Evaluation of the learning curve for external cephalic version using cumulative sum analysis

OBJECTIVE: We evaluated the learning curve for external cephalic version (ECV) using learning curve-cumulative sum (LC-CUSUM) analysis. METHODS: This was a retrospective study involving 290 consecutive cases between October 2013 and March 2017. We evaluated the learning curve for ECV on nulli and over para 1 group using LC-CUSUM analysis on the assumption that 50% and 70% of ECV procedures succeeded by description a trend-line of quadratic function with reliable R² values. RESULTS: The overall success rate for ECV was 64.8% (188/290), while the success rate for nullipara and over para 1 groups was 56.2% (100/178) and 78.6% (88/112), respectively. ‘H’ value, that the actual failure rate does not differ from the acceptable failure rate, was −3.27 and −1.635 when considering ECV success rates of 50% and 70%, respectively. Consequently, in order to obtain a consistent 50% success rate, we would require 57 nullipara cases, and in order to obtain a consistent 70% success rate, we would require 130 nullipara cases. In contrast, 8 to 10 over para 1 cases would be required for an expected success rate of 50% and 70% on over para 1 group. CONCLUSION: Even a relatively inexperienced physician can experience success with multipara and after accumulating experience, they will manage nullipara cases. Further research is required for LC-CUSUM involving several practitioners instead of a single practitioner. This will lead to the gradual implementation of standard learning curve guidelines for ECV.

Analysis of Drug Counseling for Breastfeeding Mothers at the Korean Mothersafe Professional Counseling Center; 5 Years Experience / 대한주산의학회잡지

PURPOSE: There is a dearth of information on maternal drug exposure during lactation. The Korean Mothersafe Professional Counseling Center launched helpline to provide information and clinical consultation service on drug safety during lactation as well as in pregnancy. Here, we reviewed our 5 years' experience of counseling with drug exposed breastfeeding mothers. METHODS: The questionnaires were given to drug exposed breastfeeding mothers from January 2005 to April 2010 who contacted our helpline and follow-up survey data was collected by phone call. The questionnaires included lists of symptoms that exposed mothers experienced and that was observed in their infants, as well as demographic questions and questions about lactation. RESULTS: A total of 278 mothers completed the survey and lactational exposure was estimated. Majority of them reported that their infants and themselves never experienced serious side effects of drugs during lactation. Only 3 (1.1%) babies reported side effects and 20 (7.2%) mothers reported decreased production of breast milk. Two hundred thirty two (83.5%) mothers continued breastfeeding after counseling. Lactation was stopped temporarily in 20 (7.2%) mothers and permanently in 26 (9.3%) mothers. CONCLUSION: Most of the drugs exposed during lactation did not cause serious side effects to infants and mothers. As many drugs have inadequate data to assure safety, the clinician is left with a dilemma as to where the balance of risks and benefits lie with respect to the mother and her baby. The author expect that analyses of these counseling will contribute to provide practical answers to clinicians as well as exposed mothers and to establish correct breastfeeding practice.

Cervical cerclage in asymptomatic women with a short cervix on ultrasound: Clinical efficiency for prevention of preterm birth / 대한산부인과학회지

OBJECTIVE: To investigate the clinical efficiency of the cervical cerclage for preventing preterm birth in asymptomatic women who showed a shortened cervix at the second trimester ultrasound METHODS: From January 1996 to December 2005, we retrospectively reviewed the medical records of pregnant women who received routine second trimester ultrasound (16~24 gestational weeks) without abdominal pain or bleeding at Cheil general hospital. Women with a short cervical length < or =25 mm were classified into cerclage and expectant group. Women who received cervical cerclage within 1 week after detection of cervical shortening without any change of cervical length and shape were included in cerclage group. Primary outcome was the frequency of delivery before 34 weeks' gestation. Secondary outcome was the most important risk factor for preterm delivery in pregnant women with short cervix. Chi-square test, t-test, and multiple logistic regression analysis were used for statistical analysis. P<0.05 was considered statistically significant. RESULTS: The mean gestational age at ultrasound was 21.6 weeks' gestation. A total of 111 women had short cervix, including 26 that were treated by cerclage and 85 managed expectantly. The proportion of preterm delivery before 34 weeks' gestation was higher in the cerclage group [38% (10 of 26)] than that of the expectant group [20% (17 of 85)], but there was no significant difference (P=0.069). In the univariate analysis, funneling (38% vs 16%, P=0.012) and cervical length < or =15 mm (47% vs 15%, P=0.069) were associated with preterm delivery before 34 weeks' gestation. In the multiple logistic regression analysis, a cervical length < or =15 mm had an adjusted odd ratio of 3.7 (95% CI 1.3~10.6) for preterm delivery before 34 weeks's gestation. CONCLUSIONS: These data suggest that cerclage in asymptomatic woman with a short cervix in the second trimester ultrasound does not prevent preterm delivery before 34 weeks of gestation. Woman with extremely shortened cervical length < or =15 mm needs intensive management for prevention of preterm delivery.

