[Contribution to the classification of obstetrical vesicovaginal fistula]

Our study was made with the C.H.U of the hospital of the Point G in the Service of Urology in Bamako in Mali. It is about a retrospective study in a service which has a dosage unit in load of F.V.V.O on average two hundred patients per annum. We included in our study all the F.V.V.O examined in the service which had an organic assessment. This assessment noted the aspect of the vagina and the topographic situation of the dent. Sometimes the examination of certain patients required a loco-regional anaesthesia and tests with the methylene blue to individualize the dent.

CONCLUSION

The classification proposed is the result of an experiment on the ground. It is a tool for learning thus enabling him to distinguish from the types of dent with their forecast and from the technical epic to realize.

Invited commentary: disaggregating preterm birth to determine etiology

Identifying the causes of preterm birth has been problematic, in part because of heterogeneous pathways leading to the same event, early delivery. If a risk factor affects only a subset of cases, then studies that address the aggregate outcome will generate diluted measures of association. McElrath et al. (Am J Epidemiol. 2008;168(9):980-989) examined an array of potential influences on very early preterm birth (<28 weeks' gestation) and divided cases on the basis of proximal causes. Through factor analysis, they found empirical support for dividing preterm cases into 2 groups: intrauterine inflammation (preterm labor, preterm membrane rupture, placental abruption, and cervical insufficiency) and abnormal placentation (preeclampsia and intrauterine growth restriction). Replication of this classification in less extreme preterm births is needed, requiring large numbers of preterm births that have been characterized in detail. Nonetheless, this division is worthy of study by using previously collected data to determine whether, in fact, stronger associations are found for these subsets than for preterm birth in the aggregate. Ultimately, the test of the approach is in improving our understanding of etiology, ideally generating stronger, more consistent associations with preterm birth subsets than have been found for preterm birth in the aggregate.

Pregnancy disorders that lead to delivery before the 28th week of gestation: an epidemiologic approach to classification

Epidemiologists have grouped the multiple disorders that lead to preterm delivery before the 28th week of gestation in a variety of ways. The authors sought to identify characteristics that would help guide how to classify disorders that lead to such preterm delivery. They enrolled 1,006 women who delivered a liveborn singleton infant of less than 28 weeks' gestation at 14 centers in the United States between 2002 and 2004. Each delivery was classified by presentation: preterm labor (40%), prelabor premature rupture of membranes (23%), preeclampsia (18%), placental abruption (11%), cervical incompetence (5%), and fetal indication/intrauterine growth restriction (3%). Using factor analysis (eigenvalue = 1.73) to compare characteristics identified by standardized interview, chart review, placental histology, and placental microbiology among the presentation groups, the authors found 2 broad patterns. One pattern, characterized by histologic chorioamnionitis and placental microbe recovery, was associated with preterm labor, prelabor premature rupture of membranes, placental abruption, and cervical insufficiency. The other, characterized by a paucity of organisms and inflammation but the presence of histologic features of dysfunctional placentation, was associated with preeclampsia and fetal indication/intrauterine growth restriction. Disorders leading to preterm delivery may be separated into two groups: those associated with intrauterine inflammation and those associated with aberrations of placentation.

Obesity subtypes and risk of spontaneous versus medically indicated preterm births in singletons and twins

Using data from the Missouri maternally linked files (1989-1997), the authors examined the association among maternal obesity, obesity subtypes, and spontaneous and medically indicated preterm (<37 weeks) and very preterm (<33 weeks) births in singletons and twins. Adjusted odds ratios were obtained with correction for intracluster correlation. The prevalence of obesity increased by 77% over the study period (p(trend) < 0.001). Obese mothers had a lower risk for spontaneous preterm birth, and this was more pronounced among twins (odds ratio = 0.68, 95% confidence interval: 0.62, 0.75) than singletons (odds ratio = 0.84, 95% confidence interval: 0.82, 0.87). However, this association was present only among obese women who gained less than 0.69 kg/week for singletons and between 0.23 and 0.69 kg/week for twins. By contrast, obese mothers with singleton gestation had about 50% greater odds of medically indicated preterm (odds ratio = 1.46, 95% confidence interval: 1.39, 1.54) and very preterm (odds ratio = 1.49, 95% confidence interval: 1.34, 1.65) births, and the risk increases with ascending severity of obesity (p(trend) < 0.01). For extreme obesity, the risk of medically indicated preterm and very preterm births was almost double that for nonobese women. Similar findings were observed in twins. These data suggest that obesity increases the risk for medically indicated but not spontaneous preterm birth in both singletons and twins.

