University of Aberdeen Health Services Research Unit, Foresterhill, UK.
OBJECTIVE To describe the prevalence and causes of postnatal maternal morbidity. DESIGN Questionnaire survey of postnatal patients. Further data extracted from SMR1 returns, case records and the Aberdeen Maternity and Neonatal Databank. SETTING Postnatal care in a teaching maternity hospital, midwife delivery hospital, general practitioner maternity units and in the community. SUBJECTS Twenty percent random sample of deliveries (1249 women) surveyed one week, eight weeks and 12 to 18 months after delivery. MAIN OUTCOME MEASURES Incidence of self reported maternal morbidity, treatment received, readmission rates and causes for readmission. RESULTS Of mothers in the sample 85%(99% CI 82-88%) reported at least one health problem in hospital, rising to 87%(84-90%) of those at home; 76%(71-81%) reported at least one health problem after eight weeks post-delivery. CONCLUSIONS Maternal morbidity is extensive and under-recognised after delivery. Measures to reduce and alleviate it must be sought.
A qualitative study of the experiences and expectations of women receiving in-patient postnatal care in one English maternity unit.
Kings College, London, Florence Nightingale School of Nursing and Midwifery, London, UK.
BACKGROUND Studies consistently highlight in-patient postnatal care as the area of maternity care women are least satisfied with. As part of a quality improvement study to promote a continuum of care from the birthing room to discharge home from hospital, we explored women's expectations and experiences of current in-patient care. METHODS For this part of the study, qualitative data from semi-structured interviews were transcribed and analysed using content analyses to identify issues and concepts. Women were recruited from two postnatal wards in one large maternity unit in the South of England, with around 6,000 births a year. RESULTS Twenty women, who had a vaginal or caesarean birth, were interviewed on the postnatal ward. Identified themes included; the impact of the ward environment; the impact of the attitude of staff; quality and level of support for breastfeeding; unmet information needs; and women's low expectations of hospital based postnatal care. Findings informed revision to the content and planning of in-patient postnatal care, results of which will be reported elsewhere. CONCLUSIONS Women's responses highlighted several areas where changes could be implemented. Staff should be aware that how they inter-act with women could make a difference to care as a positive or negative experience. The lack of support and inconsistent advice on breastfeeding highlights that units need to consider how individual staff communicate information to women. Units need to address how and when information on practical aspects of infant care is provided if women and their partners are to feel confident on the woman's transfer home from hospital.
Mother and Child Health Research, La Trobe University, Bundoora, Australia. email@example.com
Department of Obstetrics and Gynecology, Atatürk Education and Research Hospital, Ankara, Turkey.
Haemorrhoids are varicose veins of the rectum covered by mucosa at or near the anal canal. They are normally asymptomatic, can occur at any age and affect both males and females. In this review, we address the issue of the approach of the obstetrician to haemorrhoids and their management. Haemorrhoids are common in young women and commoner during pregnancy and the puerperium. Obstetricians and gynaecologists should be familiar with haemorrhoids, a proctological disease, diagnosis and their treatment, but they have little experience regarding the impact of pregnancy on haemorrhoids. The obstetrician must be able to relieve symptoms in patients who are pregnant, or who have just delivered.
Department of Midwifery, Fatemeh (P.B.U.H.) College of Nursing and Midwifery, Shiraz University of Medical Sciences, P.O. Box: 71645 - 111, Shiraz, Iran.
BACKGROUND AND OBJECTIVE We conducted this study to evaluate and compare postpartum sexual functioning after vaginal and caesarean births. MATERIALS AND METHODS This was a cross-sectional study that was carried out in postnatal health care in a hospital. A total of 50 primiprous women who had given birth 6-12 months ago and came to the hospital for postnatal care were asked to join the study. Forty of the women completed the entire questionnaire. Among these women, 20 delivered spontaneously with mediolateral episiotomy and 20 had elective caesarean section. Sexual function was evaluated by a validated, self-created questionnaire. A statistical evaluation was carried out by SPSS v.11. A two-part self-created validated questionnaire for data collection was administered regarding sexual function prior to pregnancy and 6-12 months postpartum. RESULTS The median time to restart intercourse in the normal vaginal delivery with episiotomy (NVD/epi) group was 40 days and in the caesarean section (C/S) group was 10 days postpartum. The most common problems in the NVD/epi group was decreased libido (80%), sexual dissatisfaction (65%), and vaginal looseness (55%). In the C/S group, the most common problems were vaginal dryness (85%), sexual dissatisfaction (60%), and decreased libido (35%). There were clinically significant differences between the two groups regarding sexual outcomes, but these differences were not statically significant. CONCLUSION Postnatal sexual problems were very common after both NVD/epi and C/S. Because sexual problems are so prevalent during the postpartum period, clinicians should draw more attention to the women's sexual life and try to improve their quality of life after delivery.