Obstetrical outcome after oocyte donation in patients with premature ovarian failure / 대한산부인과학회지

OBJECTIVE: The purposes of this study are to evaluate the obstetric outcome in pregnancies resulting from oocyte donation and to assess the factors related to the obstetric complications. METHODS: The obstetric outcome in pregnancies from the oocyte donation (n=37) was compared with that in pregnancies from conventional IVF program (n=137) in our IVF center between January 1995 and December 2000. Control group was selected by age, parity, and order of gestation matched to the study group. Pregnancy induced hypertension (PIH) was defined as blood pressure >140/90 mmHg on two or more occasions at least 6 hours apart with or without proteinuria after 20 weeks of gestation and not associated with chronic hypertension. Small for gestational age (SGA) was defined as birth weight below tenth percentile for gestational weeks. The data was analyzed using the Statistical Package for Social Sciences (SPSS). RESULTS: Early pregnancy loss rates were 37.8% (14/37) and 23.4% (32/137) in study and control group, respectively (P>0.05). PIH related factors such as mean age, parity and order of gestation were not significantly different among the two groups. However, the incidence of PIH in oocyte donation group (30.0%, 6/20) was significantly higher than control group (8.8%,9/102). There was no significant difference in the incidence of SGA between the two groups. When oocyte donation group was stratified by relationship of oocyte donor to infertile patient (sibling versus non-sibling), the incidence of early pregnancy loss and PIH was significantly higher (chi square test, P<0.05) in non-sibling group (42.3%, 11/26; 38.5%, 5/13) than in control group (23.4%, 32/137; 8.8%, 9/102). CONCLUSION: The incidence of PIH was significantly higher in pregnancies after oocyte donation. Notably, the pregnancies from non-sibling oocyte donors had much higher incidence of early pregnancy loss and PIH than pregnancies from sibling oocyte donors or control group. Therefore, the occurrence of early pregnancy loss and PIH may be related to other factors than age, parity or multiple pregnancy.

A Case of Ipsilateral Primary Ovarian Pregnancy After IVF-ET in a Patient with Previous Unilateral Salpingectomy / 대한산부인과학회잡지

Marcus and Brinsden have reported the first ovarian pregnancy achieved by IVT-ET in 1993. They reported seven cases of primary ovarian pregnancy from 116 ectopic pregnancies after IVF. With advancement of ART, the incidence of ectopic pregnancy is increasing, but ovarian pregnancy is still a rare complication. We report a case of ipsilateral primary ovarian pregnancy after IVF-ET with a patient with previous unilateral salpingectomy with a brief review of literature.

Pregnancy Outcome after Exposure of Suspected Teratogens in Early Pregnancy / 대한산부인과학회잡지

OBJECTIVE: To compare the risk of congenital anomaly after exposure to suspected teratogens in early pregnancy with the known baseline risk to the geneneral population. METHODS: From September 1999 to August 2001, we counseled about the teratogenic risk of the fetus by relevant medical literatures after assessment of type, amount, and time of exposure for 302 pregnant women exposed to suspected teratogens such as drugs, radiation, alcohol, and cigarette smoking. We followed up on the pregnancy outcome with the rate of termination of pregnancy and incidence of congenital anomaly. RESULTS: Among a total of 302 cases, 253 pregnant women (83.8%) delivered, 15 (5%) were aborted spontaneously, 34 (11.3%) were terminated. 297 pregnant women (98.3%) were lastly exposed to drugs in mean 5.3 +/- 0.2 gestational weeks. Medicines taken were gastrointestinal drugs (23%), NSAIDs (18.3%), antibiotics (16.2%), antihistamines (10.8%) in the order of frequency. 74 pregnant women (24.5%) were exposed to radiation in mean 5.1 +/- 0.5 gestational weeks. The mean dose was 234.60 mrem. 113 pregnant women (37.3%) lastly drank alcohol in mean 4.5 +/- 0.4 gestational weeks and the mean amount was 1.55 oz. 36 pregnant women (11.9%) lastly smoked in mean 4.4 +/- 0.3 gestational weeks and the mean amount was 7.3 cigarettes/day. We found structural anomalies in 5 cases (Polydactylyl, Ileal agenesis, Both ear mass, Left ectopic kidney, Meningomyelocele) and 1 chromosomal abnormality case (Trisomy18). CONCLUSION: The rate of fetal structural anomaly was 2% in this study and is not more than baseline risk of general population. Therefore, evidence-based teratogenic risk counseling may prevent unnecessary pregnancy termination.