Pregnancy after renal transplantation: ten-year single-center experience

There has been an increase in the number of pregnancies among renal transplant recipients. Our experience included 61 pregnancies in 53 patients from January 1997 to April 2007, with 6 patients having multiple pregnancies. Patients were studied for clinical, obstetrical, and perinatal outcomes. The mean patient age was 24.5 years (range, 19-38). They all received living donor kidneys. The mean transplantation-pregnancy interval was 2.7 years (range, 1.7-5.3 years). Immunosuppressive drugs consisted of cyclosporine (CsA), mycophenolate mofetil (MMF), and prednisolone (pred) in 38 patients (72%); CsA, azathioprine (AZA), plus pred were used in 15 patients (28%). Pregnancy complications were chronic hypertension in 21 patients (40%), anemia in 28 (52.6%), and urinary tract infection in 18 (34%). Twelve patients (22.6%) received blood transfusions. Pre-eclampsia was diagnosed in 14 cases (26.4%) and renal dysfunction in 11 (20.7%) with pre-eclampsia assumed to be the main cause. Three patients (5.6%) had graft losses as a result of hemorrhagic shock, sepsis, and eclampsia. Premature rupture of membranes occurred in 6 cases (11.3%), and preterm delivery occurred in 14 cases (26.4%). Eleven (20.7%) newborns were small for gestational age. One club foot and one large facial hemangioma occurred in 2 infants, respectively. One case of neonatal death was registered as a result of excessive prematurity. One mother died due to sepsis. Cesarean section was performed in 24 patients (45.2%), the main indications being related to hypertension and fetal distress. There were no significant differences between MMF-treated and AZA-treated patients with respect to clinical, obstetrical, and perinatal outcomes. This group of patients was characterized by a wide range of antenatal and perinatal problems that must be managed in specialized tertiary units to achieve the best results. MMF may be as safe as AZA in pregnancy.

[Chronic inflammatory disorders and reproduction]

The desire of reproduction is a true challenge for the physicians in charge of patients with chronic inflammatory disorders such as rheumatoid arthritis or other connective tissue diseases. It requires: 1) the strict evaluation of the potential risks of flare of the rheumatic disease because of the pregnancy; 2) the assessment of risks on pregnancy outcome and fetus development; 3) the management of the different anti-rheumatic agents in order to maintain optimal control of disease activity and avoid any teratogenic problem. Besides this, it clearly appears that inflammatory rheumatic diseases may have an impact on patients' fertility, which may be explained by different mechanisms, physical, psychological, hormonal or immunological. Moreover, some treatments may directly affect fertility, which may justify specific managements in order to preserve gonadic functions.

[Evaluation of systemic lupus erythematosus activity during pregnancy]

Pregnancy in patients with systemic lupus erythematosus (SLE) is considered a high-risk pregnancy. It is complicated by preeclampsia, premature labour and miscarriage more frequently than in the general population. Improved prognosis depends on low disease activity during conception and on appropriate medical care (SLE activity monitoring, selection of therapy safe for the mother and the developing foetus, advances in neonatology). Because symptoms of physiological pregnancy and SLE exacerbation are similar, their correct interpretation is essential for skin lesions, arthralgias, arterial hypertension or results of laboratory tests: proteinuria, thrombocytopenia or leucopenia observed in the patient. In order to standardise the assessment of SLE activity during pregnancy, scores of this activity are used. In the past, scores validated on non-pregnant populations (including male patients) were used: Systemic Lupus Erythematosus Disease Activity Index (SLEDAI), Systemic Lupus Activity Measure (SLAM), European Consensus Lupus Activity Measurment (ECLAM). Only recently have SLE activity scores been introduced that are specific for pregnant women: Lupus Activity Index In Pregnancy (LAI-P), Systemic Lupus Erythematosus Pregnancy Disease Activity Index (SLEPDAI), modified--Systemic Lupus Activity Measure (m-SLAM) and a visual three-grade score modified--Physician Global Assessment (m-PGA). So far, only scores LAI-P and m-PGA have been validated. According to the LAI-P score, clinical data are divided into 4 groups. Group 1 includes mild clinical symptoms, group 2--symptoms of involvement of internal organs, group 3 pertains to modifications of treatment and group 4 to laboratory parameters. Point values are ascribed to individual parameters depending on their intensity.

