Deborah Berman

Methods of induction of labour: A systematic review

BackgroundRates of labour induction are increasing. We conducted this systematic review to assess the evidence supporting use of each method of labour induction.MethodsWe listed methods of labour induction then reviewed the evidence supporting each. We searched MEDLINE and the Cochrane Library between 1980 and November 2010 using multiple terms and combinations, including labor, induced/or induction of labor, prostaglandin or prostaglandins, misoprostol, Cytotec, 16,16,-dimethylprostaglandin E2 or E2, dinoprostone; Prepidil, Cervidil, Dinoprost, Carboprost or hemabate; prostin, oxytocin, misoprostol, membrane sweeping or membrane stripping, amniotomy, balloon catheter or Foley catheter, hygroscopic dilators, laminaria, dilapan, saline injection, nipple stimulation, intercourse, acupuncture, castor oil, herbs. We performed a best evidence review of the literature supporting each method. We identified 2048 abstracts and reviewed 283 full text articles. We preferentially included high quality systematic reviews or large randomised trials. Where no such studies existed, we included the best evidence available from smaller randomised or quasi-randomised trials.ResultsWe included 46 full text articles. We assigned a quality rating to each included article and a strength of evidence rating to each body of literature. Prostaglandin E2 (PGE2) and vaginal misoprostol were more effective than oxytocin in bringing about vaginal delivery within 24 hours but were associated with more uterine hyperstimulation. Mechanical methods reduced uterine hyperstimulation compared with PGE2 and misoprostol, but increased maternal and neonatal infectious morbidity compared with other methods. Membrane sweeping reduced post-term gestations. Most included studies were too small to evaluate risk for rare adverse outcomes.ConclusionsResearch is needed to determine benefits and harms of many induction methods.

Premenarchal vaginal discharge: Findings of procedures to rule out foreign bodies

STUDY OBJECTIVE Vaginal discharge in children is a common gynecologic complaint and may be resistant to symptomatic and/or antibiotic treatment. In recurrent or unresponsive patients, an evaluation to rule out a foreign body is traditionally recommended. The objective of this study is to review cases of vaginal discharge referred to our institution and assess outcome and diagnosis in those who required irrigation or vaginoscopy to rule out a foreign body.A retrospective chart review was performed on all premenarchal girls identified through the University of Michigan Pediatric and Adolescent Gynecology Clinic database who were seen for evaluation of vaginal discharge between June 1996 and December 2001. The records were reviewed for age, length of time of discharge, aspects of discharge, procedures done to rule out foreign bodies, and findings of such procedures. SETTING The study was performed in a tertiary care university hospital. PARTICIPANTS Forty-one premenarchal girls were evaluated for vaginal discharge. The average age was 6.0 yr (range 3 months-11 yr). RESULTS The average duration of vaginal discharge prior to presentation was 13.7 months (range 1-42 months). Of the 41 girls, 18 girls underwent 1 procedure each, 2 girls underwent 2 procedures each, and 1 girl underwent 5 procedures. Ten vaginal irrigations in clinic were performed in 7 girls, 3 by the referring physician and 7 by us. These irrigations removed a foreign body (tissue paper) in 4 of 10 (40%) cases, 3 at our institution and 1 at an outside institution. In the three irrigation cases with foreign bodies performed at our institution, the foreign body was visible on genital examination prior to the irrigation. Seventeen vaginoscopies under anesthesia were performed in 16 girls, 5 by the referring physician and 12 by us. In the girls who underwent a vaginoscopy under anesthesia a foreign body was found in 3 of 17 (17.6%). The other findings of the vaginoscopies included: biopsy-proven severe dermatitis with no infection in 1 patient, lymphatic duct chylous drainage in 1 patient, nonspecific vulvovaginitis in 11 patients, and normal exam with eventual diagnosis of malingering in 1 patient. In all cases where a foreign body was identified, the patient presented with bloody or brown discharge. CONCLUSIONS Foreign bodies as a cause of persistent vaginal discharge in a tertiary care referral clinic were identified in 4 of 41 girls (9.8%) and 7 of 27 procedures (25.9%). One child had recurrent foreign bodies removed during 4 of 5 procedures for discharge. In children with persistent vaginal discharge, vaginal irrigation was feasible in older children (average age 7.7 yr). However, no foreign bodies were removed by irrigation that had not already been visually identified prior to the procedure. Exam under anesthesia and vaginoscopy allowed the identification of foreign bodies, and it facilitated the diagnosis of other unusual conditions.