Clinical Outcomes of Increased Nuchal Translucency in Three Years / 대한산부인과학회잡지

OBJECTIVE: To evaluate the relationship between increased nuchal translucency (NT) and abnormal pregnancy outcomes. METHODS: From January 1999 to December 2001, The 298 fetuses of increased nuchal translucency (>or=2.5 mm) in period of 10-14 weeks gestation were reviewed retrospectively. Amniocentesis and high resolution ultrasonography during second trimester were done for all cases. We analyzed septation within NT, karyotypes, structural anomalies, and adverse pregnancy outcomes such as spontaneous abortion, intrauterine fetal death and preterm delivery. RESULTS: The mean age of the patients was 30.5 +/- 3.5 years. The mean gestational age and CRL were 12.5 +/- 0.95 weeks and 6.5 +/- 1.15 mm. We observed 18 (6%) cases of abnormal karyotypes. 7/46 (15.2%) fetuses with internal septation had abnormal karyotype and 11/252 (4.4%) fetuses without internal septation had abnormal karyotype (p=0.013). Among the 280 fetuses with normal karyotype, 8 (2.8%) fetuses had structural anomalies and 18 (6.4%) fetuses had adverse pregnancy outcomes. The chromosomal abnormality and structural anomaly were significantly increased in the group of nuchal translucency thickness above 3.5 mm (p=0.001). CONCLUSION: Increased nuchal translucency is related with chromosomal abnormality and abnormal pregnancy outcomes.

Evaluation of Insulin-like Growth Factor-binding Protein-1 in Cervical Secreation as a Predictor of Preterm Delivery / 대한산부인과학회잡지

OBJECTIVE: This study is performed to assess whether detection of phosphorylated insulin like growth factor binding protein-1 (phIGFBP-1) in cervical secretions by a bed side test could be used to prediction preterm delivery in patient with regular uterine contraction. METHODS: In our prospective study, 42 women between 20.2 and 36.4 weeks gestation with regular, persistent contraction (2-3/min for 30 min). and 27 women between 22.0 and 37.0 weeks of gestation without symptoms of preterm labor were assessed for presence of cervical phIGFBP-1. Dacron swabs were applied to the cervix and assayed in 5min by using immunochromatography, actim partus test (Medix Biochemica). RESULTS: Of the 42 patients with regular uterine contractions, 22 had a positive actim partus test and 20 had a negative test. Among the 22 patients with positive test, 5 delivered preterm and other 17 patients delivered term (<37 weeks). Among the the 20 women with a negative test, 2 delivered preterm (NS). The mean concentration of phIGFBP-1 in 22 positive patients is 83.8+/-86.5 microgram/L and that in 20 negative patients is 2.1+/-5.0 microgram/L (P<0.0001) (Table 4). Sensitivity, specificity, false positive, false negative, positive predictive, and negative predictive values were 18.5, 59.6, 40.3, 28.6, 16.7, and 94.9%, respectively. CONCLUSION: The absence of cervical phIGFBP-1 is seems to be a valuable test in excluding preterm delivery in patients who have regular uterine contractions. The high negative predictive value in this study may enable physicians to prevent over treatment of patients with uterine contractions. Therefore, many unwanted side-effects and complications of potentially hazardous tocolytic therapy can be prevented.

Estimation of Mean Fetal Biometry by Using Ultrasonography in Normal Pregnancy / 대한산부인과학회잡지

OBJECTIVE: The purpose of this study was to assess the mean fetal biometry and to create a formulae for estimation of gestational week using sonographic biometry measurement. METHODS: A total 271 women of singleton gestation were involved in this study of ultrasonographic fetal biometry. During the period from June 1996 to March 1998, the length of CRL (Crown Rump Length), BPD (Biparietal Diameter), HC (Head Circumference), AC (Abdominal Circumference), HL (Humerus Length) and TL (Tibia Length) of fetuses in normal pregnancy were measured by ultrasonography at Samsung Cheil Hospital and Women's Healthcare Center. The gestational age prediction equations were derived from sigletons with the use of liner regression analysis. RESULTS: We present the percentile ranks of fetal CRL, BPD, HC, AC, HL and TL measurement from 11 to 39 week's gestation and mean value of fetal size at each week. These data were analyzed and several second grade equations were derived from the data. CONCLUSION: We created these authentic equations and tables for mean value of fetal biometry in normal pregnancy at each gestation week with minimal intervariable errors.