Impact of Pregnancy on the Outcome of Kidney Transplantation

BACKGROUND

There is still controversy over whether pregnancy adversely affects renal transplantation outcomes. We, thus, compared two groups of kidney transplant recipients in terms of patient survival and allograft function: those who did versus did not conceive posttransplant.

METHODS

This historical cohort study conducted between 1996 and 2002, divided female kidney transplant recipients of reproductive age into group I (n=86, at least one posttransplant pregnancy) and group II (n=125, no posttransplant pregnancy). The two groups were matched for age, cause of end-stage renal disease (ESRD), treatment protocol, and first creatinine (Cr). All patients received a first transplant and all had a Cr less than 1.5 mg/dL on entry into the study. The subjects were followed for 45.4 +/- 22.0 and 46.3 +/- 19.8 months, respectively (P>.05). Five-year patient and graft survivals and Cr were considered to be the main outcome measures.

RESULTS

Mean (SD) age in groups I and II was 26.6 +/- 6.6 and 26.9 +/- 8.1 years, respectively (P>.05). Five-year patient and graft survival rates were not significantly different between the study groups. Of the women in group 1, only 9 (10.5%) subjects displayed elevated serum Cr levels (>1.5 mg/dL) at the end of follow-up, while the serum Cr levels in 35 (28%) group II patients were above 1.5 mg/dL (P=.024).

CONCLUSION

Our results indicates pregnancy did not seem to adversely affect patient and graft survival among kidney transplant recipients. Renal transplantation in stable women of childbearing age should not be a contraindication to pregnancy.

[Pregnancy after kidney transplantation : the Erasme Hospital experience]

Kidney transplantation can restore the fertility of women with chronic renal insufficiency, allowing them to bear children. Yet, pregnancy after renal graft is associated with high maternal and fetal morbidity. The purpose of this case-controlled retrospective study was to evaluate maternal and fetal outcomes of pregnancies in renal transplant recipients, and to compare the results to a control population. We studied 18 pregnancies in 14 renal grafted patients, between 1990 and 2003. Each pregnancy was paired for age, number of pregnancies and parity with 2 controls. The analyses concerned the presence of risk factors at the conception, the outcome of the pregnancy and the occurring of maternal-fetal complications. There were significantly more infections (50 % versus 11 %), anaemia (28 % versus 3 %), caesarean sections (72 % versus 14 %), intrauterin growth restriction (39 % versus 3 %), premature babies (44 % versus 8 %) and small weights at birth (50 % versus 8 %) in the transplanted women and a trend to an increased incidence of hypertensive complications. One baby of a transplanted mother died. No deterioration of renal function nor any maternal death occurred. In conclusion, the rates of maternal-fetal complications in pregnancies after kidney transplantation found in our hospital are similar to those of the literature and in comparison with controls, make them high-risk pregnancies. Nevertheless, by respecting certain criteria, the majority have a successful outcome.

Diagnosis summary and coding of obstetric conditions in the government hospitals in Pattalung Province, the effects of audit and feedback

OBJECTIVE

Assess the effects of audit and feedback through a seminar on the obstetric summary and coding system with respect to the International Classification of Diseases, Tenth Revision (ICD-10) and to determine factors associated with the error of summary and coding audit.

MATERIAL AND METHOD

The medical records of 1,629 and 1,337 women with obstetric conditions admitted to one provincial and nine district hospitals in Pattalung Province, Southern Thailand, were evaluated before and after a seminar, respectively.

RESULT

The error of coding audit among cases with normal conditions and those with abnormal conditions after the seminar was reduced significantly from 40.7 to 13.0% and from 81.8% to 61.2%, respectively (p < 0.001). A seminar was a significant factor to reduce the errors of summary and coding. In contrast, the incorrect diagnosis summary, abnormal obstetric conditions and the district hospital were significantly associated with the increase of the coding errors.