Matthew F Chersich, Nicole Kley, Stanley M F Luchters, Carol Njeru, Elodie Yard, Mary J Othigo, Marleen Temmerman
Department of Obstetrics and Gynaecology, Ghent University, Belgium. firstname.lastname@example.org
BACKGROUND In sub-Saharan Africa, few services specifically address the needs of women in the first year after childbirth. By assessing the health status of women in this period, key interventions to improve maternal health could be identified. There is an underutilised opportunity to include these interventions within the package of services provided for woman-child pairs attending child-health clinics. METHODS This needs assessment entailed a cross-sectional survey with 500 women attending a child-health clinic at the provincial hospital in Mombasa, Kenya. A structured questionnaire, clinical examination, and collection of blood, urine, cervical swabs and Pap smear were done. Women's health care needs were compared between the early (four weeks to two months after childbirth), middle (two to six months) and late periods (six to twelve months) since childbirth. RESULTS More than one third of women had an unmet need for contraception (39%, 187/475). Compared with other time intervals, women in the late period had more general health symptoms such as abdominal pain, fever and depression, but fewer urinary or breast problems. Over 50% of women in each period had anaemia (Hb <11 g/l; 265/489), with even higher levels of anaemia in those who had a caesarean section or had not received iron supplementation during pregnancy. Bacterial vaginosis was present in 32%(141/447) of women, while 1%(5/495) had syphilis, 8%(35/454) Trichomonas vaginalis and 11%(54/496) HIV infection. CONCLUSION Throughout the first year after childbirth, women had high levels of morbidity. Interface with health workers at child health clinics should be used for treatment of anaemia, screening and treatment of reproductive tract infections, and provision of family planning counselling and contraception. Providing these services during visits to child health clinics, which have high coverage both early and late in the year after childbirth, could make an important contribution towards improving women's health.
Urinary incontinence in nulliparous women before and during pregnancy: prevalence, incidence, and associated risk factors.
Healthy Mothers Healthy Families Research Group, Murdoch Childrens Research Institute, Parkville, P.O. Box 911, Melbourne, Victoria, 3052, Australia. email@example.com
INTRODUCTION Few studies have examined associations of prepregnancy urinary incontinence (UI). METHODS Multicentre prospective pregnancy cohort study (n = 1,507) using standardised measures to assess frequency and severity of UI. RESULTS Prevalence of UI increased from 10.8% in the 12 months before the index pregnancy to 55.9% in the third trimester. Stress incontinence (36.9%) and mixed incontinence (13.1%) were more common during pregnancy than urge incontinence alone (5.9%). UI before pregnancy was associated with childhood enuresis (adjusted odds ratio (AdjOR)= 2.4, 95% confidence interval (CI) 1.6-3.4), higher maternal body mass index (AdjOR = 2.3, 95% CI 1.4-3.8), and previous miscarriages or terminations (AdjOR = 1.6, 95% CI 1.1-2.3). The strongest predictor of incident UI in pregnancy was occasional leakage (less than once a month) before pregnancy (AdjOR = 3.6, 95% CI 2.8-4.7). CONCLUSIONS Further research is needed to elucidate the complex interplay of prepregnancy and pregnancy-related factors in the aetiology of UI in nulliparous women.
Brazilian network for the surveillance of maternal potentially life threatening morbidity and maternal near-miss and a multidimensional evaluation of their long term consequences.
Jose Cecatti, João Souza, Mary Parpinelli, Samira Haddad, Rodrigo Camargo, Rodolfo Pacagnella, Carla Silveira, Dulce Zanardi, Maria Costa, João Pinto E Silva, Renato Passini Jr, Fernanda Surita, Maria Sousa, Iracema Calderon, Lale Say, Robert Pattinson
Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Brazil. firstname.lastname@example.org.
ABSTRACT: BACKGROUND: It has been suggested that the study of women who survive life-threatening complications related to pregnancy (maternal near-miss cases) may represent a practical alternative to surveillance of maternal morbidity/mortality since the number of cases is higher and the woman herself is able to provide information on the difficulties she faced and the long-term repercussions of the event. These repercussions, which may include sexual dysfunction, postpartum depression and posttraumatic stress disorder, may persist for prolonged periods of time, affecting women's quality of life and resulting in adverse effects to them and their babies. OBJECTIVE: The aims of the present study are to create a nationwide network of scientific cooperation to carry out surveillance and estimate the frequency of maternal near-miss cases, to perform a multicenter investigation into the quality of care for women with severe complications of pregnancy, and to carry out a multidimensional evaluation of these women up to six months. METHODS/DESIGN: This project has two components: a multicenter, cross-sectional study to be implemented in 27 referral obstetric units in different geographical regions of Brazil, and a concurrent cohort study of multidimensional analysis. Over 12 months, investigators will perform prospective surveillance to identify all maternal complications. The population of the cross-sectional component will consist of all women surviving potentially life-threatening conditions (severe maternal complications) or life-threatening conditions (the maternal near miss criteria) and maternal deaths according to the new WHO definition and criteria. Data analysis will be performed in case subgroups according to the moment of occurrence and determining cause. Frequencies of near-miss and other severe maternal morbidity and the association between organ dysfunction and maternal death will be estimated. A proportion of cases identified in the cross-sectional study will comprise the cohort of women for the multidimensional analysis. Various aspects of the lives of women surviving severe maternal complications will be evaluated 3 and 6 months after the event and compared to a group of women who suffered no severe complications in pregnancy. Previously validated questionnaires will be used in the interviews to assess reproductive function, posttraumatic stress, functional capacity, quality of life, sexual function, postpartum depression and infant development.
Evaluation of changes in postnatal care using the "Parents' Postnatal Sense of Security" instrument and an assessment of the instrument's reliability and validity.
