ferritin < 15/xg/L + MCV <80fl/). The prevalence of IDA was highest in Indians (18.0%) followed by Chinese (9.9%) and Malays (4.3%). The mean (95%CI) intake of total iron was at 14.4 mg/day (95% CI 13.4, 15.5), amounting to 49.7% of the Malaysian recommended nutrient intake (RNI). Intake of iron was the highest for the Indians (16.0 mg/d) and the lowest for the Chinese ( 11.3 mg/d). Conclusions: The overall prevalence of IDA was lower compared to prevalence of anaemia. Nonetheless, the markedly higher prevalence of IDA among the Indians, despite relatively higher intake levels of iron-rich foods warrants further investigations, including the bioavailability of iron in the context of cultural practices that may influence food preferences and meal preparation.
... Controversies surround the optimal strategy for fetal surveillance and the timing of delivery of pregnancies complicated by FGR [4]. Current American College of Obstetrician and Gynecologists (ACOG) guidelines of fetal arterial Doppler evaluation in FGR utilize umbilical artery Doppler exclusively to determine the timing of delivery [5]. Although the circulatory redistribution phenomenon and brain sparing effect are well understood in FGR complicated pregnancies, the abnormal middle cerebral artery (MCA) Doppler findings has demonstrated limited predicative value for poor perinatal outcome [6]. ...
Article
Objective: The objective of this meta-analysis is to assess the value of fetal cerebro-placental Doppler ratio (CPR) in predicting adverse perinatal outcome in pregnancies with fetal growth restriction (FGR). Methods: Three databases were used: MEDLINE, EMBASE (with online Ovid interface) and SCOPUS and studies from inception to April 2015 were included. Studies that reported perinatal outcomes of fetuses at risk of FGR or sonographically diagnosed FGR that were evaluated with CPR were considered eligible. Perinatal outcomes include cesarean section (CS) for fetal distress, APGAR scores at 5 min, neonatal complications and admission to neonatal intensive care unit (NICU). Pooled data were expressed as odds ratio (OR) and confidence intervals (CI), and the summary receiver operating characteristic (SROC) curve was used to illustrate the diagnostic accuracy of CPR. Results: Seven studies were eligible (1428 fetuses). Fetuses with abnormal CPR were at higher risk of CS for fetal distress (OR=4.49, 95% CI [1.63, 12.42]), lower APGAR scores (OR=4.01, 95% CI [2.65, 6.08]), admission to NICU (OR=9.65, 95% CI [3.02, 30.85]), and neonatal complications (OR=11.00, 95% [3.64, 15.37]) than fetuses who had normal CPR. These risks were higher among studies that included fetuses diagnosed with FGR than fetuses at risk of FGR. Abnormal CPR had higher diagnostic accuracy for adverse perinatal outcomes among "sonographically diagnosed FGR" studies than "at risk of FGR" studies. Conclusion: Abnormal CPR is associated with substantial risk of adverse perinatal outcomes. The test seems to be particularly useful for follow up of fetuses with sonographically diagnosed FGR.
... Histological examination of the placenta is one of the most frequently performed investigations to identify the cause of death in cases of stillbirth [1]; its application in this context is recommended by international guidelines [2][3][4]. A recent systematic review found large variations in the methodological quality of studies of placental examination after stillbirth, with few studies of high quality [5]. ...
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Background: Stillbirth is frequently the result of pathological processes involving the placenta. Understanding the significance of specific lesions is hindered by qualitative subjective evaluation. We hypothesised that quantitative assessment of placental morphology would identify alterations between different causes of stillbirth and that placental phenotype would be independent of post-mortem effects and differ between live births and stillbirths with the same condition. Methods: Placental tissue was obtained from stillbirths with an established cause of death, those of unknown cause and live births. Image analysis was used to quantify different facets of placental structure including: syncytial nuclear aggregates (SNAs), proliferative cells, blood vessels, leukocytes and trophoblast area. These analyses were then applied to placental tissue from live births and stillbirths associated with fetal growth restriction (FGR), and to placental lobules before and after perfusion of the maternal side of the placental circulation to model post-mortem effects. Results: Different causes of stillbirth, particularly FGR, cord accident and hypertension had altered placental morphology compared to healthy live births. FGR stillbirths had increased SNAs and trophoblast area and reduced proliferation and villous vascularity; 2 out of 10 stillbirths of unknown cause had similar placental morphology to FGR. Stillbirths with FGR had reduced vascularity, proliferation and trophoblast area compared to FGR live births. Ex vivo perfusion did not reproduce the morphological findings of stillbirth. Conclusion: These preliminary data suggest that addition of quantitative assessment of placental morphology may distinguish between different causes of stillbirth; these changes do not appear to be due to post-mortem effects. Applying quantitative assessment in addition to qualitative assessment might reduce the proportion of unexplained stillbirths.
... Preterm birth was defined as delivery before 37 weeks of pregnancy were completed. The diagnosis of fetal growth restriction was made when estimated fetal weight was below the tenth percentile and was associated with abnormal fetal Doppler parameters, with low birth weight defined as <2500 gram and very low birth weight as <1500 gram [10]. Blood samples for biochemical analyses (high-sensitivity C-reactive protein (hs-CRP), fibrinogen) and a complete blood count (CBC) were obtained at 11-13 weeks and at 16-19 weeks after detailed examination. ...
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Abstract Aim: Familial Mediterranean Fever (FMF) is the most common hereditary monogenic auto-inflammatory disease. Studies suggest that inflammation persists even in attack-free periods in FMF patients. In this study, we aim to investigate the potential of simple blood parameters including neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), lymphocyte/ monocyte ratio (LMR), mean platelet volume (MPV), and platelet distributed width (PDW) as emerging inflammatory markers to identify chronic inflammations during symptom-free periods in a group of pregnant patients with FMF. Material and Method: A total of consecutive 65 singleton pregnancies, 33 with FMF and the other 32 healthy women, were followed from the first trimester to the end of the pregnancies. Blood samples for biochemical analyses (C-reactive protein, fibrinogen) and a complete blood count were obtained at 11-13 weeks and at 16-19 weeks following a detailed examination. Results: While the mean, NLR, PLR, PDW, fibrinogen, and LMR values were comparable between the groups, the mean hs-CRP levels were significantly higher and MPV values were significantly lower in the FMF group compared with the control group at both the first and second trimester. There was a significant negative correlation between hs-CRP levels with MPV at second trimester (r= -0.375 p=0.003). Discussion: Since all of our FMF patients had already been on regular colchicine therapy on admission, we admit, at least theoretically, that the anti-inflammatory and potential effects of colchicine on platelets could have altered our results. Otherwise, MPV may be used as a negative acute-phase reactant in pregnant patients with FMF. Keywords:Inflammation;Lymphocyte to Monocyte Ratio;Neutrophil to Lymphocyte Ratio; pregnancy; Platelet
... More patients are being diagnosed antenatally, a direct consequence of the extensive use of antenatal ultrasonography. [8][9][10]We had 5 of our patients diagnosed antenatally (16.6%). Most of our patients had symptoms of UTI and voiding difficulties such as poor stream, urgency, and incontinence. ...