CONCLUSION

The audit and feedback was moderately effective on summary and coding audit but the clinical significance of error reduction in abnormal obstetric conditions was marginal, thus intensive intervention, evaluation, and monitoring are necessary.

Are the Institute of Medicine Recommendations for Gestational Weight Gain Appropriate for Adolescents?

OBJECTIVE

To explore the use of Centers for Disease Control and Prevention body mass index percentiles for adolescents to classify adolescents for gestational weight gain recommendations.

DESIGN

A descriptive study using secondary data analysis.

SETTING

Memphis, Tennessee.

PARTICIPANTS

Three hundred forty-seven primiparous Black adolescents, aged 12 to 19 years, who delivered full-term infants.

MAIN OUTCOME MEASURES

Adult and adolescent body mass index categories, gestational weight gain patterns, and neonatal birthweight.

RESULTS

Adolescents, especially smaller adolescents, were misclassified when the current Institute of Medicine adult body mass index categories were used to classify them for gestational weight gain when compared to the use of the Centers for Disease Control and Prevention body mass index percentiles for adolescents as a gestational weight gain classification schema. Mean neonatal birthweights were similar no matter which schema was used. A large proportion of adolescents gained more than is recommended by the Institute of Medicine.

CONCLUSIONS

The current gestational weight gain recommendations based on adult body mass index categories may not be sufficiently specific to attain the best maternal and neonatal outcomes for adolescents. Creation of gestational weight gain recommendations based on the Centers for Disease Control and Prevention body mass index percentiles would potentially assist clinicians in counseling adolescents regarding gestational weight gain.

"Postpartum morbidity--what we can do"

Postpartum is a crucial period for a mother. During this period a mother is going through the physiological process of uterine involution and at the same time adapting to her new role in the family. Many postpartum complications occur during this period. Among the important obstetric morbidities are postpartum hemorrhage, pregnancy related hypertension, pulmonary embolism and puerperal sepsis. Common surgical complications are wound breakdown, breast abscess and urinary fecal incontinence. Medical conditions such as anemia, headache, backache, constipation and sexual problems may also be present. Unrecognized postpartum disorders can lead to physical discomfort, psychological distress and a poor quality of life for the mothers. Providing quality postnatal care including earlier identification of the problems (correction) and proper intervention will help the mother to achieve full recovery and restore her functional status back to the pre-pregnancy state sooner.

Impact of the Choice on Termination of Pregnancy Act on maternal morbidity and mortality in the west of Pretoria

AIM

To evaluate the impact of the Choice on Termination of Pregnancy Act on maternal morbidity and mortality in the west of Pretoria.

SETTING

Indigent South Africans managed in two public hospitals in the west of Pretoria.

METHOD

Data were collected on all abortions (incomplete or induced) treated in the hospitals in the study area in 1997-1998 and 2003-2005. All cases of severe acute maternal morbidity and maternal deaths due to abortion were identified for these time periods. Data exclude referrals from outside the west of Pretoria.

OUTCOME MEASURES

The case fatality rate (CFR), mortality index (MI) and maternal mortality ratio (MMR) due to abortions.

RESULTS

In 1997-1998 there were 2 050 abortions, of which 80.2% were regarded as being incomplete, and in 2003-2005 there were 3 999 abortions, of which 42.8% were regarded as incomplete. Twenty-four women who were critically ill due to complications of abortion presented in 1997-1998 (a rate of 3.05/1 000 births), compared with 50 (2.76/1 000 births) in 2003-2005. There were 5 deaths in 1997-1998 (CFR of 2.4/1 000 abortions) compared with 1 death in 2003-2005 (CFR 0.25/1 000 abortions) (p = 0.01, relative risk (RR) 0.1, 95% confidence interval (CI) 0.01 - 0.89). The MI fell from 21.7% to 2.0% (p = 0.02, RR 0.1, 95% CI 0.01 - 0.89). The MMR was 63.6/100 000 births in 1997-1998 compared with 5.54/100 000 in 2003-2005 (p = 0.017, RR 0.09, 95% CI 0.01 - 0.74).

CONCLUSION

The introduction of the Choice on Termination of Pregnancy Act has been associated with a massive reduction in women presenting with incomplete abortions. The prevalence of critically ill women due to complications of abortion has not changed, but the CFR, MI and MMR have declined significantly.