Docosahexaenoic acid pretreatment confers neuroprotection in a rat model of perinatal cerebral hypoxia-ischemia

OBJECTIVE We hypothesized that pretreatment with docosahexaenoic acid (DHA), a potentially neuroprotective polyunsaturated fatty acid, would improve function and reduce brain damage in a rat model of perinatal hypoxia-ischemia. STUDY DESIGN Seven-day-old rats were divided into 3 treatment groups that received intraperitoneal injections of DHA 1, 2.5, or 5 mg/kg as DHA-albumin complex and 3 controls that received 25% albumin, saline, or no injection. Subsequently, rats underwent right carotid ligation followed by 90 minutes of 8% oxygen. Rats underwent sensorimotor testing (vibrissae-stimulated forepaw placing) and morphometric assessment of right-sided tissue loss on postnatal day 14. RESULTS DHA pretreatment improved forepaw placing response to near-normal levels (9.5 +/- 0.9 treatment vs 7.1 +/- 2.2 controls; normal = 10; P < .0001). DHA attenuated hemisphere damage compared with controls (P = .0155), with particular benefit in the hippocampus with 1 mg/kg (38% protection vs albumin controls). CONCLUSION DHA pretreatment improves functional outcome and reduces volume loss after hypoxia-ischemia in neonatal rats.

Non-invasive pulsed cavitational ultrasound for fetal tissue ablation: feasibility study in a fetal sheep model

Currently available fetal intervention techniques rely on invasive procedures that carry inherent risks. A non‐invasive technique for fetal intervention could potentially reduce the risk of fetal and obstetric complications. Pulsed cavitational ultrasound therapy (histotripsy) is an ablation technique that mechanically fractionates tissue at the focal region using extracorporeal ultrasound. In this study, we investigated the feasibility of using histotripsy as a non‐invasive approach to fetal intervention in a sheep model.

Fetal lung lesions: can we start to breathe easier?

OBJECTIVE The purpose of this study was to develop a simple and accurate approach for risk stratification of fetal lung lesions that are associated with respiratory compromise at birth. STUDY DESIGN We conducted a retrospective review of 64 prenatal lung lesions that were managed at a single fetal care referral center (2001-2011). Sonographic data were analyzed and correlated with perinatal outcomes. RESULTS Hydrops occurred in only 4 cases (6.3%). Among fetuses without hydrops, the congenital pulmonary airway malformation volume ratio (CVR) was the only variable that was associated significantly with respiratory compromise and the need for lung resection at birth (P < .01). Based on a maximum CVR >1.0, the sensitivity, specificity, positive predictive value, and negative predictive value for respiratory morbidity were 90%, 93%, 75%, and 98%, respectively. CONCLUSION Nonhydropic fetuses with a maximum CVR >1.0 are a subgroup of patients who are at increased risk for respiratory morbidity and the need for surgical intervention. These patients should be delivered at a tertiary care center with pediatric surgery expertise to ensure optimal clinical outcomes.

Treatment with docosahexaenoic acid after hypoxia-ischemia improves forepaw placing in a rat model of perinatal hypoxia-ischemia.

OBJECTIVE Docosahexaenoic acid (DHA) is a dietary fatty acid with neuroprotective properties. We hypothesized that DHA treatment after hypoxia-ischemia would improve function and reduce brain volume loss in a perinatal rat model. STUDY DESIGN Seven-day-old Wistar rat pups from 7 litters (n = 84) underwent right carotid ligation, followed by 8% O(2) for 90 minutes. Fifteen minutes after hypoxia-ischemia, pups were divided into 3 treatment groups (intraperitoneal injections of DHA 1, 2.5, or 5 mg/kg) and 2 control groups (25% albumin or saline). At 14 days, rats underwent vibrissae-stimulated forepaw placing testing, and bilateral regional volumes were calculated for cortex, striatum, hippocampus, and hemisphere. RESULTS Posthypoxia-ischemia treatment with DHA acid significantly improved vibrissae forepaw placing (complete responses: 8.5 ± 2 treatment vs 7.4 ± 2 controls; normal = 10; P = .032, t test). Postinjury DHA treatment did not attenuate brain volume loss in any region. CONCLUSION Posthypoxia-ischemia DHA treatment significantly improves functional outcome.

Preconception counseling, fertility, and pregnancy complications after abdominal organ transplantation: a survey and cohort study of 532 recipients

Pregnancy after solid organ transplant is a significant priority for transplant recipients but how patients report being counseled is unknown.

Docosahexaenoic Acid augments hypothermic neuroprotection in a neonatal rat asphyxia model

Background: In neonatal rats, early post-hypoxia-ischemia (HI) administration of the omega-3 fatty acid docosahexaenoic acid (DHA) improves sensorimotor function, but does not attenuate brain damage. Objective: To determine if DHA administration in addition to hypothermia, now standard care for neonatal asphyxial brain injury, attenuates post-HI damage and sensorimotor deficits. Methods: Seven-day-old (P7) rats underwent right carotid ligation followed by 90 min of 8% O2 exposure. Fifteen minutes later, pups received injections of DHA 2.5 mg/kg (complexed to 25% albumin) or equal volumes of albumin. After a 1-hour recovery, pups were cooled (3 h, 30°C). Sensorimotor and pathology outcomes were initially evaluated on P14. In subsequent experiments, sensorimotor function was evaluated on P14, P21, and P28; histopathology was assessed on P28. Results: At P14, left forepaw function scores (normal: 20/20) were near normal in DHA + hypothermia-treated animals (mean ± SD 19.7 ± 0.7 DHA + hypothermia vs. 12.7 ± 3.5 albumin + hypothermia, p < 0.0001) and brain damage was reduced (mean ± SD right hemisphere damage 38 ± 17% with DHA + hypothermia vs. 56 ± 15% with albumin + hypothermia, p = 0.003). Substantial improvements on three sensorimotor function measures and reduced brain damage were evident up to P28. Conclusion: Unlike post-HI treatment with DHA alone, treatment with DHA + hypothermia produced both sustained functional improvement and reduced brain damage after neonatal HI.