... More importantly, women with GDM have a 7-fold increased risk of developing type 2 diabetes in the future compared to women who did not have GDM [7]. Infants born to mothers with GDM are more likely to experience birth injuries, neonatal hypoglycaemia, neonatal cardiac dysfunction, macrosomia, shoulder dystocia, and stillbirth [8][9][10]. Additional research findings suggest that infants born to women with GDM are at greater risk for developing metabolic syndromes [11], diabetes [12], and obesity [13][14][15]. ...
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A critical access hospital in a Midwestern state experiences an alarming number of high-risk pregnancies including pregnancies complicated by gestational diabetes mellitus. A health collaborative among local healthcare providers, a regional health system, a medical school, and the state health department was established to improve pregnancy and birth outcomes. The purpose of this study was to learn about the characteristics and health behaviours of rural pregnant women. A survey was administered to women who received care at two critical access hospitals and one federally qualified health centre between January and March 2015. Survey questions focused on pregnancy risk factors and ascertained health status, anthropometrics, prenatal education, dietary habits, physical activity, health behaviours, family medical history, and demographic characteristics. Descriptive analyses were conducted. Sample size included 177 rural women. Most respondents were Hispanic (50.3%), 18-25 years old (48.6%), completed some high school (20.5%) or high school graduate (30.7%), WIC enrolled (51.7%), and an income of < $25,000/year (54.2%). The majority were overweight (34.4%) or obese (41.6%) during pregnancy and 54% engaged in 30 minutes of moderate physical activity per day for ≤ 2 days per week. Education regarding fetal movement counts was minimal. Nearly one-third (30.5%) had an immediate family member with diabetes and 24.3% had an immediate family member with heart or circulation problems. Findings indicate that this rural population is at risk for pregnancy complications including gestational diabetes leading to an increased risk for developing type 2 diabetes and cardiovascular disease later in life. This study is an initial step toward understanding rural pregnant women in the catchment area. Follow-up studies that could further guide the design for intervention programming that aims to reduce the risk for cardiovascular disease are needed. Additional studies into annual screening for pregestational diabetes and early serial screening for gestational diabetes are also warranted.
... Risk factors identified included nulliparity, hypertension , body mass index >30, irregular menstruation and family history [25] . Most recently ACOG has characterized suspicious bleeding as irregular menses, intermenstrual bleeding and postmenopausal bleeding and said that the decision to histologically evaluate abnormal uterine bleeding in premenopausal women should be based on symptomatology and clinical presentation [26, 27] . The Canadian Society of Obstetricians and Gynecologists recommends endometrial sampling in women presenting with abnormal uterine bleeding and age over 40 or weighing more than 90 kg [28]. ...
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Background Even in the face of a substantial increase in the numbers of endometrial cancer cases and in the numbers of women who have risk factors, there is no clear agreement about the indications for assessing the endometria of women with abnormal bleeding or about the tools to use in that assessment. This study sought to determine in a group of high risk women with abnormal uterine bleeding, the probability that an outpatient endometrial aspiration would identify significant pathology. Methods Retrospective cohort study of the histology from endometrial aspirations performed from 2001 to 2008 for abnormal uterine bleeding at Harbor-UCLA Medical Center and its satellite public health clinics. Medical records were reviewed in detail to assess risk factors, descriptions of bleeding abnormalities and histologic results. ResultsThe charts of 1601 women who underwent 1636 endometrial biopsies for a wide variety of abnormal uterine bleeding patterns yielded 73 (4.6 %) cases of endometrial carcinoma, 43 cases of atypical endometrial hyperplasia (2.7 %), for an overall yield of significant pathology of 7.2 %. Hyperplasia without atypia was found in another 83 cases (5.2 %). Obesity, diabetes and postmenopausal age are associated with an increased risk of significant pathology. Bleeding patterns were so poorly documented that analysis of yield by this factor should be viewed with caution. Conclusions The probability of detecting significant uterine pathology is greatest among obese, diabetic postmenopausal women with diabetes (26.3 %). Conversely, the probability of identifying significant pathology in younger women without risk factors is less than 2 %. For women who perceive their individualized risk estimate to be too small to justify an endometrial biopsy, it may be possible to offer oral higher dose progestin therapy on the condition that persistent abnormal bleeding will require more intensive evaluation. These estimates of absolute risk of being diagnosed with significant pathology on endometrial biopsy may be helpful to patients as they consider giving informed consent for the procedure.
... One of the major challenges of defining this condition relies on the the ability to differentiate a physiologically small baby i.e., one that is small for the expected gestational age (SGA) from a pathologically small fetus, which is growth restricted. There is international consensus that an SGA fetus is one in which the estimated fetal weight (EFW) is less than the 10th centile [5][6][7] . By definition, therefore, SGA will affect approximately 10 % of pregnancies. ...
Article
Fetal growth restriction (FGR) is associated with significantly increased perinatal mortality as well as immediate and long-term morbidity. One of the most challenging aspects of this condition is the ability to accurately define and adequately diagnose it in order to determine appropriate clinical management. Within a common pathogenesis of placental insufficiency, two phenotypes, early and late FGR, have emerged. Early FGR is easier to diagnose, however, as a consequence of extreme prematurity at presentation it can be extremely challenging to manage. Late fetal growth restriction is much more problematic to diagnose but relatively straightforward to manage as delivery is a reasonable option. Areas of research with regards to FGR, which require further evaluation, include the development of more accurate screening tools in order to identify those women at risk and validation of the role of aspirin in the prevention of this condition in a prospective adequately powered trial.
... When LNG is administered after the onset of the LH surge, it appears to have no effect on the ovulatory process, and this may explain the reported failures of this EC method [11] . The effects of pre-and postovulatory administration of LNG are still not clear, and no significant change in endometrial histology is detected [12,13] . A plausible mechanism of action could primarily be ciliary dysfunction and secondary altered tubal motility to high progestin levels. ...
