Umbilical cord prolapse and perinatal outcomes.

OBJECTIVES: To determine obstetric risk factors and perinatal outcomes of pregnancies complicated by umbilical cord prolapse. METHODS: A population-based study was performed comparing all deliveries complicated by cord prolapse to deliveries without this complication. Statistical analysis was performed using multiple logistic regression models. RESULTS: Prolapse of the umbilical cord complicated 0.4% (n=456) of all deliveries included in the study (n=121,227). Independent risk factors for cord prolapse identified by a backward, stepwise multivariate logistic regression model were: malpresentation (OR=5.1; 95% CI 4.1-6.3), hydramnios (OR=3.0; 95% CI 2.3-3.9), true knot of the umbilical cord (OR=3.0; 95% CI 1.8-5.1), preterm delivery (OR=2.1; 95% CI 1.6-2.8), induction of labor (OR=2.2; 95% CI 1.7-2.8), grandmultiparity (>five deliveries, OR=1.9; 95% CI 1.5-2.3), lack of prenatal care (OR=1.4; 95% CI 1.02-1.8), and male gender (OR=1.3; 95% CI 1.1-1.6). Newborns delivered after umbilical cord prolapse graded lower Apgar scores, less than 7, at 5 min (OR=11.9, 95% CI 7.9-17.9), and had longer hospitalizations (mean 5.4+/-3.5 days vs. 2.9+/-2.1 days; P<0.001). Moreover, higher rates of perinatal mortality were noted in the cord prolapse group vs. the control group (OR=6.4, 95% CI 4.5-9.0). Using a multiple logistic regression model controlling for possible confounders, such as preterm delivery, hydramnios, etc., umbilical cord prolapse was found to be an independent contributing factor to perinatal mortality. CONCLUSIONS: Prolapse of the umbilical cord is an independent risk factor for perinatal mortality.

The reported sex and surgery satisfactions of 28 postoperative male-to-female transsexual patients.

From 1980 to July 1997 sixty-one male-to-female gender transformation surgeries were performed at our university center by one author (A.M.). Data were collected from patients who had surgery up to 1994 (n = 47) to obtain a minimum follow-up of 3 years; 28 patients were contacted. A mail questionnaire was supplemented by personal interviews with 11 patients and telephone interviews with remaining patients to obtain and clarify additional information. Physical and functional results of surgery were judged to be good, with few patients requiring additional corrective surgery. General satisfaction was expressed over the quality of cosmetic (normal appearing genitalia) and functional (ability to perceive orgasm) results. Follow-up showed satisfied who believed they had normal appearing genitalia and the ability to experience orgasm. Most patients were able to return to their jobs and live a more satisfactory social and personal life. One significant outcome was the importance of proper preparation of patients for surgery and especially the need for additional postoperative psychotherapy. None of the patients regretted having had surgery. However, some were, to a degree, disappointed because of difficulties experienced postoperatively in adjusting satisfactorily as women both in their relationships with men and in living their lives generally as women. Findings of this study make a strong case for making a change in the Harry Benjamin Standards of Care to include a period of postoperative psychotherapy.

Sub-clinical worsening of bronchial asthma during estrogen replacement therapy in asthmatic post-menopausal women.

BACKGROUND: Changes in asthma activity, in part related to the female hormonal profile, have been observed during pre-menstrual periods and during pregnancy. Estrogen replacement therapy (ERT) is an accepted routine treatment for post-menopausal women. The effect of ERT on disease activity in post-menopausal asthmatic women has not been investigated in the past and is the subject of the present study. METHODS: Fifteen post-menopausal women with mild to moderate asthma completed two 30-day periods in which they measured peak expiratory flow (PEF) at home and filled in a daily diary of asthma-related symptoms. The first monitoring period was pre-ERT and the second was during ERT. In addition spirometry was performed on each woman three times, twice pre-ERT and once during ERT. RESULTS: The average daily PEF decreased from 241 (57.9, S.D.) l/min pre-ERT to 226.7 (62.7) l/min during ERT (P < 0.004). Significant differences between the two study periods were also found in morning and evening PEF values. Diurnal variation, measured as the difference between morning and evening PEF values, decreased significantly from 22.3 (26.7) l/min pre-ERT to 17.5 (26.8) l/min during ERT (P < 0.007). The average daily consumption of bronchodilator inhalers increased significantly from 3.7 puffs/day pre-ERT to 4.3 puffs/day during ERT (P < 0.006). Although the differences in spirometry between the two periods did not reach statistical significance, a trend towards a worsening of the obstructive disorder during ERT was observed. However, the general feeling of well-being of the asthmatics did not change during the two periods. CONCLUSIONS: During ERT a sub-clinical worsening of disease activity was found in postmenopausal women with mild to moderate asthma. We also detected a decrease in diurnal variation. Our findings should be substantiated by additional studies.

Influence of estrogen replacement therapy on airway reactivity.

