Elective caesarean section at 38 weeks versus 39 weeks: neonatal and maternal outcomes in a randomised controlled trial.

OBJECTIVES: To investigate whether elective caesarean section before 39 completed weeks of gestation increases the risk of adverse neonatal or maternal outcomes. DESIGN: Randomised controlled multicentre open-label trial. SETTING: Seven Danish tertiary hospitals from March 2009 to June 2011. POPULATION: Women with uncomplicated pregnancies, a single fetus, and a date of delivery estimated by ultrasound scheduled for delivery by elective caesarean section. METHODS: Perinatal outcomes after elective caesarean section scheduled at a gestational age of 38 weeks and 3 days versus 39 weeks and 3 days (in both groups ±2 days). MAIN OUTCOME MEASURES: The primary outcome was neonatal intensive care unit (NICU) admission within 48 hours of birth. Secondary outcomes were neonatal depression, NICU admission within 7 days, NICU length of stay, neonatal treatment, and maternal surgical or postpartum adverse events. RESULTS: Among women scheduled for elective caesarean section at 38⁺³ weeks 88/635 neonates (13.9%) were admitted to the NICU, whereas in the 39⁺³ weeks group 76/637 neonates (11.9%) were admitted (relative risk [RR] 0.86, 95% confidence interval [95% CI] 0.65-1.15). Neonatal treatment with continuous oxygen for more than 1 day (RR 0.31; 95% CI 0.10-0.94) and maternal bleeding of more than 500 ml (RR 0.79; 95% CI 0.63-0.99) were less frequent in the 39 weeks group, but these findings were insignificant after adjustment for multiple comparisons. The risk of adverse neonatal or maternal outcomes, or a maternal composite outcome (RR 1.1; 95% CI 0.79-1.53) was similar in the two intervention groups. CONCLUSIONS: This study found no significant reduction in neonatal admission rate after ECS scheduled at 39 weeks compared with 38 weeks of gestation.

Use of 360-degree assessment of residents in internal medicine in a Danish setting: a feasibility study.

BACKGROUND: The aim of the study was to explore the feasibility of 360 degree assessment in early specialist training in a Danish setting. Present Danish postgraduate training requires assessment of specific learning objectives. Residency in Internal Medicine was chosen for the study. It has 65 learning objectives to be assessed. We considered 22 of these suitable for assessment by 360-degrees assessment. METHODS: Medical departments of six hospitals contributed 42 interns to the study. Each resident was assessed by ten persons of whom one was a secretary, four were nurses and five senior doctors. The assessors spent 14.5 minutes (median) to fill in the forms. RESULTS: Of the 22 chosen objectives, 15 could reliably be assessed by doctors, 7 by nurses and none by secretaries. CONCLUSIONS: The method was practical in busy clinical departments and was well accepted by the assessors. Reliability of the method was acceptable. It discrimintated satisfactorily between the good and not so good performers.

Stratified rates of cesarean sections and spontaneous vaginal deliveries. Data from five labor wards in Denmark--1996.

BACKGROUND: A fundamental point when auditing labor management is to ensure present and stratified process data. METHOD: Stratification of deliveries into ten mutually exclusive groups enabled comparisons of rates of cesarean sections and rates of spontaneous vaginal deliveries between labor wards. RESULTS: Data from five labor wards in Denmark in 1996 were included in the study comprising a total of 11,287 women. The overall cesarean section rates were between 13.2 and 15.2% which was not a significant difference, whereas cesarean section rates in several of the ten groups and the rates of spontaneous vaginal delivery in group 1 and 3 were significantly different between the labor wards. DISCUSSION: The method presented here is simple and can be used as an integrated part of the daily work and quality assurance. We advocate that stratification of the delivering women into ten groups should take place in every labor ward with focus on both the cesarean section rate and the rate of spontaneous vaginal delivery. Stratification provides data for periodical evaluation of the outcome within a department and for comparison between departments with different populations and policy.

[Sick leave for pregnant women in the municipality of Fjend 1987-1990]. / Sygemelding af gravide i Fjends Kommune 1987-1990.