... ABD'de tüm gebelere HBsAg taramasına 1988 yılında başlanırken, ABD'de " Preventive Services Task Force " 2004 yılında tüm gebelerin ilk vizitte HBsAg açısından tetkik edilmesini önermiştir [8] . Gerek CDC gerekse Kadın Hastalıkları ve Jinekologlar Amerikan Koleji tarafından HBsAg taramasının her gebelikte yapılması ve HBV açısından yüksek riskli olanlarda doğuma giderken de tetkik yapılması önerilmektedir [9,10]. Gebelerin HBsAg açısından taranmasının aynı zamanda maliyet etkin bir uygulama olduğu da gösterilmiştir [11] . ...
... In summary, cordocentesis results in a higher rate of fetal loss than amniocentesis used for molecular genetic diagnosis. In addition, amniocentesis which was a necessary procedure for cordocentesis has a fetal loss rate of 0.5% to 1.0% [15]. Therefore, proper prenatal counseling of the mother (and family) is necessary when cordocentesis is required. ...
... The placenta is a fundamental substrate for the development and evolution of pregnancy. Placental abnormalities affect several cases of intrauterine fetal death [7] and histological examination is strongly recommended by several international guidelines [8][9][10][11] also to interpret unfavorable pregnancy outcomes even in cases apparently occurring without clinical cause. However, despite placental examination appearing to be important in cases of intrauterine fetal death, a recent systematic review failed to identify a specific role of the various placental lesions in stillbirth [12]. ...
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Objective To investigate the proportion of stillbirths at term associated with abnormal growth using customized birth weight percentiles and to compare histological placental findings both in underweight stillborn fetuses and in live births. Methods A retrospective case-control study of 150 singleton term stillbirths. The livebirth control groups included 586 cases of low-risk pregnancies and 153 late fetal growth restriction fetuses. Stillbirths and livebirths from low-risk pregnancies were classified using customized standards for fetal weight at birth, as adequate for gestational age (AGA; 10-90th percentile), small (SGA; <10th percentile) or large for gestational age (LGA; >90th percentile). Placental characteristics in stillbirth were compared with those from livebirths using four categories: inflammation, disruptive, obstructive and adaptive lesions. Results There was a higher rate of SGA (26% vs 6%, p<0.001) and LGA fetuses (10.6% vs 5.6%, p<0.05) in the stillbirth group. Among stillbirth fetuses, almost half of the SGA were very low birthweight (≤3°percentile) (12% vs 0.3%, p<0.001). The disruptive (7.3% vs 0.17%;p<0.001), obstructive (54.6% vs 7.5%;p<0.001) and adaptive (46.6% vs 35.8%;p<0.001) findings were significantly more common in than in livebirth-low risk. Placental characteristics of AGA and SGA stillbirth were compared with those of AGA and FGR livebirth. In stillbirths-SGA we found a higher number of disruptive (12.8% vs 0%; p<0.001), obstructive (58.9% vs 23.5%;p<0.001) and adaptive lesions (56.4% vs 49%; p 0.47) than in livebirth-FGR. Conclusion The assessment of fetal weight with customized curves can identify fetuses which have not reached their genetically determined growth potential and are therefore at risk for adverse outcomes. Placental evaluation in stillbirths can reveal chronic histological signs that might be useful to clinical assessment, especially in underweight fetuses.
... The hormonal induced changes affect all women regardless of ethnicity or socio-economic status and place a burden on interpersonal relationships, mental health, and work productivity [3]. The American College of Obstetricians and Gynecologists (ACOG) recommend pharmacological treatment should be used as a first line intervention for PMDD [5]. Selective serotonin reuptake inhibitors (SSRIs) have demonstrated a small effect size in PMS change scores (standardized mean difference= −0.36, 95% CI −0.2 to −0.51) [6], although they are more effective in women with severe PMS/PMDD; showing a moderate effect size in overall symptom reduction in this population of women (standardized mean difference= −0.53, 95% CI 0.68 to −0.39) [7]. ...
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Background: The recent addition of Premenstrual Dysphoric Disorder (PMDD) to the Diagnostic and Statistical Manual (5th ed.) has highlighted the seriousness of this disorder. Many alternatives to psychoactive medication in the form of vitamins, minerals, and plant extracts have been trialled by women seeking a natural treatment approach. We plan to explore whether a well validated micronutrient formula, EMPowerplus Advanced, can outperform a recognized single nutrient treatment, vitamin B6, for the treatment of Premenstrual Syndrome (PMS). Methods: This will be a randomized treatment control study. Eighty women will be recruited and assigned to one of two treatment groups; EMPowerplus Advanced or vitamin B6. Baseline daily data will be collected for an initial two cycles, followed by three months of active treatment. A natural follow up will take place three cycles post treatment. Results: The primary outcome measure will be PMS change scores as based on results from the Daily Record of Severity of Problems (DRSP). The number of treatment responders for each of the two groups will yield a comparison score between the two treatments, with participants deemed as a responder if they show a total PMS score improvement of 50% from their baseline scores on the DRSP. Conclusion: If a micronutrient formula proves more effective for treating PMS, not only does it give women suffering from the condition a viable treatment option, but it may also suggest one cause of PMS; that is insufficient minerals and vitamins.
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BACKGROUND: Chorionic villus sampling (CVS) is an invasive diagnostic procedure done in early pregnancy to obtain cells for the prenatal diagnosis of chromosomal and genetic defects. AIMS: To study the indications, results and complications of pregnancies following transabdominal chorionic villus sampling (CVS). STUDY DESIGN AND SETTINGS: This is a retrospective analytical study on women who had undergone transabdominal CVS in a single unit at the Obstetrics and Gynaecology department, Christian Medical College, Vellore from January 2012 to December 2014. MATERIAL AND METHODS: All pregnant women who underwent CVS for various indications during the specified period were included in the study. The clinical details of the women were retrieved from the hospital database regarding age, domicile, obstetric history, family history, gestation age, indication and outcome of procedure. RESULTS: Total 67 women had undergone transabdominal CVS during the study period. Out of 67 procedures, tissue retrieval was possible in 64 (95.52%) cases. Out of 64 samples, 2 (2.98%) were contaminated. Most of the procedures were done between 11-13 weeks gestation. The most common indication for doing the procedure was for chromosomal disorders (39%). Forty six women (74.19%) had normal results and 16 (25.80%) had abnormal results. Of those with abnormal results, 9 (14.51%) fetuses were affected including 3 with chromosomal abnormalities whereas 7 (11.29%) had carrier state. Majority of abnormal results were found when indication for the procedure was previous affected child. No woman had vaginal bleeding, leaking or pregnancy loss within 3 weeks of procedure. CONCLUSION: Transabdominal CVS is a safe and reliable outpatient procedure for prenatal diagnosis in early pregnancy and should be considered as procedure of choice. CVS is beneficial in providing early prenatal diagnosis and offering further options of management if pregnancy is affected. In experienced hands miscarriage rate following the procedure is very low.