Women's groups' perceptions of maternal health issues in rural Malawi

BACKGROUND

Improvements in preventive and care-seeking behaviours to reduce maternal mortality in rural Africa depend on the knowledge and attitudes of women and communities. Surveys have indicated a poor awareness of maternal health problems by individual women. We report the perceptions of women's groups to such issues in the rural Mchinji district of Malawi.

METHODS

Participatory women's groups in the Mchinji district identified maternal health problems (172 groups, 3171 women) and prioritised problems they considered most important (171 groups, 2833 women). In-depth qualitative data was obtained through six focus-group discussions with the women's groups, three with women's group facilitators, and four interviews with facilitator supervisors.

FINDINGS

The maternal health problems most commonly identified by more than half the groups were anaemia (87%), malaria (80%), retained placenta (77%), obstructed labour (76%), malpresentation (71%), antepartum and postpartum haemorrhage (70% each), and pre-eclampsia (56%). The five problems prioritised as most important were anaemia (sum of rank score 304), malpresentation (295), retained placenta (277), obstructed labour (276). and postpartum haemorrhage (275). HIV/AIDS and sepsis were identified or prioritised much less because complexity and contextual factors hindered their consideration.

INTERPRETATION

Rural Malawian women meeting in participatory groups showed a developed awareness of maternal health problems and the concern and motivation to address them. Community mobilisation strategies, such as women's groups, might be effective at reducing maternal mortality because they can draw on the collective capacity in communities to solve problems and make women's voices heard by decision-makers.

The specific dermatoses of pregnancy revisited and reclassified: Results of a retrospective two-center study on 505 pregnant patients

OBJECTIVES

We sought to evaluate the frequency and clinical characteristics of pruritic dermatoses in pregnancy and to assess a rationalized classification.

METHODS

Data of 505 pregnant patients seen at two university-based dermatologic hospitals (1994-2004) were retrospectively studied.

RESULTS

Diagnoses included eczema in pregnancy (49.7%), polymorphic eruption of pregnancy (PEP) (21.6%), pemphigoid gestationis (PG) (4.2%), intrahepatic cholestasis of pregnancy (ICP) (3%), prurigo of pregnancy (0.8%), pruritic folliculitis of pregnancy (0.2%), and miscellaneous dermatoses (20.6%). Eczema in pregnancy, prurigo of pregnancy, and pruritic folliculitis of pregnancy showed considerable overlap and were summarized as atopic eruption of pregnancy (AEP). While PEP, PG, and ICP presented in late pregnancy, AEP started significantly earlier. Primigravidae and multiple gestations were characteristic for PEP, abdominal involvement for PEP and PG, and a history of affected pregnancies for ICP.

LIMITATIONS

This was a retrospective study.

CONCLUSION

We propose classifying the dermatoses of pregnancy as PG, PEP, AEP, and ICP. Stereotypic immunofluorescence and laboratory findings are diagnostic of PG and ICP, whereas distinct clinical characteristics facilitate discrimination between PEP and AEP.

Pregnancy outcome in adolescent and adult - a case comparison study

This study outlined the consequences of adolescent pregnancy with comparison to adults in Mymensingh Medical College Hospital, Mymensingh. It was a case-comparison study. The study population was the mothers who admitted and delivered at the Obstetrics and Gynaecology ward of hospital during April-June 2003. Sample size was 220 mothers, out of which 110 were primigravidae adolescent mothers and 110 were adults. The study finding showed that adolescents were 2.105 times and 3.679 times more at risk than adults to suffer from anaemia and UTI during pregnancy. Among adolescents 74(67.3%) and in adults 39(35.5%) had obstetric complications during pregnancy and the adolescents were 3.742 times more at risk than the adults. PET and Eclampsia were more common in adolescent than adult mothers. 86(78.2%) adolescents and 36(32.7%) adult mothers had complications before delivery. Pre term labour, Premature rupture of membrane (PROM) and Intra-uterine foetal death (IUD) were more common in adolescents than adult mothers. Stillbirths were more in adolescent mothers 23(20.9%) and adults 11(10.0%). There was more low birth weight (LBW) newborns in adolescents 42(38.2%) than adults 18(16.4%). As a result the adolescents were 3.157 times more likely to give birth to low birth weight babies . The newborns of the adolescent mothers were nearly 2 times more at risk to develop asphyxia neonatorum (p< 0.030, odds ratio=1.806).

