Maria Bullarbo

Vaginal administration of the nitric oxide donor isosorbide mononitrate for cervical ripening at term: a randomized controlled study☆

OBJECTIVEnOur aim was to examine the effect of the nitric oxide donor isosorbide mononitrate on the uterine cervix at term and to evaluate possible adverse effects of this treatment.nnnSTUDY DESIGNnTerm pregnant women were randomly selected to receive either 40 mg vaginally administered isosorbide mononitrate or placebo 4 hours before elective cesarean section. Cervical status, maternal blood pressure, maternal pulse rate, fetal heart rate, umbilical arterial Doppler indices, and various side effects were examined.nnnRESULTSnIsosorbide mononitrate induced a significant increase in cervical distensibility. It also caused a significant change in maternal blood pressure and maternal pulse rate. In addition, the frequency of maternal headache and palpitations was significantly higher in the isosorbide mononitrate group versus the placebo group. However, the intensity of these symptoms was moderate.nnnCONCLUSIONnVaginal administration of 40 mg of isosorbide mononitrate induces cervical ripening at term. Although the majority of women experienced side effects, no serious clinical maternal or fetal adverse effects, resulting in specific medication or emergency cesarean section, were diagnosed.

Sublingual nitroglycerin for management of retained placenta

The aim of the study was to investigate the effect of sublingual nitroglycerin for management of retained placenta and to assess possible adverse effects of the treatment.

Real-time PCR-assay in the delivery suite for determination of group B streptococcal colonization in a setting with risk-based antibiotic prophylaxis

Abstract Objective: Intrapartum antibiotic prophylaxis (IAP) reduces the incidence of neonatal early onset group B streptococcal infections. The present study investigated if an automated PCR-assay, used bedside by the labor ward personnel was manageable and could decrease the use of IAP in a setting with a risk-based IAP strategy. Methods: The study comprises two phases. Phase 1 was a multicenter, randomized, controlled trial. Women with selected risk-factors were allocated either to PCR-IAP (prophylaxis given if positive or indeterminate) or IAP. A vaginal/rectal swab and superficial swabs from the neonate for conventional culture were also obtained. Phase 2 was non-randomized, assessing an improved version of the assay. Results: Phase 1 included 112 women in the PCR-IAP group and 117 in the IAP group. Excluding indeterminate results, the assay showed a sensitivity of 89% and a specificity of 90%. In 44 % of the PCR assays the result was indeterminate. The use of IAP was lower in the PCR group (53 versus 92%). Phase 2 included 94 women. The proportion of indeterminate results was reduced (15%). The GBS colonization rate was 31%. Conclusion: The PCR assay, in the hands of labor ward personnel, can be useful for selection of women to which IAP should be offered.

Nitroglycerin for Management of Retained Placenta: A Multicenter Study

The primary aim was to determine if sequential administration of oxytocin and nitroglycerin is effective for management of retained placenta when performed by obstetricians with no experience of the method. Secondary aims were to examine possible adverse effects of nitroglycerin. One hundred and five women with retained placenta were randomly selected to receive either 1u2009mg nitroglycerin or placebo tablets sublingually if intravenous oxytocin had failed to expel the placenta. At two of the hospitals some of the midwives were familiar with the use of nitroglycerin. The other midwives and all the participating obstetricians had no clinical experience of the method. In the treatment group, detachment of placenta following nitroglycerin occurred in 37.3% of the women compared to 20.4% in the placebo group (P = 0.056). In the two hospitals with some experience of the method, placenta was removed in 9 of 19 (47.4%) women in the nitroglycerin group compared to 3 of 17 (15.0%) women in the placebo group. No adverse effects of clinical importance were registered. Although the difference between the two groups did not reach statistical significance, the higher success rate in the two hospitals with some experience could indicate that clinical experience is of importance in order to achieve placental detachment.

Sublingual nitroglycerin seems to be effective in the management of retained placenta

Background. A common approach in the management of retained placenta is administration of oxytocin followed by controlled cord traction. Previously it has also been demonstrated that intravenously administered nitroglycerin facilitates manual extraction of retained placenta. The purpose of the present trial was to examine the success rate and safety of sequential administration of intravenous oxytocin in combination with sublingual nitroglycerin for the delivery of retained placenta. Methods. The report is a chart review of 24 women with retained placenta despite intravenously administered oxytocin. The women were given sublingual nitroglycerin (1 mg) to promote detachment of the placenta. Some 5 min after resorption of the tablets, controlled cord traction was carried out for a maximum of 5 min. In addition, changes in blood pressure following treatment with nitroglycerin and total blood loss during delivery were registered. Results. Twenty‐one of the women delivered the placenta successfully following sublingual administration of nitroglycerin. The procedure failed in 3 women and operative manual removal under regional or general anesthesia was undertaken. No complications due to nitroglycerin were registered. Conclusions. Sequential administration of oxytocin and nitroglycerin seems to be an effective and safe procedure in the management of retained placenta. However, larger studies are needed to confirm the encouraging results of the present trial.

Study protocol of SWEPIS a Swedish multicentre register based randomised controlled trial to compare induction of labour at 41 completed gestational weeks versus expectant management and induction at 42 completed gestational weeks.

