Pregnant women with lower back tattoos who wish to have an epidural placed during labour pose a dilemma to anesthesiologists. Clear guidelines have not been established. We reviewed the epidural risks in pregnant women with low back tattoos and have suggested precautionary measures to minimise them. Given the limited information available, and in the absence of a clear evidence-based medical contraindication, an epidural technique should not be excluded in those women with a lower back tattoo.

"Fetal heart rate patterns during repeated episodes of maternal clinical shock." Journal of Obstetrics and Gynaecology, 6(3), pp. 181–182

Objective To determine sonographic dimensions of the fetal facial profile in normal pregnancy.Methods This was a prospective, cross-sectional study of 397 normal healthy fetuses at 14-33 weeks of gestation. After exclusion of the small numbers of patients at the tipper GAs, 379 patients between 14.0 and 26.9 weeks of gestation were included in the analyses. The sagittal plane of the fetal facial profile was evaluated using transvaginal and transabdominal ultrasound. Distances from the tip of the nose to the mouth (the line between the lips), from the mouth to the gnathion (lower chin), from the upper philtrum to the mouth, and from the mouth to the tipper concavity of the chin were measured and are presented according to gestational age (GA).Results There was a significant linear correlation between GA and the distance from the tip of the nose to the mouth (r = 0.943; P < 0.00001; y = -37.98 + 7.54 x GA), from the mouth to the gnathion (r = 0.946; P < 0.00001; y = -46.34 + 7.95 x GA), from the tipper level of the philtrum to the mouth (r = 0.71; P < 0.00001; y = 0.22 + 3.33 x GA) and from the mouth to the upper concavity of the chin (r = 0.665; P < 0.00001; y = 1.65 + 2.95 x GA). The ratio between the distance from the tip of the nose to the mouth and that from the mouth to the gnathion was also almost constant throughout gestation, as was the ratio between the distance from the tipper philtrum to the mouth and that from the mouth to the tipper concavity of the chin.Conclusions We provide normative data of the fetal facial profile across GA. Our data offer a potential tool for the prenatal diagnosis of abnormal fetal facial profile. Copyright (C) 2009 ISUOG. Published by John Wiley & Sons, Ltd.

Objective: To assess the potential effect of educational intervention on episiotomy practice.Study design: A survey of the attitude of obstetrical caregivers toward episiotomy was conducted among obstetricians and midwives in the three public hospitals in Haifa. Data regarding episiotomy rates was collected for the years 2001-2003. At the beginning of 2002, lectures on the risks and benefits of episiotomy were given in two hospitals. Episiotomy rates before and after the lecture were compared.Results: A significant and lasting reduction in episiotomy rates was observed in the two hospitals where lectures were given. There were no clinically significant and consistent changes in the episiotomy practices in the third hospital.Conclusion: Education may play an important role in changing common medical practices, as in episiotomy. It was clearly shown that our beliefs are not always up to date. We call for periodic reassessment of all medical procedures, as common and accepted as they are. (c) 2005 Elsevier Ireland Ltd. All rights reserved.

OBJECTIVE: To estimate and report the incidence and perinatal significance of hypoglycemia during the 100-g oral glucose tolerance test in pregnant women.METHODS: Over a 3-year period, we analyzed the incidence and perinatal outcome of pregnant women who experienced hypoglycemia, defined as a plasma glucose level of 50 mg/dL or less while undergoing the 100-g oral glucose tolerance test. The study group included women who delivered singletons at term. Women who underwent the 100-g oral glucose tolerance test during the same period and had no hypoglycemia served as the control group.RESULTS: A total of 805 women were included in the study, which comprised 51 women (6.3%) who experienced hypoglycemia during the test and 754 women in the control group. Gestational diabetes mellitus was diagnosed in 5/51 (9.8%) women in the study group, compared with 216/754 (28.6%) women in the control group (P < .03), and the neonates born to these women had significantly lower birth weights.CONCLUSION: The incidence of reactive hypoglycemia during the 100-g oral glucose tolerance test in our population is 6.3%. Women who experience hypoglycemia during the test have a significantly lower incidence of gestational diabetes and neonatal birth weights. (c) 2005 by The American College of Obstetricians and Gynecologists.