Article
Objective: The aim of this study was to define patient knowledge and perceptions of pessaries to identify barriers to care and inform physician counseling efforts. Methods: An anonymous survey was distributed to a convenience sample of new patients presenting to the urogynecology clinic at a single academic medical center. Data analysis was performed using standard bivariate and logistic regression models. Results: A total of 254 women completed the survey. Only half of respondents indicated prior knowledge of pessaries. The most common source of prior knowledge was a physician or other health care provider (100/130, 76.9%); comparatively few women had heard about pessaries from any other source. Patients presented with a negative view of pessaries, 3.6 ± 2.2 on a 0- to 10-point Likert scale, and only a third of patients indicated they would consider pessary use as a treatment option for their condition. On multivariable logistic regression, having previously seen a gynecologist (P = 0.03) and a lower level of education (P = 0.05) independently predicted aversion to pessary use. Conclusions: Only half of patients presenting to a referral-based practice had previous knowledge of vaginal pessaries. Few patients had heard about pessaries from any source other than a physician or other health care provider. Patients presented with a negative impression of pessaries and a high level of aversion to pessary use. Patients who indicated they would decline pessary use reported a lower level of education and were more likely to have previously seen a gynecologist for evaluation of their condition. These data may inform physician counseling efforts.
Article
Background: Vertical transmission of hepatitis C virus (HCV) is the most common route of pediatric HCV infection. Approximately 5% percent of children born to HCV-positive mothers develop chronic infection. Recommendations employ risk-based HCV testing of pregnant women, and screening children at a young age. This study assesses testing rates of children born to HCV-positive mothers in a major US city with a high burden of HCV infection. Methods: HCV surveillance data reported to the Philadelphia Department of Public Health (PDPH) are housed in the Hepatitis Registry. Additional tests, including negative results, were retrospectively collected. HCV data were matched with 2011-2013 birth certificates of children ≥20 months to identify HCV-positive mothers and screened children. The observed perinatal HCV seropositivity rate was compared to the expected rate (5%). Results: 8,119 females (12-54 years) were HCV-positive and in the Hepatitis Registry. Of these, 500 (5%) had delivered ≥1 child, accounting for 537 (1%) of the 55,623 children born in Philadelphia during the study period. Eighty-four (16%) of these children had HCV testing; four (1% of the total) were Confirmed cases. Twenty-four additional children are expected to have chronic HCV infection, but were not identified by 20 months of age. Conclusion: These findings illustrate that a significant number of women giving birth in Philadelphia are HCV-positive and that most of their at-risk children remain untested. To successfully identify all HCV-infected children and integrate them into HCV-specific care, practices for HCV screening of pregnant women and their children should be improved.
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Physicians engage in risk stratification as a normative part of their professional duties. Risk stratification has the potential to be beneficial in many ways, and implicit recognition of this potential benefit underlies its acceptance as a cornerstone of the medical profession. However, risk stratification also has the potential to be harmful. We argue that ‘profiling’ is a term that corresponds to risk stratification strategies in which there is concern that ethical harms exceed likely or proven benefits. In the case of risk stratification for health goals, this would occur most frequently if benefits were obtained by threats to justice, autonomy or privacy. We discuss implications of the potential overlap between risk stratification and profiling for researchers and for clinicians, and we consider whether there are salient characteristics that make a particular risk stratification algorithm more or less likely to overlap with profiling, such as whether the risk stratification algorithm is based on voluntary versus non-voluntary characteristics, based on causal versus non-causal characteristics, or based on signifiers of historical disadvantage. We also discuss the ethical challenges created when a risk stratification scheme helps all subgroups but some more than others, or when risk stratification harms some subgroups but benefits the aggregate group.
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Background and Aim: Birth in the 21 st century is characterized by interventions. That interventions increase the risk for mother and baby without improving outcomes. The aim of this study was to compare the effect of physiological birth and routine normal delivery on some of maternal and fetus outcomes. Methods: This quasi-experimental study was performed on 160 pregnant women. The participants were allocated in two groups of physiological birth (n=80) and routine normal delivery (n=80). Inclusion criteria were as following: Apgar score between one and five; dilatation between three and four cm; maternal age between 18-35 years; gestational age between 37-40 weeks; cephalic presentation and neonatal birth weight of 2500-4000 gr. Physiological birth care included labor begins on its own, freedom of movement throughout labor, continuous labor support, spontaneous pushing, no separation of mother and baby. Routine birth cares include routine interventions in labor or birth. Rate of cesarean, Apgar score and neonatal intensive care unit were evaluated in both groups. Data were analyzed by SPSS 16. The t-test, chi-square and Mann Whitney were the statistical tests of choice. Results: Rate of cesarean was significantly different between two groups (p=0.005). First minute Neonatal Apgar score was significantly different (p=0.011), but fifth minute Apgar was similar in both groups (p=0.470). The transmission to neonatal intensive care unit had also significant difference among two groups (p=0.029). Conclusion: The present study showed that the physiological birth is safe. It seems that the physiological birth decreases the rate of cesarean and transmission to neonatal intensive care unit, also improves the first minute neonatal Apgar scores.
Article
Introduction: Many birth units use central fetal monitoring (CFM) under the assumption that greater surveillance improves perinatal outcomes. The unexpected loss of the CFM system at a tertiary unit provided a unique opportunity to evaluate outcomes and staff attitudes toward CFM. Methods: This retrospective cohort study compared patient data from 2,855 electronically monitored women delivering over a 12-month period, where CFM was available for the first 6 months but unavailable for the following 6 months. Primary outcomes relating to neonatal morbidity and secondary outcomes relating to intrapartum interventions were examined. Additionally, birth unit staff members were surveyed about aspects of care related to CFM. Results: There were no significant differences in perinatal outcomes between the cohorts. While unadjusted analysis suggested a lower spontaneous vaginal birth rate (55.4% vs 60.3%) and a higher cesarean delivery rate (25.1% vs 22.0%, p = 0.026), together with higher epidural (53.0% vs 49.2%, p = 0.04) and fetal blood sampling (11.8% vs 9.4%, p = 0.03) rates in the presence of CFM, these differences were lost when adjusted for prostaglandin ripening. Over half of the staff (56.0% of midwives, 54.0% of obstetricians) reported spending more time with the laboring woman in the period without CFM. Conclusions: This single institution's experience indicates that in birth units staffed for one-to-one care in labor, central fetal monitoring does not appear to be associated with either a benefit on perinatal outcomes or an increase in cesarean delivery and other interventions. However, it is associated with a reduction in the time a midwife spends with the laboring woman.