Department of Obstetrics & Gynaecology, Helsingborg Hospital, Helsingborg, Sweden. email@example.com
BACKGROUND A sense of security is important for experiences of parenthood in the early postpartum period. The objectives of this study were to evaluate two models of postnatal care using a questionnaire incorporating the Parents' Postpartum Sense of Security (PPSS) instrument and to test the validity of the PPSS instrument. METHODS Postal surveys were sent to 234 mothers who had experienced two different forms of postnatal care (study group and control group) and returned by 86.8%. These two groups of mothers were compared for total scores on the PPSS instrument. Demographic variables and mothers' opinions about care interventions were also compared and these variables were tested for correlations with the total PPSS score. A regression analysis was carried out to assess areas of midwifery care which might affect a sense of security. The internal consistency and concurrent validity of the instrument were tested for the total population. RESULTS there were no significant differences between the groups for scores on the PPSS instrument. A total of three variables predicted 26% of the variability on the PPSS scores for the study group and five variables predicted 37% of the variability in the control group. One variable was common to both:"The midwives on the postnatal ward paid attention to the mother as an individual". There were significant correlations between the total PPSS scores and scores for postpartum talks and visits to the breastfeeding clinic. There was also a significant correlation between the single question:"I felt secure during the first postpartum week" and the total PPSS score. Tests for internal consistency and concurrent validity were satisfactory. CONCLUSION The proposed new model of care neither improved nor impaired mothers' feelings of security the week following birth. Being seen as an individual by the midwife who provides postnatal care may be an important variable for mothers' sense of postnatal security. It is possible that postpartum talks may encourage the processing of childbirth experiences in a positive direction. Availability of breastfeeding support may also add to a sense of security postpartum. The PPSS instrument has shown acceptable reliability and validity.
Mayday University Hospital, Croydon, Surrey, United Kingdom.
Although many women experience sexual problems in the postpartum period, research in this subject is under-explored. Embarrassment and preoccupation with the newborn are some of the reasons why many women do not seek help. Furthermore, there is a lack of professional awareness and expertise and recognition that a prerequisite in the definition of sexual dysfunction is that it must cause distress to the individual (not her partner). Sexual dysfunction is classified as disorders of sexual desire, arousal, orgasm and pain. However, in the postpartum period the most common disorder appears to be that of sexual pain as a consequence of perineal trauma. Health care workers need to be made aware of this silent affliction as sexual morbidity can have a detrimental effect on a women's quality of life impacting on her social, physical and emotional well-being.
University Hospital of North Staffordshire, Stoke-on-Trent, UK.
INTRODUCTION Over 85% of women having a vaginal birth suffer some perineal trauma. Spontaneous tears requiring suturing are estimated to occur in at least a third of women in the UK and USA, with anal sphincter tears in 0.5% to 7% of women. Perineal trauma can lead to long-term physical and psychological problems. METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of intrapartum surgical and non-surgical interventions on rates of perineal trauma? What are the effects of different methods and materials for primary repair of first- and second-degree tears and episiotomies? What are the effects of different methods and materials for primary repair of obstetric anal sphincter injuries (third- and fourth-degree tears)? We searched: Medline, Embase, The Cochrane Library, and other important databases up to April 2007 (BMJ Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS We found 38 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS In this systematic review we present information relating to the effectiveness and safety of the following interventions: active pushing, spontaneous pushing, and sustained breath-holding (Valsalva) method of pushing; continuous support during labour; conventional suturing; different methods and materials for primary repair of obstetric anal sphincter injuries; episiotomies (midline and mediolateral incisions); epidural analgesia; forceps; methods of delivery ("hands-on" method,"hands poised"); water births; non-suturing of muscle and skin (or perineal skin alone); passive descent in the second stage of labour; positions (supine or lithotomy positions, upright position during delivery); restrictive or routine use of episiotomy; sutures (absorbable synthetic sutures, catgut sutures, continuous sutures, interrupted sutures); and vacuum extraction.
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Randomised comparison of percutaneous angioplasty vs continued medical therapy for hypertensive patients with atheromatous renal artery stenosis. Scottish and Newcastle Renal Artery Stenosis Collaborative Group.
J Webster, F Marshall, M Abdalla, A Dominiczak, R Edwards, C G Isles, H Loose, J Main, P Padfield, I T Russell, B Walker, M Watson, R Wilkinson
Aberdeen Royal Infirmary, Foresterhill, Scotland.
BACKGROUND: Data from randomised studies are lacking on the value of interventional procedures in the management of atheromatous renal artery stenosis. This randomised prospective trial compared the effects on blood pressure (BP) and renal function of percutaneous transluminal angioplasty vs medical therapy in hypertensive patients with both unilateral and bilateral disease. METHODS: A total of 135 eligible patients were identified, of whom 55 (44%) were randomised. Eligible patients had sustained hypertension, with a minimum diastolic BP of 95 mm Hg on at least two anti-hypertensive drugs. Renal artery stenosis was defined by renal angiography as at least 50% stenosis in the affected vessel. All patients were observed during an initial 4-week run-in period on a fixed drug regimen and subsequent changes measured from this 4-week baseline. RESULTS: Blood pressure fell during the run-in period in all groups. In patients with bilateral renal artery stenosis randomised to angioplasty, a statistically significant (P<0.05) fall in BP was observed at latest follow-up (range 3-54 months). The mean fall in BP at latest follow-up in the angioplasty group, corrected for the medical group response, was 26/10 mm Hg. In patients with unilateral renal artery stenosis, no statistically significant or clinically important differences in outcome were observed between the two groups. No significant differences or trends in serum creatinine were observed between or within any group during follow-up. Major outcome events (death, myocardial infarction, heart failure, stroke, dialysis) were similar in the angioplasty and medical groups during follow-up. In the 40/135 patients undergoing angioplasty, serious or potentially serious complications attributable to the procedure were observed in 11 patients, bleeding at the arterial site (8 patients) being the most frequent. CONCLUSIONS: In hypertensive patients with atheromatous renal artery stenosis, percutaneous renal angioplasty results in a modest improvement in systolic BP compared with medical therapy alone. This benefit was confined to patients with bilateral disease. No patient was 'cured', renal function did not improve, and intervention was accompanied by a significant complication rate.
Department of Obstetrics and Gynaecology, Medical School, Aberdeen, Scotland, United Kingdom.