All of 417 pregnancies in 1987-1990 in a rural community were retrospectively evaluated with emphasis on age, parity, previous spontaneous or induced abortion, occupation during pregnancy and sick leave from work. No difference was found in prevalence of sick leave between the employed women and the unemployed. Thirty-five percent of the women experienced sick leave at some time during pregnancy. The greatest single diagnostic group was pelvic insufficiency, which accounted for 33.5% of all days of sick leave up to the 32nd week of gestation. The incidence of pelvic insufficiency was high: 76 in 1000 deliveries. This may in part be due to a change in diagnostic criteria. Logistic regression analysis revealed that being a multipara was associated with a significantly higher risk of sick leave in the present pregnancy. Furthermore, being employed as a nurse, a shop assistant, a seamstress or a factory worker was associated with a significantly higher risk of sick leave during pregnancy in comparison with employment as a secretary. When investigating relationships between occupational conditions and the outcome of pregnancy, sick leave during pregnancy because of the same conditions may interfere significantly.

[Psoas abscesses--still a current problem in Denmark]. / Psoasabscesser--stadig aktuelle i Danmark.

Two cases of secondary, non-tuberculous psoas abscesses are presented, stressing that psoas abscesses are not restricted to tuberculous diseases of the spine (Pott's disease). In one case, the aetiology was diverticulitis with perforation located to the left colonic flexure. The patient was treated by a two-step operative procedure creating drainage and a primary anastomosis, which in the post-operative course was leaking. The patient died because of recurrent abscess formation and sepsis. The other patient received an aorto-bifemoral prosthesis two years prior to the current hospitalisation, and a bilateral psoas abscess appeared in the presence of this prosthesis. In both cases, the psoas abscesses presented below the inguinal ligament before diagnosis was made and even in the latter case with a delay of several months.

[Pulmonary edema during terbutaline infusion against threatened premature labor]. / Lungeødem under terbutalininfusion mod truende for tidlig fødsel.

A case of pulmonary oedema during tocolytic therapy with terbutaline infusion is reported. Although a cardiogenic cause for this type of pulmonary oedema has never been proven, it is believed that physiologic changes in pregnancy aggravated by beta-2 stimulation together with fluid overload constitute the pathophysiologic background to this serious complication.

Puerperal inversion of the uterus.

Puerperal inversion of the uterus is very rare but dramatic and life-threatening. Prompt treatment is necessary. A case is reported and the literature reviewed.

[Total uterine rupture of a cesarean section scar during attempted vaginal delivery under epidural analgesia]. / Total uterusruptur af sectiocikatrice under forsøg på vaginal forløsning under epidural analgesi.

A case of complete uterine rupture and abruptio placentae during an attempt of vaginal delivery under epidural analgesia in a woman with previous caesarean section is described and discussed. When using epidural analgesia for such a patient during vaginal delivery it is imperative that newly developed pain should be ascribed to the uterine scar and the diagnosis of threatening uterine rupture be made immediately.

[Toxic shock syndrome after Cesarean section]. / Toksisk shock syndrom efter sectio caesarea.

A case of toxic shock syndrome (TSS) after caesarean section is reported. Strains Staphylococcus aureus (phage type 80/42E/81/83A--mixed type) producing toxic shock syndrome toxin-1 in very great grantities amounts were isolated from the surgical wound. The diagnosis is often difficult in non-menstrual cases in which TSS is not expected.

Recurrent cerebral embolism in cardiac amyloidosis.

Cardiac involvement is common in systemic amyloidosis. The most frequent cardiovascular manifestations are congestive heart failure and arrhythmias. Embolic complications often occur after the onset of these symptoms. We report a 46-year-old woman with systemic amyloidosis, who sustained two middle cerebral artery strokes and shortly after developed symptoms of cardiac and renal failure with a rapid fatal course. Postmortem findings revealed mural thrombi in the left atrium as the source of embolism to the brain, to the spleen, and to the left kidney. As no evidence of congestive heart failure or arrhythmias was found in the beginning, the mechanism of mural thrombosis was probably an alteration in the thrombogenicity of the endocardium itself.

Hypoglycaemic coma in severe primary hypothyroidism.

A 76-year-old woman was admitted to the hospital in comatose condition. Her blood glucose was 1.7 mM. Immediately after intravenous glucose treatment she attained normal consciousness. The diagnosis of severe primary hypothyroidism was subsequently made and no sign of other diseases was detected. After thyroid replacement therapy fasting blood glucose levels rose to normal and no further hypoglycaemic episodes occurred. It is emphasized, that hypoglycaemia may be the direct cause of severely impaired consciousness in hypothyroidism requiring immediate and specific therapy.