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The discrimination between benign and malignant adnexal masses in ultrasound images represents one of the most challenging problems in gynecologic practice. In the study described here, a new method for automatic discrimination of adnexal masses based on a neural networks approach was tested. The proposed method first calculates seven different types of characteristics (local binary pattern, fractal dimension, entropy, invariant moments, gray level co-occurrence matrix, law texture energy and Gabor wavelet) from ultrasound images of the ovary, from which several features are extracted and collected together with the clinical patient age. The proposed technique was validated using 106 benign and 39 malignant images obtained from 145 patients, corresponding to its probability of appearance in general population. On evaluation of the classifier, an accuracy of 98.78%, sensitivity of 98.50%, specificity of 98.90% and area under the curve of 0.997 were calculated.
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Objective: To describe the prevalence of antenatal hospitalizations, compare characteristics of women with and without antenatal hospitalizations, and compare timing, length of stay, and reason for hospitalization among pregnancies conceived with and without assisted reproductive technology (ART). Methods: We performed a retrospective cohort analysis using linked ART surveillance, vital records, and hospital discharge data from Michigan to calculate the hospitalization ratio as the number of antenatal admissions per 100 live birth deliveries for ART and non-ART deliveries during 2004-2012 and compare trends by ART status. We then restricted analysis to 2008-2012 and used logistic, multinomial, and Poisson regression analysis to model antenatal admissions, trimester of admission, and length of stay, respectively, for ART compared with non-ART deliveries. We examined reason for hospitalization by ART status. Results: Between 2004 and 2012, the hospitalization ratio for ART deliveries decreased from 14.6 to 12.3 per 100 deliveries (P<.001). Of 557,708 live deliveries during 2008-2012, 22,763 (4.1%) had an antenatal hospitalization. Assisted reproductive technology was a risk factor for having any antenatal admission (singletons adjusted risk ratio [RR] 1.63, 95% confidence interval [CI] 1.43-1.83; multiples adjusted RR 1.24, 95% CI 1.12-1.38) and two or more admissions (singletons adjusted RR 1.86, 95% CI 1.25-2.75; multiples adjusted RR 1.33, 95% CI 1.14-1.54). The percent of time (days) hospitalized during the antenatal period was greater for ART deliveries than non-ART deliveries (singleton adjusted RR 1.28, 95% CI 1.09-1.51; multiples adjusted RR 1.14, 95% CI 1.01-1.29). The most common reason for antenatal admission was preterm labor among all non-ART and multiple gestation deliveries and vaginal bleeding among ART singleton gestations. Conclusion: Deliveries after ART were associated with increased risk of antenatal admissions and longer hospitalizations compared with non-ART deliveries.
Article
Background: The World Health Organization (WHO) is in the process of updating antenatal care (ANC) guidelines. Objectives: To map the existing clinical practice guidelines related to routine ANC for healthy women and to summarise all practices considered during routine ANC. Search strategy: A systematic search in four databases for all clinical practice guidelines published after January 2000. Selection criteria: Two researchers independently assessed the list of potentially eligible publications. Data collection and analysis: Information on scope of the guideline, type of practice, associated gestational age, recommendation type and the source of evidence were mapped. Main results: Of 1866 references, we identified 85 guidelines focusing on the ANC period: 15 pertaining to routine ANC and 70 pertaining to specific situations. A total of 135 interventions from routine ANC guidelines were extracted, and categorised as clinical interventions (n = 80), screening/diagnostic procedures (n = 47) and health systems related (n = 8). Screening interventions, (syphilis, anaemia) were the most common practices. Within the 70 specific situation guidelines, 102 recommendations were identified. Overall, for 33 (out of 171) interventions there were conflicting recommendations provided by the different guidelines. Conclusion: Mapping the current guidelines including practices related to routine ANC informed the scoping phase for the WHO guideline for ANC. Our analysis indicates that guideline development processes may lead to different recommendations, due to context, evidence base or assessment of evidence. It would be useful for guideline developers to map and refer to other similar guidelines and, where relevant, explore the discrepancies in recommendations and others. Tweetable abstract: We identified existing ANC guidelines and mapped scope, practices, recommendations and source of evidence.
Article
Aims: To compare the incidence of large-for-gestational-age (LGA) infants in women diagnosed with gestational diabetes mellitus (GDM) early and late in pregnancy, and evaluate associated factors. Methods: A total of 284 women with GDM who commenced antenatal care before 20 weeks of gestation were enrolled: 142 were diagnosed before 20 weeks (early GDM) and 142 were diagnosed after 20 weeks of gestation after normal initial screening tests (late GDM). Incidence of LGA infants were compared. Factors associated with LGA and pregnancy outcomes were evaluated. Results: Both groups had comparable baseline characteristics. The late GDM group were more likely to gain weight greater than recommended (P = 0.009) and less likely to have optimal glycemic control (P = 0.035). Incidences of maternal and neonatal complications, including LGA, were not significantly different between the groups. Logistic regression analysis demonstrated that the timing of GDM diagnosis was not significantly associated with LGA. Less gestational weight gain than recommended decreased the risk of LGA by 76% (adjusted odds ratio [OR] 0.24, 95% confidence interval [CI] 0.09-0.67, P = 0.007), while gestational weight gain greater than recommended doubled the risk of LGA (adjusted OR 1.99, 95% CI 1.03-3.87, P = 0.041). Good glycemic control also reduced the risk of LGA by 66% (adjusted OR 0.34, 95% CI 0.16-0.71, P = 0.886). Conclusion: Gestational weight gain and glycemic control, but not timing of diagnosis, were independently associated with LGA in women with GDM. Women diagnosed with GDM early had similar rates of LGA infants as women diagnosed late.