Aim: To determine how the omission of the third hour glucose measurement of the 100 g oral glucose tolerance test (GTT) affects the diagnosis of gestational diabetes mellitus (GDM).Methods: Retrospective chart review of 876 women delivered in a tertiary care hospital in Israel during a threeyear period, who underwent a 100 g 3 hour oral GTT following an abnormal 50 g glucose screen. GDM was diagnosed according to the criterion standard accepted in the Fourth International Workshop Conference on GDM. The results of the 100 g 3 hour oral GTT were then retrospectively reevaluated by omission of the third hour plasma glucose measurement from the criterion standard.Results: GDM was diagnosed in 28.4% of the study patients, while the omission of the third hour glucose measurement resulted in a 26.4% diagnosis of GDM. The perinatal data of the 18-omitted cases suggests that their exclusion from the GDM group would not have altered substantially the perinatal outcome of the study cohort.Conclusions: A 100 g 2 hour oral GTT is a simple and economic alternative to the 100 g 3 hour oral GTT.

The Centers for Disease Control and Prevention (CDC) have recently published new guidelines for prevention of group B streptococcal (GBS) disease. 1 Prevention of prenatal group B streptococcal diseaseA public health perspective. MMWR. 1996; 45 (RR-7): 1-24 Google Scholar These new guidelines are in consensus with the American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG), who previously published their own, different, recommendations. 2 American Academy of PediatricsGuidelines for prevention of group B streptococcal (GBS) infection by chemoprophylaxis. Committee on infectious diseases and committee on fetus and newborn. Pediatrics. 1992; 90: 775-778 PubMed Google Scholar , 3 Group B streptococcal infections in pregnancyACOG's recommendations. ACOG Newsl. 1993; 37: 2 Google Scholar The new CDC guidelines allow two approaches: a screening-based strategy (a modification of the AAP strategy), and a risk-factor approach (a modification of the ACOG approach). According to the screening-based approach all pregnant women should be screened at 35–37 weeks' gestation for anogenital GBS colonisation. Intrapartum antimicrobial prophylaxis (IAP) should be offered to all pregnant women identified as GBS carriers, even without risk factors. If the result of GBS culture is not known at the time of labour, IAP should be administered in the presence of risk factors: less than 37 weeks' gestation, more than 18 hours of membrane rupture, or temperature higher than 38°C. The alternative approach is a prophylaxis strategy based on the presence of the above mentioned intrapartum risk factors alone. Regardless of which strategy is used, women who were treated for symptomless GBS bacteriuria detected during pregnancy and women who previously have given birth to an infant with GBS disease should receive IAP. 1 Prevention of prenatal group B streptococcal diseaseA public health perspective. MMWR. 1996; 45 (RR-7): 1-24 Google Scholar

Objective: To evaluate the effect on perinatal outcome of replacing glucose measurements for the diagnosis of gestational diabetes mellitus in central laboratories with those obtained by portable glucose meter.Study design: Simultaneously, venous blood samples were taken at the 100-g glucose tolerance test, and finger capillary blood glucose levels were also measured with a portable glucose meter in 180 pregnant patients. Patient management was according to the venous plasma glucose results. Following deliveries, the women were reallocated to diagnostic groups by both methods of measurements and by using the same cutoff values, and the outcome data were compared.Results: By using glucose values obtained by portable glucose meters instead of the results attained in the central laboratory, more women were diagnosed with gestational diabetes (33 vs 25) and the perinatal outcome was comparable.Conclusions: Obstetricians have to identify glucose intolerance during pregnancy in order to prevent macrosomia and its perinatal complications. These goals can be achieved with at least the same efficacy by performing the 100-g glucose tolerance test with a portable glucose meter as with current laboratory methods. Such an approach is time and resource saving and more convenient for both patients and health providers.

OBJECTIVE:The purpose of this study was to evaluate patient satisfaction for oral analgesia for postcesarean pain management.STUDY DESIGN:A prospective study was conducted on women who underwent cesarean section with regional analgesia. Women were treated with ibuprofen 400 mg in liquid-filled capsules on the first postoperative day by two modes of drug administration: on patient demand (n = 60) and at predetermined regular intervals (n = 54). Pain intensity and satisfaction were self-evaluated by the patients with use of a visual analog scale.RESULTS:Patients in the fixed time interval group had lower pain scores (by 38%-54%, P <.001) compared with the on-demand group. Satisfaction scores in both groups were high but superior in the fixed time interval group (87.5 +/- 18.8, median 94.5, vs 78.6 +/- 21, median 85, P <.001).CONCLUSIONS:Oral, nonnarcotic, postcesarean analgesia provides satisfactory pain relief. Patient satisfaction can be further enhanced by providing the medications in fixed time intervals rather than leaving it to patient request.