International consensus statement on an update of the classification criteria for definite antiphospholipid syndrome (APS)

New clinical, laboratory and experimental insights, since the 1999 publication of the Sapporo preliminary classification criteria for antiphospholipid syndrome (APS), had been addressed at a workshop in Sydney, Australia, before the Eleventh International Congress on antiphospholipid antibodies. In this document, we appraise the existing evidence on clinical and laboratory features of APS addressed during the forum. Based on this, we propose amendments to the Sapporo criteria. We also provide definitions on features of APS that were not included in the updated criteria.

Obstetric admissions to the intensive care unit: a 12-year review

OBJECTIVE

The objective was to ascertain the prevalence, causes and outcome of critically ill obstetric patients admitted to the intensive care unit (ICU).

DESIGN

The design was a retrospective collection of data.

SETTINGS

The setting was a multidisciplinary ICU in a University hospital.

PATIENTS

All obstetric patients admitted to the ICU over a 12-year period from May 1992 to April 2004 were reviewed.

METHODS

Data collected included demographic characteristics of the patients, pre-existing medical conditions, obstetric complications, invasive procedures required in the ICU and outcome of the patients.

RESULTS

The incidence of obstetric admissions to the ICU represented 0.22% of all deliveries during the study period. The majority (84.4%) of patients were admitted to the ICU postpartum. Obstetric haemorrhage (32.8%) and pregnancy-induced hypertension (17.2%) were the two main obstetrical reasons for admission. The remainder included medical disorders (37.5%) and other causes (6.2%). Associated major complications included adult respiratory distress syndrome (ARDS) and HELLP (haemolysis, elevated liver enzymes and low platelets) syndrome. The perinatal mortality rate was 20% and the maternal mortality rate 9.4%.

CONCLUSIONS

A team approach consisting treatment by obstetricians, intensive care specialists and anaesthesiologists provided optimal care for the patients. Improved management strategies for obstetric haemorrhage and hypertension may significantly reduce maternal morbidity.

[The effect of Chernobyl accident on the development of non malignant diseases]

The early medical complications of Chernobyl accident include post radiation disease, which were diagnosed in 134 subjects affected by ionizing radiation. 28 persons died during the first 100 days after the event. The increase occurrence of coronary heart disease, endocrine, haematological, dermatological and other diseases were observed after disaster in the contaminated territories. We also discussed the impact of ionizing radiation from Chernobyl accident on pregnancy and congenital defects occurrence. Changes following the Chernobyl accident, as the inhabitants migration from contaminated regions, political and economic conversions, led to depression, anxiety, and even to "epidemic" of mental diseases. Increased suicide rate, car accidents, alcohol and drug abuse have been observed in this population. Nowadays vegetative neurosis is more often diagnosed in Ukrainian children. Epidemiological studies were conducted on the ionising radiation effect on the health and on the dose of received radiation after Chernobyl accident face numerous problems as the absence of reliable data regarding diseases in the contaminated territories.

Medical audit of maternal deaths in the Lagos University Teaching Hospital, Nigeria

OBJECTIVES

To determine the rate of autopsy certification of maternal deaths; evaluate concordance and/discordance rates between autopsy and clinical diagnoses of maternal deaths, and to compare these with findings from other parts of the world.

DESIGN

Retrospective study.

SETTING

The Lagos University Teaching Hospital (LUTH), Nigeria between January 1989 and December 1998.

SUBJECTS

Women who died from pregnancy-related complications having been on admission in or having presented as emergencies to LUTH.

RESULTS

In the study period, 445 maternal deaths were registered in the LUTH mortuary. Autopsies were performed on 371 of these, giving an autopsy rate of 83.37%. Only 230 cases were found suitable for evaluation of concordance and discordance. Two hundred and six of these (89.57%) had related clinical and autopsy diagnoses (concordance) while 24 (10.43%) had completely unrelated diagnoses (discordance).

CONCLUSION

Adequate investigation of cause of death using the autopsy will assist in accurately determining the sequence of events that result in death and hence provide required statistics for the planning of appropriate interventions.