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Anemia is the commonest hematological disorder that occurs in pregnancy. According to the recent standard laid down by ‘WHO’, anemia is present when the Hemoglobin (Hb) concentration in the peripheral blood is 11 gm/dl or less. The most common cause of anemia in pregnancy is lack of iron. Less often, it is caused by folic acid deficiency. In some populations, 80% of pregnant women are anemic. Those most at risk are women from low socio-economic groups and teenagers. Anemia is diagnosed by estimating the hemoglobin concentration and examining a peripheral blood smear for the characteristic red blood cell changes. Iron and folate supplementation is indicated during pregnancy to prevent the complications. DOI: http://dx.doi.org/10.3329/medtoday.v26i1.21314 Medicine Today 2014 Vol.26(1): 49-52
Article
Objectives: Our aim was to evaluate the size of the fetal thymus by sonography in pregnancies with intrauterine growth restriction (IUGR) and to search for a possible relationship between a small fetal thymus and adverse perinatal outcomes. Methods: The transverse diameter of the fetal thymus was prospectively measured in 150 healthy and 143 IUGR fetuses between 24 and 40 weeks' gestation. The fetuses with IUGR were further divided according to normal or abnormal Doppler assessment of the umbilical and middle cerebral arteries and ductus venosus. Measurements were compared with reference ranges from controls. To determine which perinatal outcomes were independently associated with a small fetal thymus, a multivariate logistic regression analysis was performed. Results: Thymus size was significantly lower in IUGR fetuses compared to controls (P < .05). Among IUGR fetuses, thymus size was significantly smaller in IUGR fetuses with abnormal Doppler flow compared to normal flow (P < .05). A small thymus in IUGR fetuses was independently associated with early delivery (odds ratio [OR], 1.24; 95% confidence interval [CI], 1.05-1.49; P= .023), respiratory distress syndrome (OR, 1.36; 95% CI, 1.09-1.78; P= .005), early neonatal sepsis (OR, 1.65; 95% CI, 1.11-2.42; P= .001), and a longer stay in the neonatal intensive care unit (OR, 1.33; 95% CI, 1.08-1.71; P = .017). Conclusions: Intrauterine growth restriction is associated with fetal thymic involution, and a small fetal thymus is an early indicator of adverse perinatal outcomes in pregnancies complicated by IUGR.
Article
Objective: Limited understanding of risk factors exists for postpartum hemorrhage (PPH) post-vaginal delivery. The aim of this study was to identify risk factors for PPH post-vaginal delivery within a contemporary obstetric cohort. Study design: Retrospective case-control study. PPH was classified by an estimated blood loss ⩾500 ml. Risk factors for PPH were identified using univariable and multivariable logistic regression. We secondarily investigated maternal outcomes and medical and surgical interventions for PPH management. Results: The study cohort comprised 159 cases and 318 controls. Compared with a second-stage duration <2 h, a second stage⩾3 h was associated with PPH (adjusted odds ratio=2.3; 95% CI=1.2 to 4.6). No other clinical or obstetric variables were identified as independent risk factors for PPH. Among cases, 4% received red blood cells and 1% required intensive care admission. Conclusion: Although PPH-related morbidity may be uncommon after vaginal delivery, PPH should be anticipated for women after a second stage ⩾3 h.Journal of Perinatology advance online publication, 15 December 2016; doi:10.1038/jp.2016.225.
Article
Background: The purpose of this study was to clarify cardiovascular structure and function in small for gestational age (SGA) infants across a range of intrauterine growth restriction (IUGR) severity.Methods and Results:This prospective study included 38 SGA infants and 30 appropriate for gestational age (AGA) infants. SGA infants were subclassified into severe and mild SGA according to the degree of IUGR. Cardiovascular structure and function were evaluated using echocardiography at 1 week of age. Compared with the AGA infants, both the severe and mild SGA infants showed increased left ventricular diastolic dimensions (severe SGA 10.2±2.4, mild SGA 8.2±1.3, and AGA 7.3±0.7 mm/kg, P<0.05 for all) and decreased global longitudinal strain (severe -21.1±1.6, mild -22.5±1.8, and AGA -23.8±1.8%, P<0.05 for all). Severe SGA infants showed a decreased mitral annular early diastolic velocity (severe 5.6±1.4 vs. AGA 7.0±1.3 cm/s, P<0.01) and increased isovolumic relaxation time (severe 51.3±9.2 vs. AGA 42.7±8.2 ms, P<0.01). Weight-adjusted aortic intima-media thickness and arterial wall stiffness were significantly greater in both SGA infant groups. These cardiovascular parameters tended to deteriorate with increasing IUGR severity. Conclusions: SGA infants, including those with mild SGA, showed cardiovascular remodeling and dysfunction, which increased with IUGR severity.
Article
Objective: To compare the accuracy of various sonographic estimated fetal weight (sEFW) formulas for the prediction of small for gestational age (SGA) neonates. Methods: A retrospective analysis of 6,126 fetal biometrical measurements performed within 3 days of delivery. SGA prediction was evaluated for various sEFW formulas by calculating the sensitivity, specificity, positive/negative predictive value (PPV/NPV), likelihood ratio (+LR/-LR), overall accuracy and area under the receiver operating characteristic curve (AUC). Systematic error, random error, proportion of estimates >10% of birth weights, actual and absolute weight differences were compared between SGA and non-SGA neonates. Results: Overall, 638 (10.4%) neonates were SGA. There was considerable variation among formulas in sensitivity (mean ± SD, 62 ± 14.4%; range, 32.4-91.2), PPV (72.5 ± 10.7%; 45.8-95.6) and +LR (24.2 ± 10.9; 7.2-57.3), mild variation in specificity (96.6 ± 2.7%; 87.4-99.4), NPV (94.6 ± 5.3%; 72.2-98.9) and -LR (0.4 ± 0.1; 0.1-0.7) and minimal variation in AUC (mean, 0.93; range, 0.91-0.93). The majority of formulas had a lower accuracy for the SGA neonates, with systematic error and random error ranging from -4.2 to 14.3% and from 8.4 to 12.9% for SGA, and from -8.7 to 16.1% and from 7.2 to 10.5% for non-SGA, respectively. Conclusion: sEFW formulas differ in their accuracy for SGA prediction. In our population, the most accurate formula for SGA prediction was Hadlock's formula utilizing femur length, abdominal and head circumference.
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Objective: The objective of this study was to compare the performance of the US Preventive Services Task Force (USPSTF) recommended WHO Fracture Risk Assessment Tool (FRAX) threshold score of 9.3% (calculated without femoral neck bone density) with the Simple Calculated Osteoporosis Risk Estimate (SCORE), Osteoporosis Self-Assessment Tool (OST), and the Osteoporosis Risk Assessment Instrument (ORAI) to identify osteoporosis in younger women. Methods: We conducted a retrospective review of women ages 50 to 64 years who underwent dual-energy radiographic absorptiometry (DXA) at our institution over a 6-month period. Scores for the FRAX, ORAI, OST, and SCORE tools were calculated using various thresholds: FRAX ≥9.3%, SCORE ≥6, OST <2, and ORAI ≥9. Sensitivity, specificity, and area under the receiver-operating characteristic curve for detection of densitometric osteoporosis by DXA for each tool were compared. Results: A total of 290 women were identified. Of these, 284 (97.9%) were white, and the mean ± standard deviation age was 56.6 ± 3.4 years. Fifty (17.2%) had osteoporosis of the lumbar spine and/or femoral neck on DXA. Sensitivity, specificity, and area under the receiver-operating characteristic curve for identifying densitometric osteoporosis at the femoral neck and/or spine were 36%, 73%, and 0.55 for FRAX; 74%, 42%, and 0.58 for SCORE; 56%, 69%, and 0.63 for the OST; and 52%, 67%, and 0.60 for the ORAI, respectively. Conclusions: DXA screening based on the USPSTF-recommended FRAX threshold score of 9.3% has a low sensitivity to identify densitometric osteoporosis in women ages 50 to 64. Lowering the threshold score would increase sensitivity but would also increase the number of women sent for screening DXA. Use of the validated SCORE tool would improve sensitivity to identify osteoporosis in this age group.