BackgroundObservational data shows that postterm pregnancy (≥42 gestational weeks, GW) and late term pregnancy (≥41 GW), as compared to term pregnancy, is associated with an increased risk for adverse outcome for the mother and infant. Standard care in many countries is induction of labour at 42 GW. There is insufficient scientific support that induction of labour at 41 GW, as compared with expectant management and induction at 42 GW will reduce perinatal mortality and morbidity without an increase in operative deliveries, negative delivery experiences or higher costs. Large randomised studies are needed since important outcomes; such as perinatal mortality and hypoxic ischaemic encephalopathy are rare events.Methods/DesignA total of 10 038 healthy women ≥18xa0years old with a normal live singleton pregnancy in cephalic presentation at 41 GW estimated with a first or second trimester ultrasound, who is able to understand oral and written information will be randomised to labour induction at 41 GW (early induction) or expectant management and induction at 42 GW (late induction). Women will be recruited at university clinics and county hospitals in Sweden comprising more than 65 000 deliveries per year. Primary outcome will be a composite of stillbirth, neonatal mortality and severe neonatal morbidity. Secondary outcomes will be other adverse neonatal and maternal outcomes, mode of delivery, women’s experience, cost effectiveness and infant morbidity up to 3xa0months of age. Data on background variables, obstetric and neonatal outcomes will be obtained from the Swedish Pregnancy Register and the Swedish Neonatal Quality Register. Data on women’s experiences will be collected by questionnaires after randomisation and 3xa0months after delivery. Primary analysis will be intention to treat. The statistician will be blinded to group and intervention.DiscussionIt is important to investigate if an intervention at 41 GW is superior to standard care in order to reduce death and lifelong disability for the children. The pregnant population, >41 GW, constitutes 15–20xa0% of all pregnancies and the results of the study will thus have a great impact. The use of registries for randomisation and collection of outcome data represents a unique and new study design.Trial registrationThe study was registered in Current Controlled Trials, ISRCTN26113652 the 30th of March 2015 (DOI 10.1186/ISRCTN26113652).

Proteomic Analysis of Early Mid-Trimester Amniotic Fluid Does Not Predict Spontaneous Preterm Delivery

Objective The aim of this study was to identify early proteomic biomarkers of spontaneous preterm delivery (PTD) in mid-trimester amniotic fluid from asymptomatic women. Methods This is a case-cohort study. Amniotic fluid from mid-trimester genetic amniocentesis (14–19 weeks of gestation) was collected from 2008 to 2011. The analysis was conducted in 24 healthy women with subsequent spontaneous PTD (cases) and 40 randomly selected healthy women delivering at term (controls). An exploratory phase with proteomics analysis of pooled samples was followed by a verification phase with ELISA of individual case and control samples. Results The median (interquartile range (IQR: 25th; 75th percentiles) gestational age at delivery was 35+5 (33+6–36+6) weeks in women with spontaneous PTD and 40+0 (39+1–40+5) weeks in women who delivered at term. In the exploratory phase, the most pronounced differences were found in C-reactive protein (CRP) levels, that were approximately two-fold higher in the pooled case samples than in the pooled control samples. However, we could not verify these differences with ELISA. The median (25th; 75th IQR) CRP level was 95.2 ng/mL (64.3; 163.5) in women with spontaneous PTD and 86.0 ng/mL (51.2; 145.8) in women delivering at term (p = 0.37; t-test). Conclusions Proteomic analysis with mass spectrometry of mid-trimester amniotic fluid suggests CRP as a potential marker of spontaneous preterm delivery, but this prognostic potential was not verified with ELISA.

Self-diagnosis of Vulvovaginal Candidiasis is Poor - A Comparison of Diagnostic Methods Introducing ò-Glucan as a Complement

Aim: Self-diagnosis of Vulvovaginal Candidiasis (VVC) may result in misuse of over-the counter (OTC) antifungals. In this study the accuracy of self-diagnosis, clinical diagnosis, and laboratory diagnostic methods, including vaginal smear microscopy and a new method for the diagnosis of VVC (β-glucan), were compared using positive yeast culture as gold standard for diagnosis of VVC. Methods: Women with self-diagnosed VVC (n=88), intending to buy OTC antifungals, were recruited from pharmacies and health care providers. A clinical examination was performed including vaginal samples for quantitative culturing of yeast, for β-glucan determination and vaginal smear microscopy (VSM). Results: In all symptomatic women, 66% were culture-positive for yeast, 20% had bacterial vaginosis (BV) (12% concurrent with VVC), and 25% were not diagnosable. The sensitivity and specificity for diagnosis of VVC were similar for β-glucan (77% and 97%) and VSM (67% and 97%, respectively), while the sensitivity was low for clinical examination (40%). The sensitivity of VVC diagnosed by analysis of β-glucan was equal to gynecological examination combined with VSM. Conclusion: The accuracy of self-diagnosis of VVC is poor. To reduce misdiagnosis women should be offered complementary diagnostic methods. For correct diagnosis analysis of β-glucan or a combination of clinical examination and laboratory VSM is recommended. In cases of therapy resistance vaginal yeast cell culture is recommended. A future rapid bedside test of β-glucan would be useful avoiding misdiagnosis.

A Case of Chronic Ectopic Pregnancy Manifested by Rectal Bleeding

Ectopic pregnancy resulting in perforation of the rectum and rectal bleeding is clinically rare. We report an extremely rare case of chronic ectopic pregnancy with decreasing low levels of serum β-HCG resulting in rectal bleeding. A 31-year-old woman, gravida 3, para 3, with moderate abdominal pain and rectal bleeding was diagnosed with a tubal pregnancy. The tube was adherent to the rectum. Following salpingo-oophorectomy, the perforation of the rectum was sutured. Biopsies from the rectum as well as the tube confirmed chronic ectopic pregnancy. This case illustrates that diagnosing ectopic pregnancy is sometimes extremely challenging and it underlines the importance of follow-up consultations when the final diagnosis has not yet been reached.