Ethical implications of aggressive obstetric management at less than 28 weeks of gestation.

BACKGROUND: The purpose of this study is to evaluate the outcome of infants born between 23 and 28 completed weeks of gestational age for whom aggressive obstetric management was performed. METHODS: Prenatal data were collected retrospectively from medical records. Neonatal mortality, early morbidity, and the outcome at one year corrected for postconceptional age (corrected age) were determined. RESULTS: Ninety-seven infants were included in the study. Serious early morbidity decreased with increasing gestational age. All the infants born prior to 24 weeks showed serious early morbidity: only 26% of the infants born at 24 weeks or later did. There was a significant decline in mortality with increasing gestational age, as there was also in birth weight (p<0.001, p<0.001). Sixty-seven percent of the infants prior to 24 weeks showed disability at one year corrected age whereas only 13% at 24 weeks or older did. The likelihood of having a surviving child without disability was 12.5% at 23 weeks, 39% at 24 weeks, 50% at 25 weeks, 52% at 26 weeks, and 70% at 27 weeks. CONCLUSION: Viability of fetuses at 23 and 24 weeks of gestation remains ethically and clinically controversial. It cannot be reliably established at that time that there is a fair balance of clinical goods over harms for the survivor at 23 weeks. On the other hand we should continue to treat fetuses at 24 weeks as viable, because 50% of them survived and 78% of those survived without disability. Neonatal mortality and survival with disability further decreases with increasing gestational age.

Acupuncture for cervical ripening and induction of labor at term--a randomized controlled trial.

OBJECTIVE: The aim of this study was to evaluate whether acupuncture at term can influence cervical ripening, induce labor and thus reduce the need for postdates induction. METHODS: On the estimated date of confinement (EDC) women were prospectively randomized to an acupuncture group (AG) or a control group (CG). Data of 45 women were evaluated (AG, n = 25; CG, n = 20). Inclusion criteria were as follows: confirmed EDC, uncomplicated course of pregnancy, singleton pregnancy in cephalic presentation. Exclusion criteria were as follows: cervical dilation > 3 cm, active labor, premature rupture of membranes, previous cesarean section, pathologies in mother or fetus. Women were examined at 2-day intervals. The cervical length was measured with vaginal ultrasonography, cervical mucus was obtained for a fetal Fibronectin test and the cervical status was assessed according to the Bishop score. In the AG, the points Hegu (Large Intestine 4) and Sanyinjiao (Spleen 6) were pierced on both sides every second day. If women were not delivered 10 days after EDC, labor was induced by administering vaginal prostaglandin tablets. RESULTS: The cervical length in the AG was shorter than that in the CG on day 6 and day 8 after EDC (P = 0.04 for both). In the AG the time period from the first positive Fibronectin test to delivery was 2.3 days, while that in the CG was 4.2 days (P = 0.08). The time period from EDC to delivery was on average 5.0 days in the AG and 7.9 days in the CG (P = 0.03). Labor was induced in 20% of women in the AG (n = 5) and in 35% in the CG (n = 7) (P = 0.3). Overall duration of labor, and first and second stage of labor were not different in the two groups. In 56% of women who underwent acupuncture (n = 14) and in 65% of controls (n = 13), Oxytocin was used to augment labor. (P = 0.54). CONCLUSION: Acupuncture at points LI4 and SP 6 supports cervical ripening at term and can shorten the time interval between the EDC and the actual time of delivery.

[Surgical vs. conservative treatment of fractures of the thoracolumbar transition]. / Operative vs. konservative Behandlung von Frakturen des thorakolumbalen Ubergangs.