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The association between folic acid supplementation, prior to conception and/or during pregnancy and pregnancy outcomes, has been the subject of numerous studies. The worldwide recommendation of folic acid is at least 0.4 mg daily for all women of reproductive age, and 4–5 mg in high-risk women. In addition, evidence shows that folic acid supplementation could modulate other adverse pregnancy outcomes, specifically, in pregnancies complicated by seizure disorders, preeclampsia, anemia, fetal growth restriction and autism. This review summarizes the available national and international guidelines, concerning the indications and dosage of folic acid supplementation during pregnancy. In addition, it describes the potential preventive benefits of folic acid supplementation on multiple maternal and fetal outcomes, as well as potential risks.
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A prospective study was conducted in centre in Southern Thailand, to evaluate agreement in EFM interpretation among various physicians in order to find out the most practical system for daily use. We found strong agreement of very normal FHR tracings among the FIGO, NICHD 3-tier and 5-tier systems. The NICHD 3-tier was more compatible with the FIGO system than 5-tier system. Overall inter-observer agreement was moderate for the NICHD 3-tier system while inter-observer agreement of 5-tier system was fair also the intra-observer agreement was higher in the NICHD 3-tier system. So the 3-tier systems are more suitable than the 5-tier system in general obstetric practice. • Impact statement • What is already known on this subject: The 3-tier and 5-tier systems were widely used in general obstetrics practice. • What the results of this study add: The inter- and intra-observer agreement of NICHD 3-tier system was higher than the 5-tier system. • What the implications are of these findings for clinical practice and/or further research: The 3-tier systems were more suitable than the 5-tier systems in general obstetrics practice.
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Background Care during pregnancy and performing consultation for delivery preparation play an important role in improving pregnant women’s knowledge. Objective The purpose of this study was to investigate the effect of consultation and instruction in the preparation classes for delivery on pregnancy consequences, including choosing the type of delivery, the performed type of delivery, and infant’s weight. Methods This study was conducted in 2015 on 170 pregnant women who had been referred to the prenatal clinic in Hamedan. The participants were randomly divided into intervention and control groups. Eight sessions of consultation for delivery preparation were held for the women in 20 to 36 weeks of pregnancy. The control group received only the routine care. After 37 weeks of pregnancy, the participants answered a questionnaire. The infant’s weight was measured after birth. Data were analyzed Using SPSS-21 and McNemar–Bowker Test, independent t-test, chi-square test, and Fisher exact test. Results Results showed a significant statistical difference between the two groups concerning their selective and performed delivery (p<0.001). The weight of infants in the intervention group was significantly higher than that of those in the control group (p<0.001). Conclusion The findings of this study showed that the consultation for delivery preparation had a positive effect on some pregnancy consequences such as selecting the type of delivery performed and infant’s weight. Trial registration The trial was registered at the Iranian Registry of Clinical Trials (http://www.irct.ir) with the IRCTID: IRCT2015012513405N9. Funding The authors received no financial support for the research, authorship, and/or publication of this article.
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amilelik, kadın hayatının en heyecan verici ve özel dönemlerinden biri-dir. Bu süreçte fetal büyüme ile beraber metobolik, hormonal değişiklikler ve artan ihtiyaçlar anne adayları için hastalıkların sebebi olabilir. Bu fi-ziksel değişiklikler gebelerde özellikle hematolojik hastalıkların tanısını da zorlaş-tırır. Gebelikte plazma volümü %32-50 artarken eritrosit volümü %18-30 artar, dilüsyonel değişiklikler gözlenir. Anemi kan hemoglobin (hgb) düzeyinin düşük-lüğü olarak tanımlanır. Anemi özelikle az gelişmiş ve gelişmekte olan ülkelerde daha sık görülmesine rağmen, tüm dünya ülkelerini ilgilendiren önemli bir halk Turkiye Klinikleri J Fam Med-Special Topics 2016;7(3) 17 Gebelerde Anemiye Yaklaşım Ö ÖZ ZE ET T Anemi gebelikte en yaygın izlenen hematolojik hastalıktır. Özellikle az gelişmiş ve geliş-mekte olan ülkelerde hem anne hem de fetüsta risk oluşturduğu için önemli bir halk sağlığı sorunu olarak kabul edilmektedir. Kadınların hayatında gebelik oldukça arzulanan ve heyecan verici bir durum olsa da, bu süreçte artan anabolik aktivitelerle, büyük bir stres sebebi olabilir. Bu değişik-likler çoğu annenin besin ihtiyacını oldukça artırır. Gebelikte bütün kadınlar daha fazla yiyecek, de-ğişik besinler ve mikro besin takviyelerine ihtiyaç duyarlar. Beslenmenin olmaması ya da yetersiz olması durumunda vücudun kendi rezervleri tüketilir ve bu eksikliklere bağlı hastalıklar gelişir. Demir eksikliği anemisi ve doğum sırasında akut kan kaybına bağlı anemi gebelikte izlenen en önemli anemi nedenleridir. Bu çalışmanın amacı aneminin nedenleri ve yönetimi ile ilgili kısa bir değerlendirme yapmaktır. Ayrıca çalışmada gebelik sırasında aneminin taraması ile ilgili klinis-yenlere destek verilmesi amaçlanmıştır. A An na ah ht ta ar r K Ke el li im me el le er r: : Anemi; anemi,demir eksikliği; gebelik; prenatal tani; önleme ve kontrol A AB BS ST TR RA AC CT T Anemia is the most common hematologic abnormality in pregnancy. It is still considered a public health problem because it is hazardous to both mother and fetus particularly in low-to middle-income countries. Although pregnancy itself is a desirable and exciting state in a woman's life, it is a condition of great stress because of many anabolic activities that take place during this period. Many of these changes tremendously increase the nutritional requirements of the mother. During pregnancy all women need more food, a varied diet, and micronutrient supplements. A lack of a nutrient or poor nutrition can result in a deficiency disease because in this situation the body's own reserves are used. The two most common causes of anemia in pregnancy are iron deficiency and acute blood loss during childbirth. The purpose of this study is to provide a brief overview of the management and the causes of anemia. This study also aimed to assist to clinicians in the screening process of anemia during pregnancy. K Ke ey y W Wo or rd ds s: : Anemia; anemia, iron-deficiency; pregnancy; prenatal diagnosis; prevention & control T Tu ur rk ki iy ye e K Kl li in ni ik kl le er ri i J J F Fa am m M Me ed d-S Sp pe ec ci ia al l T To op pi ic cs s 2 20 01 16 6; ;7 7((3 3)): :1 17 7-2 24 4