BACKGROUND. Medical termination of pregnancy can be successfully performed with a combination of mifepristone (RU 486) and a prostaglandin analogue. We conducted a prospective, randomized trial to compare oral with vaginal administration of the prostaglandin E1 analogue misoprostol for first-trimester abortion in women treated initially with mifepristone. METHODS. The study population consisted of 270 women seeking abortion within 63 days after the onset of amenorrhea. The dose of mifepristone was 600 mg, and the dose of misoprostol was 800 micrograms. The study had two primary end points: expulsion of the conceptus without the need for a surgical procedure, and abortion within four hours after the administration of misoprostol. RESULTS. Expulsion of the conceptus without the need for a surgical procedure occurred in 95 percent of the women who received misoprostol vaginally and in 87 percent of those who received it orally (P = 0.03). The rate of continued pregnancy was 7 percent with the oral regimen and 1 percent with the vaginal regimen (P = 0.01). Ninety-three percent of the women receiving misoprostol vaginally had abortions within four hours, as compared with only 78 percent of the women receiving the drug orally (P < 0.001). Vomiting and diarrhea were reported more frequently by the women who received oral misoprostol than by those who received vaginal misoprostol (P = 0.04 and P = 0.002, respectively). CONCLUSIONS. After the administration of mifepristone, vaginal administration of misoprostol is more effective and better tolerated than oral administration for the induction of first-trimester abortion.
Antenatal screening for carriers of cystic fibrosis: randomised trial of stepwise v couple screening.
Z H Miedzybrodzka, M H Hall, J Mollison, A Templeton, I T Russell, J C Dean, K F Kelly, T M Marteau, N E Haites
University of Aberdeen, Foresterhill.
OBJECTIVE To perform a rigorous comparative evaluation of stepwise and couple approaches to antenatal carrier screening for cystic fibrosis. DESIGN Pragmatic randomised trial. SETTING Hospital antenatal clinic serving a regional population. SUBJECTS 2002 women (couples) attending for booking antenatal visit at less than 17 weeks' gestation with no family history of cystic fibrosis. INTERVENTIONS Offering counselling and carrier testing for cystic fibrosis, either to women in the first instance (stepwise) or to couples (couple screening). MAIN OUTCOME MEASURES Uptake rates; anxiety; knowledge of cystic fibrosis and carrier status (both partners); attitudes to health, pregnancy, the baby, and screening (both partners); and uptake of carrier testing by relatives. RESULTS Uptake of screening was the same for both approaches (90%). After delivery most women remembered test results and their meaning, but 53/253 (21%) of those with negative results of couple testing had forgotten that repeat testing would be advisable if they had a pregnancy with a new partner. With stepwise screening women identified as carriers had high levels of anxiety when results were received (mean anxiety score 52.3). This dissipated with a reassuring partner's result (carriers' mean anxiety score 36.1) to levels similar to those receiving negative results from couple screening. Of those receiving negative results, women who had stepwise screening were significantly less anxious than those who had couple screening (mean score with result 32.1 v 35.4, 95% confidence interval for difference -4.7 to -2.1). CONCLUSIONS Couple screening allows carriers to avoid transient high levels of anxiety, but is associated with more anxiety and false reassurance among most screenees who will test negative. Stepwise screening gives carriers and their relatives genetic information and is, in our opinion, the better method.
Psychological responses following medical abortion (using mifepristone and gemeprost) and surgical vacuum aspiration. A patient-centered, partially randomised prospective study.
Department of Obstetrics and Gynaecology, Aberdeen Maternity Hospital, United Kingdom.
BACKGROUND A substantial body of objective data now exists to support the consensus view that induced abortion results in a low incidence of psychiatric morbidity. However, these data do not include more recent advances in abortion technology. Medical abortion entails a participatory role on the part of the woman, who may perceive more pain or see products of conception. The physical and psychological events experienced by women undergoing this procedure may lead to differences in psychopathology. METHODS 363 women undergoing legal induced abortion up to 63 days gestation were allocated by a prospective partially randomised design to undergo medical abortion (using mifepristone 600 mg followed 48 h later by gemeprost 1 mg vaginal pessary) or vacuum aspiration performed under general anesthesia. This study design allowed women with a preference for a particular method to undergo that method; women without preferences were allocated at random. Women completed sensitive and reliable psychometric instruments (the Hospital Anxiety and Depression Scale and a semantic differential rating scale designed to measure self-esteem) prior to abortion and 16 days later. RESULTS There were no significant differences between women allocated at random to medical abortion or vacuum aspiration in post-abortal anxiety, depression or low self-esteem. Women with high levels of mood disturbance prior to abortion, who were smokers or who had medical complications following abortion were at highest risk of post-abortal mood disorder. CONCLUSIONS Medical abortion is a psychologically safe as surgical vacuum aspiration. The quantitative findings of the study support the consensus view that abortion is associated with high incidence of psychological benefit, whichever method is used.
Med Phys. 2012 Jun ;39 (6):3802-3803 22756605
SU-E-T-426: Comparison of HDR Brachytherapy for Cervix Cancer Using an Adaptive Simulated Annealing Program and Oncentra- for Simultaneously Integrated Boost.
Rush University Medical Center, Chicago, IL.