Developmental programming for allergy: a secondary analysis of the Mothers, Omega-3, and Mental Health Study

OBJECTIVE Fetal dysregulation of T helper cell pathways may predispose to allergy, as high cord blood T helper 2/T helper 1 ratios have been shown to precede development of allergic diseases. We aimed to determine whether prenatal eicosapentaenoic acid and docosahexaenoic acid supplementation reduces T helper 2 to T helper 1-associated chemokine ratios. We also explored the effect of mode of delivery on T helper 2/T helper 1 ratios. STUDY DESIGN We conducted a secondary analysis of a randomized placebo controlled trial initially performed to assess the effects of docosahexaenoic acid or eicosapentaenoic acid supplementation on pregnancy-related depressive symptoms among 126 participants. Cord plasma specimens from 98 newborns were assayed for chemokines associated with T helper 2 (thymus and activation-regulated chemokine [CCL17], macrophage-derived chemokine [CCL22], eotaxin [CCL 11]) and T helper 1 (interferon-inducible protein-10 [CXCL 10]) by enzyme-linked immunosorbent assay and Multiplex immunoassays. Ratios of log-transformed chemokines macrophage-derived chemokine/interferon-inducible protein-10 and thymus and activation-regulated chemokine/interferon-inducible protein-10 were compared between groups by analyses of variance. Multiple linear regression was performed to examine associations between treatments and chemokine ratios, adjusting for covariates. RESULTS After adjusting for gestational age at delivery, birthweight, and mode of delivery, both omega-3 supplementation groups were associated with lower macrophage-derived chemokine/interferon-inducible protein-10 ratios than placebo (eicosapentaenoic acid: coefficient -1.8; 95% confidence interval [CI], -3.6 to -0.05; P = .04; docosahexaenoic acid: -2.0; 95% CI, -3.9 to -0.07; P = .04). Similar associations were found for thymus and activation-regulated chemokine/interferon-inducible protein-10 (eicosapentaenoic acid: -1.5; 95% CI, -3.0 to 0.06; P = .06; docosahexaenoic acid -2.2; 95% CI, -3.8 to -0.52; P = .01). Cesarean delivery was associated with higher macrophage-derived chemokine/interferon-inducible protein-10 (1.6; 95% CI, 0.01-3.3; P = .049) and thymus and activation-regulated chemokine/interferon-inducible protein-10 (1.5; 95% CI, 0.1-2.9; P = .042) ratios than vaginal delivery. CONCLUSION Prenatal supplementation with eicosapentaenoic acid and docosahexaenoic acid resulted in decreased cord blood T helper 2/T helper 1 chemokine ratios. Cesarean delivery was associated with a pronounced T helper 2 deviation at birth.

Docosahexaenoic acid confers neuroprotection in a rat model of perinatal hypoxia-ischemia potentiated by Escherichia coli lipopolysaccharide-induced systemic inflammation.

OBJECTIVE Lipopolysaccharide pretreatment potentiates hypoxic ischemic injury. We hypothesized that docosahexaenoic acid pretreatment would improve function and reduce brain volume loss in this rat model of perinatal brain injury and inflammation. STUDY DESIGN Seven-day-old rats were divided into 3 groups: intraperitoneal docosahexaenoic acid 1 mg/kg and lipopolysaccharide 0.1 mg/kg, 25% albumin and lipopolysaccharide, and normal saline. Injections were given 2.5 hours before carotid ligation, followed by 90 minutes 8% O2. Rats underwent sensorimotor function testing and brain volume loss assessment on postnatal day 14. RESULTS Docosahexaenoic acid pretreatment improved vibrissae forepaw placing scores compared with albumin/lipopolysaccharide (mean+/-standard deviation weighted score/20: 17.72+/-0.92 docosahexaenoic acid/lipopolysaccharide vs 13.83+/-0.82 albumin/lipopolysaccharide; P<.007). Albumin/lipopolysaccharide rats scores were worse than those of the normal saline/normal saline rats (13.83+/-0.82 vs 17.21+/-0.71; P=.076). No significant differences in brain volume loss were observed among groups. CONCLUSION Lipopolysaccharide inflammatory stimulation in conjunction with hypoxic ischemic resulted in poorer function than hypoxic ischemic alone. Docosahexaenoic acid pretreatment had significantly improved function in neonatal rats exposed to lipopolysaccharide and hypoxic ischemic.