The effect of estrogen on smooth muscle in various organs is unpredictable. Little is known about the effect of estrogen on respiratory tract smooth muscle, particularly in humans. In the present study we used the histamine challenge test (HCT) to assess the effect of estrogen replacement therapy (ERT) on airway reactivity in postmenopausal women who did not suffer from respiratory disease. Thirty-six women who were undergoing treatment at the postmenopausal clinic completed the study. All participants were nonsmokers whose pulmonary function tests were normal. HCT was performed twice before the inception of ERT, and a third time 4-6 weeks after ERT was begun. None of the 36 women demonstrated a 20% decrease in FEV1 values (PC20) after inhaling histamine at a concentration of 8 mg/ml, either before or during ERT. The maximal decrease in FEV1 values in response to the maximum concentration of histamine was significantly lower during ERT compared to the pretreatment period. The average maximal decrease in FEV1 during ERT was 2.63 +/- 2.72% (mean +/- DS) compared to 5.21 +/- 4.47% and 6.57 +/- 5.28% on the 2 tests prior to therapy (p < 0.0002). We conclude that ERT has an inhibitory effect on the bronchial reactivity of respiratory smooth muscle. There is no cause for concern about increased airway reactivity as an adverse effect of this therapy.

Acceptability and skin reactions to transdermal estrogen replacement therapy in relation to climate.

The acceptability and skin reaction of Estraderm Transdermal Therapeutic Systems as a function of climatic variability were examined in various zones which alter considerably in their temperature and humidity. An open, noncomparative prospective study was carried out in four institutional out-patient menopausal clinics in varying climatic areas. Eighty symptomatic postmenopausal patients without previous estrogen replacement were examined. Estraderm T.T.S. 50 was applied twice weekly in four weekly cycles. Norethisterone-acetate tablets (1 mg), were taken orally for 12 consecutive days. Using a questionnaire, the subjects were asked about the efficacy of the treatment on postmenopausal symptoms, the adhesiveness and tolerability. The results were matched with the meteorological conditions. The duration of the study was 6 months. Acceptability of Estraderm T.T.S. is high (78.7%). Discontinuation of treatment was found in 21.3% of the study group. The main reason for discontinuation is due to skin reactions which occurred in 14 of the 80 patients (17.5%). Meteorological conditions in this study did not influence the rate of skin reactions. No difference in acceptability of the treatment was found in relation to the mean temperature and mean humidity as registered in the dry desert and the humid coastal areas.

Listeria monocytogenes. The role of transabdominal amniocentesis in febrile patients with preterm labor.

Two women with preterm labor and intraamniotic infection with Listeria Monocytogenes are presented. In both patients, the prenatal diagnosis of Listeriosis was made by transabdominal amniocentesis. The immediate prominent observation was meconium staining of the amniotic fluid. We propose that an amniocentesis should be performed in women with premature labor and fever. If the amniotic fluid is meconium stained and the Gram stain examination reveals Gram positive rods, Listeria Monocytogenes should be suspected and the patient should be treated accordingly until the culture results are obtained.

Complications associated with the macrosomic fetus.

A retrospective study was done on 525 infants who weighed more than 4,500 g. The rates of grand multiparity, diabetes mellitus, pregnancy-induced hypertension, deliveries in women over 35 years of age, placenta previa and weight gain of more than 15 kg were higher than in a control group weighing 2,500-4,000 g. The rates of delivery with instruments and cesarean section were also significantly higher. The main indication for cesarean section in the study group was cephalopelvic disproportion, while in the control group it was repeat cesarean section. Rates of postpartum hemorrhage, shoulder dystocia, oxytocin augmentation of labor and tears in the birth canal far exceeded those in the control group. Maternal and fetal morbidity and perinatal mortality were significantly higher than in the control group. The complications were due to a difficult second stage of labor. Delivery of the macrosomic fetus by cesarean section is highly recommended except for the subgroup of women who already delivered a macrosomic child.

Fracture and chemical composition of the deposit formed on the Lippes loop after prolonged use.

In order to confirm or refute the theory that there is the need to replace IUD's every few years due to their breaking, 26 Lippes Loops were tested. The sediment found on the devices was composed mainly of calcium carbonate. After removal of the sedimentation, it was seen that there was some corrosion of the body of the devices which caused a decrease in the IUD thickness. Pressure tests showed that an IUD which has been in use for a long period of time is more rigid, has less ability to deform and breaks under less pressure. It seems that the current medical opinion stating that IUD's should be replaced every few years, is valid.

PIP: This study was carried out to confirm or refute the theory that IUDs need to be replaced every few years due to their breaking. Fracture and chemical composition of the deposit formed on 26 Lippes Loops after prolonged use (up to 7 years) were analyzed. The sediment consisted of calcium carbonate (77.2-83.1%), magnesium (.32-.41%), sodium (1.7-2%), and zinc (.14-.21%). The amount of sediment increased the longer the IUD was in the uterus without a change in chemical composition. The length of time in use also caused an increase in rigidity, a decrease in flexibility, and a decrease in the structural thickness of the IUD. After 1 year of use a pressure of 75 kg would only cause a depression while an IUD which had been in use for 5.5 years would break under a pressure of 25 kg. It is concluded that the current medical opinion stating that IUDs should be replaced every few years is a valid theory.