Purpose: High dose rate (HDR) volumetric brachytherapy is an effective method of treating advanced cervix carcinoma. Local failure is associated with multiple factors including higher maximal standardized uptake value (SUV) values in fluorodeoxyglucose positron emission tomography (FDG- PET) scans. The purpose of this study is to evaluate the ability to simultaneously boost regions of high SUV values using an in-house adaptive simulated annealing (ASA) algorithm and the Oncentra® (Nucletron V.B., Veenendaal, The Netherlands) treatment planning system, thereby potentially improving local control. Methods: Five cervix cancers were evaluated for brachytherapy treatment (tandem/ring and/or interstitial needles). MRI and PET images were obtained post-implant and fused with treatment planning CTs to define a high-risk (HR) CTV (cervix and tumor on MRI) and GTV (volume with >50% of the maximum SUV on PET). The prescribed dose was 5-6 Gy to the HR CTV and 7-9 Gy to the GTV. Treatment plans were first generated in Oncentra® with IPSA followed by manual graphic optimization by the physician. Plans were also independently optimized using the ASA program. The two plans were compared side by side and one was chosen for treatment. Dose-volume parameters including D90, V100 of targets, D2cc to the critical organs, and generalized equivalent uniform dose (gEUD) of all structures were compared between the ASA and the Oncentra plans. Results: Both ASA and Oncentra plans were considered acceptable by the physician in four of five cases. Two ASA plans were chosen due to better critical organ sparing and tumor coverage. Two Oncentra plans were preferred because of lower doses to critical organs. One ASA plan was not accepted because of a higher bowel dose. Conclusions: Both ASA and Oncentra® planning methods produce acceptable treatment plans for optimized brachytherapy of cervix carcinoma. Continued studies are warranted to further determine the relative strength of each method. This study was supported in part by a research grant from Varian Medical System Inc.
Med Phys. 2012 Jun ;39 (6):3733-3734 22756313
Rush University Medical Center, Chicago, IL.
Purpose: To assure high accuracy in radiation delivery during linear accelerator based stereotactic radiosurgery procedures, a Winston-Lutz test is typically performed to measure the effective isocenter wander over the wide range of gantry and couch angles employed. Ideally, this deviation is lower than 1-1.5 mm depending on institutional tolerances. Automation of this test with portal imaging allows a large amount of data to be taken and processed. This study explores the effect of various collimation techniques on beam-center stability, and addresses one technique of repositioning in response. Methods: Winston-Lutz shots were obtained using a Trilogy linear accelerator, BrainLab Winston-Lutz pointer, and electronic portal imaging from a full range of gantry and couch angles. The test was repeated using MLCs, a 10mm stereotactic cone from BrainLab, and jaws for beam collimation. All images were processed using an in-house MATLAB-based program which calculates the distance between the tungsten ball and aperture center with accuracy within ∼0.1mm. Ideal shifts were calculated by minimizing this variation from gantry rotation alone, and performed manually. Results: The in-plane gantry sag was found to be on the order of ∼0.8mm, independent of collimation technique or setup. The MLC carriage had a ∼0.3mm cross-plane displacement to the inferior from the cone center, negated by a 90 degree collimator rotation. The total gantry misalignment was greatest near gantry 180 (∼1.5mm), varying by collimation method. Optimizing to minimize gantry error reduced errors to less than 0.7mm but increased the effect of couch rotation. Conclusions: Isocenter evaluation is dependent on collimation method used, and should be conducted with the same technique as delivery. It may be useful to consider the varying delivery accuracy from different couch/gantry angles during treatment planning. Repositioning methods after couch rotation may affect ideal laser positions.
Med Phys. 2012 Jun ;39 (6):3718 22756248
Rush University Medical Center, Chicago, IL.
Purpose: To test the ability of the SunNuclear ArcCHECK QA device to detect errors artificially introduced in a helical Tomotherapy plan. Methods: Delivery sinograms from clinically-used plans were extracted from the Tomotherapy treatment planning system (TPS), and modified to reflect several delivery errors: leaf pair incorrectly always open, leaf pair always closed, leaves slow to close once open, and desynchronization between leaf pattern and projection number. QA plans were created using the Tomotherapy TPS with the high dose area aligned to the annular region containing the diodes, and delivered to the ArcCHECK device. The position of the device remained constant between deliveries of the altered sinograms. Measured data were compared to calculated dose using the ArcCHECK dose analysis tools with a 3%/3mm γ tolerance. Results: ArcCHECK was able to detect delivery differences except for peripheral leaves remaining open for the entirety of the procedure (the % agreement for measurement points increased in this case). Altering the sinogram by one projection (∼7°) or increasing leaf open time by 50ms resulted in <80% agreement. Increasing leaf open time by 250ms, fully opening or closing the central two leaves, or creating a ∼100° gantry starting position error yielded passing rates below 30% and were clearly detectable. Conclusions: For many years the gamma passing rate has been used as the standard for comparing measured and calculated dose distributions. However, arbitrary shifting of the dose distribution may mask delivery errors, especially in a less intuitive measurement pattern. Having the ability to simulate possible errors should provide the medical physicists with tools to evaluate the sensitivity and response of a particular QA device. Investigation into the types and magnitudes of detectable errors may lead to more robust QA.
Med Phys. 2012 Jun ;39 (6):3656 22755987
Rush University Medical Center, CHICAGO, IL.
Purpose: This study aims to evaluate the effectiveness of compression in immobilizing tumor during stereotactic body radiotherapy (SBRT) for lung cancer. Methods: Published data have demonstrated bigger respiratory motion in lower lobe than in upper lobe during normal breathing. We hypothesize that 4DCT-based patient selection and abdominal compression would immobilize lung tumor volumes effectively, regardless of their location. We retrospectively reviewed 12 SBRT lung cases treated with Trilogy® (Varian Medical System, Palo Alto, CA). Either compression plate or Vac-LokTM was used as abdomen compression of the SBRT immobilization system (Body Pro-LokTM, CIVCO) to restrict patients' breathing during CT simulation and treatment delivery. These cases are grouped into 2 categories: lower and upper lobe tumor, each with 6 cases. Records for 33 treatments were studied. On each treatment day, the patient was set up to the bony anatomy using kV-kV-match. A CBCT was performed to further set up the patient to the tumor based on the soft tissue information. The shifts from CBCT-setup were analyzed as displacement vectors demonstrating the magnitude of the tumor motion relative to the bony anatomy. Results: The mean magnitude of displacement vectors for upper lobe and lower lobe were 3.7±2.7 and 4.2±6.3,[1S.D.] mm, respectively. The Wilcoxon rank sum test indicates that the difference in the displacement vector between the two groups is not statistically significant (p-value = 0.33). Conclusions: The magnitude of shifts from CBCT were small with mean value <5mm in SBRT lung treatments. No statistically significant difference were observed in the displacement of tumor between lower and upper lobes. With limited sample size, this suggests that our current 4DCT screening/abdominal compression approach is effective in restricting the respiration-induced tumor motion despite its location within the lung. We plan to confirm this Result in additional patients.