A total of 86 patients suffering from fractures of the thoracolumbar spine were followed up after an average time period of 57 months (12-98). Of these patients, 56 were treated operatively and 30 conservatively. According to the AO/ASIF classification, 66% of the operated group were fractures of type A, 29% of type B, and 5% of type C. All patients were operated on by means of dorsal locking instrumentation with pedicular fixation and, apart from six patients, with transpedicular cancellous bone grafting. The conservative group was treated according to the guidelines of Böhler with closed reduction, plaster cast, and rehabilitation program. All fractures in the conservative group were of type A. At follow-up of all operated cases, the local gibbus angle had improved by a reduction of on average 18.6 degrees and was followed by a loss of correction of 12.5 degrees ending in a final gain of 6.1 degrees at follow-up. At follow-up of the conservatively treated cases, the local gibbus angle showed an improvement of 11.1 degrees at reduction and a loss of correction of 14.9 degrees after reduction. The remaining result was -3.6 degrees, that means an increase of kyphoses compared to the x-ray at admission. In order to be able to compare two homogeneous groups only fractures of type A were used. Comparison of the two groups showed an improvement of the vertebral body angle of 70% (11.3 degrees) after reduction in the surgical group and 46% (6.1 degrees) in the conservatively treated group. The subsequent loss of correction was 19% (3 degrees) in the surgical and 34% (4.5 degrees) in the conservatively treated group. The remaining gain at follow-up was 51% (8.3 degrees) in the surgical and only 12% (1.6 degrees) in the conservative group. The local gibbus angle had improved on average by 17.1 degrees after reduction in the surgical and by 11.1 degrees in the conservatively treated group. Loss of correction was 71% (12.2 degrees) and 132% (14.9 degrees), respectively. The final result at follow-up showed a decrease of kyphosis of 4.9 degrees in the surgical and an increase of kyphosis of 3.7 degrees in the conservatively treated group. The difference was significant. Within the surgical group, 75% of the loss of correction was caused by the discs and 25% by the vertebral body. In the conservatively treated group it was 69% and 31%, respectively. Concerning loss of correction, no difference was seen between patients with and without intercorporal bone grafting. There was no relationship between radiological and clinical outcome. Whereas 15% of the patients of the surgical group were not satisfied or moderately satisfied with the result, all patients in the conservatively treated group were satisfied or very satisfied. Based on the good clinical results of the conservative treatment we can conclude that in stable fractures without severe deformity, and in patients who are in bad general condition, conservative treatment can considered as an alternative to surgical treatment.

[Aneurysm of the splenic artery: rupture in pregnancy]. / Aneurysma der Arteria lienalis: Ruptur in der Schwangerschaft.

The rupture of a splenic artery aneurysm during pregnancy is a rare event. Two thirds of all ruptures happen during the third trimester. We report a case of a patient at 39 weeks of gestation suffering from abdominal pain and fetal distress. At cesarean delivery an aneurysm of the splenic artery was found to be the reason for the hematoperitoneum. Spleen, aneurysm and the tail of the pancreas were removed. The patient and her infant survived without further damage. Increased blood flow and changes in the vascular wall put pregnant women at risk for rupture of an aneurysm. In case of acute abdominal pain accompanied by progressive hypotension in a pregnant patient, a rupture of the splenic artery has to be considered. Active management and operation are the most important procedures for diagnosis and therapy of the bleeding. Abdominal delivery will help to establish diagnosis and should be performed immediately.

The fast-reacting fetal fibronectin test: a screening method for better prediction of the time of delivery.

OBJECTIVE: Our aim was to determine from what time onward fetal fibronectin is consistently detectable in the cervicovaginal secretions before delivery and to what extent the actual time of delivery can be better determined by this procedure than by the sole use of the Bishop score. STUDY DESIGN: A fast-reacting fetal fibronectin test was performed on 206 women on their expected date of confinement. In addition, the cervical status was evaluated with use of a modified Bishop score. Follow-up evaluations were subsequently carried out in the course of the routine examinations. RESULTS: Women with a positive fetal fibronectin test result and a high Bishop score were delivered after a median of 1.7 days. Conversely, women with a negative fetal fibronectin test result and a low Bishop score were delivered after a median of 7.1 days. CONCLUSION: Determination of fetal fibronectin in combination with the Bishop score makes it possible to predict the actual time of delivery with a greater degree of accuracy.

Haemoperfusion through activated charcoal in dogs with fulminant liver failure.

The effects of 8-hour haemoperfusion through an activated charcoal column on fulminant hepatic failure were assessed in 10 dogs. The survival in the perfused animals was significantly prolonged and the onset of liver encephalopathy was markedly delayed compared to the controls. Significant decrease in plasma bilirubin and total plasma phenols was found in the perfused group. No other laboratory changes due to heemoperfusion were found. The charcoal column retained its adsorptive capability throughout the experiment as judged from phenol clearance values. In spite of current scepticism regarding its clinical use, further trials with haemoperfusion in acute liver failure seem to be warranted.