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Background: Postpartum anemia is associated with maternal and perinatal morbidity. Population-level data may inform guideline development for postpartum anemia screening. Our objectives were to evaluate the associations between potential predictors (predelivery anemia and postpartum hemorrhage [PPH]) with severe postpartum anemia after Cesarean section. Study design and methods: Data were collected from 70,939 hospitalizations for Cesarean section performed at Kaiser Permanente Northern California facilities between 2005 and 2013. Severe postpartum anemia was defined as a hemoglobin (Hb) level of less than 8 g/dL before hospital discharge. Using multivariable logistic regression, we assessed the associations between predelivery anemia and PPH with severe postpartum anemia. Distributions of these characteristics among women with severe postpartum anemia were evaluated. Results: The overall rate of severe postpartum anemia was 7.3% (95% confidence interval [CI], 7.1%-7.4%). Severe postpartum anemia was strongly associated with a predelivery Hb level between 10 and 10.9 g/dL (adjusted odds ratio [aOR], 5.4; 95% CI, 4.89-5.91), predelivery Hb level of less than 10 g/dL (aOR, 30.6; 95% CI, 27.21-34.6), and PPH (aOR, 8.45; 95% CI, 7.8-9.16). The proportions of women with severe postpartum anemia were highest for those experiencing PPH but no predelivery anemia (12.2%; 95% CI, 11.0%-13.6%) and those who did not incur PPH nor predelivery anemia (10.7%; 95% CI, 9.6%-12.0%). Conclusions: Our findings suggest that PPH and predelivery anemia are strong independent risk factors for severe postpartum anemia. Optimization of patients' Hb before delivery may reduce the incidence of severe anemia after Cesarean section.
Article
Background: With the development and widespread use of combination antiretroviral therapy, HIV-infected women live longer, healthier lives. Previous research has shown that, since the adoption of combination antiretroviral therapy in the United States, rates of morbidity and adverse obstetric outcomes remained higher for HIV-infected pregnant women compared with HIV-uninfected pregnant women. Monitoring trends in the outcomes these women experience is essential, as recommendations for this special population continue to evolve with the progress of HIV treatment and prevention options. Objective: We conducted an analysis comparing rates of hospitalizations and associated outcomes among HIV-infected and HIV-uninfected pregnant women in the United States from 2004 through 2011. Study design: We used cross-sectional hospital discharge data for girls and women age 15-49 from the 2004, 2007, and 2011 Nationwide Inpatient Sample, a nationally representative sample of US hospital discharges. Demographic characteristics, morbidity outcomes, and time trends were compared using χ(2) tests and multivariate logistic regression. Analyses were weighted to produce national estimates. Results: In 2011, there were 4751 estimated pregnancy hospitalizations and 3855 delivery hospitalizations for HIV-infected pregnant women; neither increased since 2004. Compared with those of HIV-uninfected women, pregnancy hospitalizations of HIV-infected women were more likely to be longer, be in the South and Northeast, be covered by public insurance, and incur higher charges (all P < .005). Hospitalizations among pregnant women with HIV infection had higher rates for many adverse outcomes. Compared to 2004, hospitalizations of HIV-infected pregnant women in 2011 had higher odds of gestational diabetes (adjusted odds ratio, 1.81; 95% confidence interval, 1.16-2.84), preeclampsia/hypertensive disorders of pregnancy (adjusted odds ratio, 1.58; 95% confidence interval, 1.12-2.24), viral/mycotic/parasitic infections (adjusted odds ratio, 1.90; 95% confidence interval, 1.69-2.14), and bacterial infections (adjusted odds ratio, 2.54; 95% confidence interval, 1.53-4.20). Bacterial infections did not increase among hospitalizations of HIV-uninfected pregnant women. Conclusion: The numbers of hospitalizations during pregnancy and delivery have not increased for HIV-infected women since 2004, a departure from previously estimated trends. Pregnancy hospitalizations of HIV-infected women remain more medically complex than those of HIV-uninfected women. An increasing trend in infections among the delivery hospitalizations of HIV-infected pregnant women warrant further attention.
Article
Amniotic fluid embolism occurring following diagnostic amniocentesis is extremely rare. Only 2 cases have been reported in the English literature over the past 55 years, the most recent one approximately 3 decades ago. We present a case of amniocentesis at 24 weeks' gestation that was performed as part of an evaluation of abnormal fetal ultrasound findings. Immediately following amniotic fluid aspiration, maternal hemodynamic collapse occurred, initially diagnosed and treated as anaphylactic shock. Shortly after initial therapy, coagulopathy was noted and amniotic fluid syndrome suspected. Rapid response restored maternal hemodynamic stability; however, the fetus had suffered fatal damage.
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Therapeutic apheresis (TA) is a complex extracorporeal procedure for the treatment of several acute and chronic diseases. TA in pregnancy is considered safe for both mother and fetus and has the same indications of non-pregnant patients. TA can be used during the entire course of the pregnancy with the following purposes: (i) to treat several maternal acute and chronic conditions; (ii) to treat fetal conditions; (iii) to avoid administration of drugs potentially harmful to the fetus; and (iv) to reach a more advanced gestational age in order to prevent fetal prematurity. We report three successfully treated patients throughout pregnancy, for differential indications: thrombotic thrombocytopenic purpura, red blood cells alloimmunization and ulcerative colitis. Multiple courses of TA have been performed without any complications for the mother and the fetus. A review and a discussion on the particular TA implications related to maternal-fetal medicine have been reported. When approaching TA in pregnancy, clinicians have to consider the severity of disease, the strength of the indications, and the gestational age. Each case must be evaluated individually on the basis of existing evidence since, despite the increasing use, specific guidelines for apheresis in pregnancy are still lacking.
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