The effect of urinary incontinence on health utility and health-related quality of life in men following prostate surgery.
Department of General Practice, National University of Ireland, Galway, Ireland. firstname.lastname@example.org
AIMS The impact of urinary incontinence (UI) on health-related quality of life (HRQoL) has been less well researched in men than women and the general population. This study aims to assess the association between UI and HRQoL in men 1 year after prostate surgery. METHODS Planned secondary analysis of data from two parallel randomized controlled trials of active conservative treatment for UI in 853 men following radical prostatectomy (RP) and transurethral resection of the prostate (TURP). Men of any age were eligible for trial inclusion if they were experiencing UI 6 weeks after undergoing RP or TURP at 34 centers in the United Kingdom. Univariate and multivariate analysis considered associations between health status (SF-12 and EQ-5D) and self-reported UI. Multivariate analysis controlled for age, obesity, UI prior to surgery, and concomitant fecal incontinence. RESULTS Mean age of 411 men in the RP trial was 62.3 years (SD 5.7) and 442 men in the TURP trial was 68.0 (SD 7.9). Of men with UI at 6 weeks after surgery, 76.7% in the RP group and 63.2% in the TURP group still had UI at 12 months. Any UI at 12 months was significantly associated with reduced HRQoL in the RP group and lower EQ-5D and SF-12 Mental Component Scores in the TURP group. CONCLUSION Any UI is a significant factor in reduced HRQoL in men following prostate surgery, particularly younger men who undergo RP. Its importance to patients as an adverse outcome should not be underestimated.
Cytology and clinical spectrum of sexually transmitted infections in Lebanese women as revealed by pap smear: a cross-sectional study from 2002-2006.
W G Karam, A Rady, I Abdallah Hajj Hussein, C Assaad, J Saliba, G Aftimos, M Mortada, M Hazzouri, N Bedrossian, S Naji, A Leone, A R Jurjus
Institut National de Pathologie, Beirut, Lebanon.
To study the cytology profile of cervical smears and the respective prevalence and incidence of certain cervico-vaginal infections detectable by routine Pap smear cytology in Lebanese women from 2002 to 2006. Pap smear cytology results were compiled from the archives of the Institut National de Pathologie for the period extending from 2002 until 2006. This study covered 118,230 cervical specimens obtained from Lebanese women attending clinics and hospitals in all the five districts of Lebanon; prevalence and incidence rates for infections detectable by routine Pap smear examination were determined. A rise in prevalence of these infections by 2.1 percent (2,555) from 2002 to 2006 was revealed. A doubling of Pap smears showing HPV-associated changes was detected (1.4 percent in 2002 to 2.9 percent in 2006), and a simultaneous almost 7-fold increase of Atypical Squamous Cells of Undetermined Significance (ASCUS) cytology was detected during this period; the rise in ASCUS cytology was age-dependent. Moreover, a 60 percent increase in prevalence of bacterial vaginosis (2.3 percent in 2002 to 3.7 percent in 2006) and a more than 3-fold decline in Trichomonas vaginalis infection (1 percent in 2002 to 0.3 percent in 2006) were also noted in this population during this period. An increase in the prevalence and incidence of cervico-vaginal infections detectable by Pap smear cytology in Lebanese women was revealed from 2002 to 2006. Such changes could point to recent modifications of sexual and health behaviours in the Lebanese community.
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Department of Obstetrics and Gynecology, Hospital Universitario Materno-Infantil de Canarias (Canaries University Hospital Maternity Ward), Las Palmas de Gran Canaria, Spain. email@example.com
Acute fatty liver of pregnancy is a rare cause of jaundice and liver failure associated with high maternal and fetal mortality. We analysed five consecutive cases of acute fatty liver of pregnancy, along with the associated morbidity, mortality and complications. Between January 1999 and January 2008, a total of 68,524 deliveries were assisted at the Obstetrics and Gynaecology Department of the Hospital Universitario Materno-Infantil de Canarias (Canaries University Hospital Maternity Ward); among them, five cases of acute fatty liver of pregnancy were identified.
Pharm World Sci. 2010 Feb 10;: 20146098
Post natal use of analgesics: comparisons between conventional postnatal wards and a maternity hotel.
Department of Pharmacy, School of Pharmacy, University of Oslo, P.O. Box 1068, Blindern, 0318, Oslo, Norway, firstname.lastname@example.org.
Aim To investigate factors related to analgesic use after delivery, and especially whether rates of analgesic use were different in a midwife-managed maternity hotel as compared to conventional postnatal wards. Setting One maternity hotel and two conventional postnatal wards at Ullevål University Hospital in Oslo, Norway. Method Data were obtained from hospital records for 804 women with vaginal deliveries. Main outcome measure Postnatal analgesic use. Results Overall, approximately half the women used analgesics after vaginal delivery in both conventional postnatal wards and maternity hotel. The factors that were significantly associated with use of analgesics postnatally in multivariate analysis were multiparity, having a non-Western ethnicity, smoking in pregnancy, younger age, instrumental delivery, analgesic use during labour, maternal complications post partum, and duration of postnatal stay 4 days or more. Conclusion The use of analgesics is determined by socio-demographic and obstetric factors rather than the organisation of the ward.
