Factors related to obstetric third and fourth degree perineal lacerations in a Jamaican cohort

OBJECTIVES

The aim of this study was to identify significant and modifiable risk factors associated with obstetric third and fourth degree perineal lacerations and to produce recommendations that may reduce their morbidity and prevalence.

METHODS

This is a retrospective case control study performed between March 2004 and March 2008. All patients diagnosed with third and fourth degree perineal lacerations were identified (cases) along with randomly assigned controls who delivered during the same time period. Nineteen cases and 38 controls were identified giving a total of 57 patients. Each patient's hospital record was collected and the data extracted.

RESULTS

When analysed for weight greater than or equal to 3.5 kg versus birthweight of less than 3.5 kg, the difference between cases and controls was found to be statistically significant, with a p-value of 0.012. Of the cases, 21% had an operative delivery (forceps or vacuum) whereas only 2.6% of the controls had an operative delivery. This was found to be statistically significant (p = 0.011).

CONCLUSION

This study has shown that the two main factors related to the obstetric third and fourth degree perineal lacerations were babies weighing more than 3.5 kg and the use of forceps or vacuum to assist with deliveries. These high risk patients should be attended to by the most senior staff that is available.

Hereditary hemorrhagic telangiectasia: two distinct ENG deletions in one family

Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant disorder characterized by aberrant vascular development. Mutations in endoglin (ENG) or activin A receptor type II-like 1 (ACVRL1) account for around 90% of HHT patients, 10% of those are large deletions or duplications. We report here the first observation of two distinct, large ENG deletions segregating in one pedigree. An ENG exon 4-7 deletion was observed in a patient with HHT. This deletion was identified in several affected family members. However, some affected family members had an ENG exon 3 deletion instead. These deletions were detected by multiplex ligation-dependent probe amplification and confirmed by mRNA sequencing and an oligo-CGH array. Linkage analysis revealed that one individual with the exon 3 deletion inherited the same chromosome from his mother who has the exon 4-7 deletion. This finding has important clinical implications because it shows that targeted family-specific mutation analysis for exon deletions could have led to the misdiagnosis of some affected family members.

FIBRILLATION OF THE AURICLES: ITS EFFECTS UPON THE CIRCULATION

When the auricles fibrillate, the following effects are observed. 1. The arterial blood pressure may rise, fall, or remain stationary. Usually it falls. If it falls, it generally rises again towards or to the initial pressure. 2. The venous pressure changes are the reverse of the arterial. 3. The intestinal volume and the cardiac output changes are in the same direction as those of arterial blood pressure. 4. From these observations it may be concluded that the peripheral circulatory effects are purely passive. 5. The volume of the heart decreases except in instances where there is reason to believe that the circulation is failing. All the changes described in the foregoing paragraphs, and also the variations in blood pressure reactions which occur from time to time, are attributable to alterations in the rate of ventricular contraction. Similar, though perhaps less profound changes, are seen when the heart rate accelerates in like degree in response to regular induction shocks.

High-throughput whole-genome sequencing to dissect the epidemiology of Acinetobacter baumannii isolates from a hospital outbreak

Shared care of military and civilian patients has resulted in transmission of multidrug-resistant Acinetobacter baumannii (MDR-Aci) from military casualties to civilians. Current typing technologies have been useful in revealing relationships between isolates of A. baumannii but they are unable to resolve differences between closely related isolates from small-scale outbreaks, where chains of transmission are often unclear. In a recent hospital outbreak in Birmingham, six patients were colonised with MDR-Aci isolates indistinguishable using standard techniques. We used whole-genome sequencing to identify single nucleotide polymorphisms in these isolates, allowing us to discriminate between alternative epidemiological hypotheses in this setting.