Acute colonic pseudo-obstruction, or Ogilvie syndrome can be a major surgical complication. Ogilvie syndrome, unlike adynamic ileus, is usually not self-limiting and may cause ischemic necrosis and colonic perforation, with a mortality rate as high as 50 percent. Ogilvie syndrome represents a diagnostic and therapeutic challenge that deserves a multidisciplinary approach. We present a case report and a literature review of the syndrome.

Background: Most congenital pulmonary arteriovenous malformations are associated with hereditary hemorrhagic telangiectasia. During pregnancy, pulmonary hemorrhage can occur, compromising maternal and fetal health. Cases: We studied three pregnancies in two women with hemorrhagic telangiectasia complicated by pulmonary arteriovenous malformations. A 28-year-old primigravida’s fetus died at 25 weeks’ gestation, and she had embolotherapy with coil springs, which corrected the hypoxemic state. In a subsequent pregnancy she delivered a healthy 2315-g infant at 38 weeks’ gestation. A 19-year-old primigravida had spontaneous hemothorax at 26 weeks’ gestation with severe hypoxemia and a growth-restricted fetus without umbilical artery diastolic flow. Pulmonary arteriovenous malformation was diagnosed by computed tomography of the maternal lung. She had continued pulmonary bleeding, so emergency lung lobectomy was done. Maternal hypoxemia and umbilical diastolic flow improved, and she had term delivery of a healthy 2250-g infant. Conclusion: Antenatal diagnosis and treatment of women with hereditary hemorrhagic telangectasia and pulmonary arteriovenous malformations might prevent potentially life-threatening fetomaternal complications.

The clinical features of preeclampsia have been traditionally ascribed to a generalized vascular endothelial cell dysfunction. The present study investigates the effect of sera from preeclamptic women and normal pregnancy on the metabolism of intracellular Ca2+ concentration ([Ca2+](i)) in normal cultured vascular smooth muscle cells (VSMC). Sera were obtained from normotensive pregnant women (NTP) (n = 17), preeclamptic women (PE) (n = 15), pregnant women with chronic (essential) hypertension (pregnant EHT) (n = 8), non-pregnant women with essential hypertension (non-pregnant EHT) (n = 12). and age-matched non-pregnant normotensive women (NNP) (n = 18). Serum (10%) was applied to both primary cultures of rat aortic smooth muscle cells and to the A-10 vascular muscle cell line. Levels of [Ca2+](i) were determined fluorometrically. After a 4-h incubation with serum, basal [Ca2+](i) was not significantly altered. However, compared with normal pregnant sera, PE sera markedly reduced hormonally induced Ca2+ transients. Thus, following acute stimulation of rat VSMC (primary cultures) with 10(-8)M angiotensin II, peak [Ca2+](i) responses (% increment over base line) were 443 +/- 22, 184 +/- 18, 259 +/- 12, 274 +/- 23, and 255 +/- 15% in NTP, PE, pregnant EHT, non-pregnant EHT, and NNP, respectively (P < 0.01 PE versus NTP, P < 0.05 PE versus NNP and pregnant and non-pregnant EHT). These effects of sera on [Ca2+](i) were qualitatively reproduced in platelets obtained from healthy volunteers. Also, depolarization-activated Ca2+ influx in VSMC was affected by the different sera groups in a manner similar to that seen with hormonally induced [Ca2+](i) responses. The altered [Ca2+](i) changes by PE sera disappeared 5 wk after delivery. The effect of the different sera groups on hormonally triggered Ca2+ transients in normal VSMC, as well as the normalization of [Ca2+](i) responses after delivery, suggest the presence of a circulating serum factor in PE. inasmuch as [Ca2+](i) is the major determinant of VSMC tone, it is possible that consequent to the attenuation of [Ca2+](i) responses, this putative circulating factor counterbalances the intense vasoconstriction in PE.

Objective: Cesarean section is one of the most common operations. The new technologies of postoperative pain treatment such as patient-controlled analgesia, are expensive and may limit women caring for their newborns shortly after delivery. The present study assessed patient satisfaction with oral analgesia following cesarean section. Study design: An open prospective study was conducted on all women who had a cesarean section with epidural analgesia, during two consecutive periods of 3 months each. In the first group of 109 women, an oral solution of 1 g dipyrone was allowed every 4 h, upon patient request. Patients requesting additional analgesia were administered a tablet of 30 mg immediate-release morphine sulfate. In the second group of 90 women, the same protocol was used; however, oral morphine was the drug of choice and dipyrone was used for rescue analgesia. Pain intensity and satisfaction were self-evaluated by patients using a visual analog scale. Results: The results of each study period were independently evaluated. The demographic and obstetrical variables were similar in both groups. The duration of analgesic effect of dipyrone was 6.5 h and the satisfaction score was 90. The duration of analgesic effect of oral morphine was 5.05 h and the satisfaction score was 83.7. Overall, patients in both groups requested only 25% of the permissible dosage of analgesia. Conclusions: Oral analgesia following cesarean section provides satisfactory pain relief, is easily administered, and is a substantially less costly alternative to the new pain treatment technologies currently in use.