Cathy Nabet, Nathalie Lelong, Marie-Laure Colombier, Michel Sixou, Anne-Marie Musset, François Goffinet, Monique Kaminski
INSERM UMRS 953, Research Unit on Perinatal Health and Women's and Children's Health, Villejuif Cedex, France;
Aim: To analyse the association between maternal periodontitis and preterm birth (<37 weeks' gestation) according to the causes of preterm birth. Materials and Methods: Epipap is a case-control multi-centre study of singleton livebirths. One thousand one hundred and eight women with preterm deliveries and 1094 with deliveries at term (>/=37 weeks) at six French maternity units were included. Periodontal examinations after delivery identified localized and generalized periodontitis. Cases were classified according to four causes of preterm birth. Polytomous logistic regression analysis was used to control for confounders (maternal age, parity, nationality, educational level, marital status, employment during pregnancy, body mass index before pregnancy, smoking status) and the examiner. Results: Localized periodontitis was identified in 129 (11.6%) cases and in 118 (10.8%) control women and generalized periodontitis in 148 (13.4%) and 118 (10.8%), respectively. A significant association was observed between generalized periodontitis and induced preterm birth for pre-eclampsia [adjusted odds ratio 2.46 [95% confidence intervals (95% CI)1.58-3.83]. Periodontitis was not associated with spontaneous preterm birth or preterm premature rupture of membranes or with the other causes. Conclusion: Maternal periodontitis is associated with an increased risk of induced preterm birth due to pre-eclampsia.
Case Western Reserve University School of Medicine. email@example.com
Postpartum depression occurs in at least one in seven new mothers, usually within the first 6 months after delivery. By the time of onset of postpartum depression, the mother has usually long since been discharged from the maternity hospital. Early identification and treatment of these mothers reduces both maternal and infant suffering. Careful risk-benefit decision-making regarding various treatment options in the postpartum should be discussed with the mother. Risks of untreated depression include poor bonding with the infant, lack of self care, infant neglect and infanticide.
Cliona M Murphy, Khulood Murad, Richard Deane, Bridgette Byrne, Michael P Geary, Fionnuala M McAuliffe
Rotunda Hospital, Dublin, Ireland.
OBJECTIVE To assess the prevalence and causes of severe maternal morbidity in Dublin over a two year period from 2004 to 2005. STUDY DESIGN A prospective cohort study from January 2004 to December 2005 was undertaken in the three large maternity hospitals in Dublin, which serve a population of 1.5 million people. All are tertiary referral centres for obstetrics and neonatology and have an annual combined delivery rate of circa 23,000 births. Cases of severe maternal morbidity were identified. A systems based classification was used. The primary cause of maternal morbidity and the number of events experienced per patient was recorded. RESULTS We identified 158 women who fulfilled the definition for severe maternal morbidity, giving a rate of 3.2 per 1000 maternities. There were two maternal deaths during the time period giving mortality to morbidity ratio of 1:79. The commonest cause of severe morbidity was vascular dysfunction related to obstetric haemorrhage. Eclampsia comprised 15.4% of cases. Intensive care or coronary care admission occurred in 12% of cases. CONCLUSION The prevalence of severe maternal morbidity in this population is 3.2/1000 maternities. Obstetric haemorrhage was the main cause of severe maternal morbidity.
Department of Social and Pediatric Dentistry, School of Dentistry, Federal University of Juiz de Fora.
It has been recently suggested that periodontal disease is an associated factor for prematurity and low birth weight. The aim of this work was to assess the periodontal status of puerperae and determine its possible relationship with preterm low birth weight (PLBW) delivery. The sample included 59 women seen at two maternity hospitals in Juiz de Fora, MG, Brazil. Nineteen mothers had premature and low birth weight babies (gestational age below 37 weeks and birth weight below 2,500 g - group I), and 40 had mature, normal weight babies (gestational age over 37 weeks and birth weight over 2,500 g - group II). The mothers' data were obtained from medical files, interview, and periodontal clinical examination carried out up to 48 hours after delivery. The Periodontal Screening and Recording (PSR) was used for periodontal assessment. The association between periodontal disease and PLBW was expressed as odds ratio (OR). There was a higher rate of periodontal disease in group I (84.21%- 16/19) as compared with group II (37.5%- 15/40). The data also showed a significant association between periodontal disease and PLBW (OR = 8.9 - 95% CI: 2.22-35.65 - p = 0.001). It was concluded that maternal periodontal disease was an associated factor for prematurity and low birth weight in this sample.
How is maternal psychosocial health assessed and promoted in the early postnatal period? Findings from a review of hospital postnatal care in Victoria, Australia.
Mother and Child Health Research, La Trobe University, Carlton, Victoria, Australia. firstname.lastname@example.org
OBJECTIVE to describe how women's maternal health, particularly at a psychosocial level, is assessed and promoted during the postnatal hospital stay. DESIGN postal survey of public hospitals providing postnatal care and interviews with care providers. SETTING all publicly funded maternity units and selected health professionals in Victoria, Australia. PARTICIPANTS hospital postal survey: sixty six hospital respondents; interviews: 38 maternity unit managers, clinical midwives and medical practitioners. FINDINGS there was little consistency across the State in relation to routine observations of the mother. Physical checks were much more common than enquiring about how women felt physically. Practice in psychosocial assessment was also diverse, with care plans/maps (clinical pathways) being the main tool to guide assessment. Most participants reported that psychosocial assessment was undertaken during pregnancy. Follow-up after birth also varied. Hospital respondents reported that emotional well-being is assessed postnatally by observation and conversation with women. Participants who were interviewed reported that midwives had mixed skills in assessing and dealing with complex psychosocial issues. Three hospitals administer the Edinburgh Postnatal Depression Scale to women in the days after birth, and three hospitals provide routine sessions of structured debriefing. Survey participants reported that the busy and, at times, chaotic nature of postnatal wards affected the provision of care and the level of psychosocial support offered to women. KEY CONCLUSIONS although one of the stated aims of early postnatal care is the promotion of maternal well-being, the diversity of practices and the routine nature of many of these practices suggest that care is often not individualised or woman-centred. The reliance of detecting and managing women with particular psychosocial issues during pregnancy results in this aspect of care being given less priority postnatally than may be ideal. IMPLICATIONS FOR PRACTICE strategies are required to provide health professionals with guidelines and skills to enhance the detection of women who have, or have the potential to develop, health problems after birth. This requires a reorganisation of the way early postnatal care is provided in relation to the use of routine practices; the ability of caregivers to spend time with women in an environment that offers privacy and confidentiality; the structuring of care around individual needs; and opportunities for women to be cared for by caregiver/s with whom they have met before.
Azza A El-Mahally, Ibrahim F Kharboush, Naila H Amer, Mohamed Hussein, Tawfik Abdel Salam, Adel A Youssef
Health Administration and Planning and Behavioral Sciences Department, Faculty of Medicine, Alexandria University.
Puerperal infections are an important cause of maternal morbidity and mortality in developing nations. Investigators have noted several risk factors for developing puerperal sepsis. However, the relative importance of these risk factors varies and has to be determined for each setting. Therefore the aim of the present work was to determine the risk factors for puerperal sepsis in Alexandria, Egypt. A case-control design was used to study the risk factors of puerperal sepsis in Alexandria. The study included 160 puerperal sepsis cases and 160 controls. Puerperal sepsis cases were recruited from the fever hospital as well as from 3 rural health units and three urban health offices in Alexandria. A pre-designed interviewing questionnaire was used to collect data about risk factors of puerperal sepsis. Logistic regression analysis indicated that very low socio-economic score (OR = 6.4), no ANC (OR = 4.5), delivery at a governmental maternity hospital (OR = 203.4), frequent vaginal examinations (OR = 5.1), anemia during puerperium (OR = 4.3), unsanitary vaginal douching during puerperium (OR = 19.9) and unhygienic preparation of diapers used immediately after delivery (OR = 12.1) were significantly related to the occurrence of puerperal sepsis. Improving infection control measures during delivery, limiting the frequency of vaginal examinations, and avoiding all unhygienic practices related to delivery are strongly recommended.
Cross-sectional study was performed in all maternity units of Tbilisi, Georgia, with delivering 18,554 women between 1 January 2004 and 1 January 2005. There were 267 cases of severe obstetric morbidity giving a prevalence of 14,2 per 1000 deliveries (95% CI 12,6-16,0). During the study there were 3 maternal deaths. Disease specific morbidities per 1000 deliveries were: severe pre - eclampsia - 5,0 (95% CI 4,1-6,2); hysterectomy during 24 hours after delivery - 4,5 (95% CI 3,6-5,6); hemorrhage - 2,3 (95% CI 1,7-3,1), sepsis 1,3 (95% CI 0,9-2,0); eclampsia - 0,74 (95% CI 0,44-1,25); uterine rupture - 0,16 (95% CI 0,05-0,47); HELLP-syndrome - 0,11 (95% CI 0,03-0,39). Severe obstetric morbidity and its relation to mortality may be more sensitive measures of pregnancy outcome than mortality alone and allows for an effective audit system of maternal care.
Health Services Research Unit, University of Aberdeen Medical School, Aberdeen, Scotland. email@example.com
OBJECTIVE To identify obstetric and other risk factors for urinary incontinence that occurs during pregnancy or after childbirth. DESIGN Questionnaire survey of women. SETTING Maternity units in Aberdeen (Scotland), Birmingham (England) and Dunedin (New Zealand). POPULATION A total of 3405 primiparous women with singleton births delivered during 1 year. METHODS Questionnaire responses and obstetric case note data were analysed using multivariate analysis to identify associations with urinary incontinence. MAIN OUTCOME MEASURES Urinary incontinence at 3 months after delivery first starting in pregnancy or after birth. RESULTS The prevalence of urinary incontinence was 29%. New incontinence first beginning after delivery was associated with older maternal age (oldest versus youngest group, OR 2.02, 95% CI 1.35-3.02) and method of delivery (caesarean section versus spontaneous vaginal delivery, OR 0.28, 95% CI 0.19-0.41). There were no significant associations with forceps delivery (OR 1.18, 95% CI 0.92-1.51) or vacuum delivery (OR 1.16, 95% CI 0.83-1.63). Incontinence first occurring during pregnancy and still present at 3 months was associated with higher maternal body mass index (BMI>25, OR 1.68, 95% CI 1.16-2.43) and heavier babies (birthweight in top quartile, OR 1.56, 95% CI 1.12-2.19). In these women, caesarean section was associated with less incontinence (OR 0.39, 95% CI 0.27-0.58) but incontinence was not associated with age. CONCLUSIONS Women have less urinary incontinence after a first delivery by caesarean section whether or not that first starts during pregnancy. Older maternal age was associated with new postnatal incontinence, and higher BMI and heavier babies with incontinence first starting during pregnancy. The effect of further deliveries may modify these findings.