OBJECTIVE:To examine the influence of epidural analgesia on labor and delivery in nulliparous and multiparous women.DESIGN:Data were collected on 847 consecutive parturients with singleton pregnancy and vertex presentation (384 nulliparous and 463 multiparous). The obstetrical and labor characteristics including maternal age, parity, gestational age, previous cesarean section, instrumental delivery, mode and timing of analgesia, mode of delivery, indications for cesarean section or instrumental delivery were analyzed comparing patients who received epidural analgesia with women who received systemic analgesia.RESULTS:Epidural analgesia was administered in 233 nulliparous and 141 multiparous women. A stepwise logistic regression analysis revealed that epidural analgesia independently affected the rate of non-spontaneous delivery and the duration of the second stage of labor in nulliparous (P=0.0017 and P=0.0036, respectively) and multiparous (P=0.001 and P=0.0081, respectively) women. Epidural analgesia independently affected the duration of labor only in nulliparous women (P=0.0001).CONCLUSION:Women should be informed that prolongation of labor and increase in nonspontaneous deliveries should be expected when choosing epidural analgesia in labor.

Objective The objective of this study was to obtain a nomogram of the fetal alveolar ridge development, as a basis for the diagnosis of primary cleft palate.Design A cross-sectional study of 323 normal pregnant women of 14-32 weeks' gestation. Several biometric measurements were obtained throughout pregnancy, including the width of the fetal alveolar ridge.Results A nomogram of the width of the fetal alveolar ridge during 14-32 weeks' gestation is presented. A linear growth Junction was observed between alveolar ridge width and gestational age, biparietal diameter, head circumference, femoral length and humeral length. The alveolar ridge width in all eight cases of cleft palate was above two standard deviations and the 90th centile of our nomogram.Conclusion We provide a nomogram of the growth of the fetal alveolar ridge between 14 and 32 weeks' gestation. This will aid the detection of primary cleft palate during routine prenatal sonography.

Describes a simple, yet generic database implementation framework for medium-sized datasets, as they occur during tests and applications of automated theorem provers. The implementation covers the automatic extraction of database objects from a set of text files, a text-based interface for simple database operations and a tool for document generation. This paper refers to a database of SETHEO proof data as an example. It concludes with the description of DBFW (DataBase FrameWork) as a statistics and usage-feedback component of the interactive proof system ILF (Integrated Logical Functions).

OBJECTIVE:To compare the outcome of matched triplets and twins delivered by cesarean section by order of delivery.STUDY DESIGN:39 sets of triplets delivered abdominally were matched to 39 sets of twins also delivered by cesarean section in the same gestational age. The newborns outcome according to their birth order was analyzed.RESULTS:The mortality rate of triplets was twice than that of matched twins. While first born triplets had mortality rates similar to the first and second twins, there was a threefold increase in mortality rates of the second and third triplets as compared to the first triplet or twin.CONCLUSIONS:Triplets have a poorer outcome than twins even when they are delivered abdominally at the same gestational age. These differences are particularly noted in the second and third newborns.

The aim of the present study was to investigate the umbilical cord measurements in pregnant patients with gestational diabetes. We found that the umbilical cord was significantly larger in fetuses of mothers with gestational diabetes than in the normal population and that the main increase in the width is attributed to an increase in Wharton jelly content. It is suggested that this finding may be an additional parameter that can differentiate between the appropriate-for-gestational-age fetus from a normal pregnancy and that from a pregnancy in a mother with gestational diabetes, and between the macrosomic fetus of a diabetic pregnancy from the genetically large fetus.

It has been suggested that vibroacoustic stimulation might be stressful to the fetus. The present study was designed to evaluate whether the stimulus induces passage of meconium in labor. Patients in labor at term with healthy fetuses and intact membranes were randomized to a vibroacoustic stimulation or sham test. The incidence of meconium was the same in both groups. Pregnancy outcome variables were also similar in both groups. In conclusion, vibroacoustic stimulation does not increase the incidence of meconium passage of labor of healthy fetuses.