Successful outcome with intrauterine transfusion in non-immune hydrops fetalis secondary to congenital syphilis.

BACKGROUND: Congenital syphilis is rare, but the incidence has increased over the last few years in Alberta. Previous reports of fetal hydrops secondary to syphilis are few and have not demonstrated the application of middle cerebral artery peak systolic velocity (MCA PSV) to monitor for fetal anemia, or reported successful management with intrauterine transfusion. CASE: A 17-year-old primigravida at 28 weeks' gestational age with positive syphilis serology and fetal hydrops was treated with high-dose intravenous penicillin. An elevated MCA PSV suggested fetal anemia. Successful intrauterine cordocentesis and transfusion of packed red blood cells led to resolution of fetal hydrops. The fetus delivered spontaneously at 35 weeks' gestation with no clinical signs of congenital syphilis. CONCLUSION: Syphilitic hydrops may be successfully managed with high dose intravenous penicillin, measurement of MCA PSV, and intrauterine transfusion.

Transvaginal sonography and fiberoptic illumination of uterine vessels for abdominal cervicoisthmic cerclage.

BACKGROUND: Transabdominal cervicoisthmic cerclage is a procedure carried out to increase the fetal salvage rates in women who are poor candidates for the more usual procedure of transvaginal cerclage or for those with previously failed vaginal procedures. Although several modifications have been applied to the original procedure in an attempt to reduce the morbidity, bleeding arising from trauma to the uterine vessels during suture placement remains problematic. CASE: Our technique involves transilluminating the uterine vessels during placement of the 5-mm-wide Mersilene (Ethicon Inc., Peterborough, Ontario, Canada) tape suture through an avascular space above the junction of the cervix and the uterine isthmus. This obviates the need to dissect or tunnel into the broad ligament. Simultaneous intraoperative transvaginal ultrasonography is used to enhance high suture placement at the isthmus and monitor the fetoplacental unit. We have used this technique in a series of five women with cervical incompetence for seven pregnancies. All but one procedure resulted in live term births. There were no major complications. CONCLUSION: Simultaneous intraoperative ultrasonography and uterine vessel transillumination simplified suture placement during abdominal cerclage, and reduced the amount of dissection and bleeding.

Computer telephony: automated calls for medical care.

BACKGROUND: The computer telephony system (CTS) combines computer and telephone to automate the collection, processing and dissemination of information. Many innovative applications of the CTS have emerged. In this article we summarize the evidence for CTS-based medical interventions based on randomized controlled trials. METHODS: We searched for trials in MEDLINE, CINAHL, the Cochrane Central Register of Controlled Trials, and bibliographies of retrieved articles, review articles and textbooks. We excluded non-English articles and those pertaining to psychology, addiction, psychiatry, research and education. RESULTS: In health care delivery, 3 of 4 trials of CTS-based interventions improved clinic show rates. In preventive health care, 4 of 5 showed higher childhood immunization rates. For nutrition, 2 small trials showed no clear benefit in cholesterol lowering or in weight reduction, but 1 trial showed a benefit in fibre intake. For increasing physical activity, 1 smaller trial showed no benefit but a larger one did. For medical management of chronic conditions, 1 trial showed improved hemoglobin A(1c) levels and 1 trial showed better processes of care in diabetes. In hypertension management, 1 trial found better adherence to medication regimens and control of blood pressure. In outpatient oncology care, 1 trial showed better supportive care. For support of caregivers for dementia patients, 1 trial showed no benefit. One small trial showed better adherence to medication in seniors. CONCLUSIONS: The CTS has diverse applications in medical care; however, the evidence for these is limited. Despite being impersonal, the reliability and availability of the CTS make it attractive for reminders and follow-up. More research is needed to determine the role of the CTS in medical care.

A randomized controlled trial of outpatient versus inpatient labour induction with vaginal controlled-release prostaglandin-E2: effectiveness and satisfaction.

BACKGROUND: Outpatient management in obstetrics is expanding, but evidence to support outpatient labour induction is needed. OBJECTIVE: To compare the effectiveness, acceptability, duration of hospitalization, and safety of outpatient and inpatient induction of labour with intravaginal controlled-release prosta-glandin-E2 (CR-PGE2). METHODS: A prospective, randomized, controlled trial enrolled 300 women at term with parity < or = 5 and singleton pregnancies in cephalic presentation. Each had an unscarred uterus, a normal non-stress test (NST), and a Bishop score of < or = 6. After insertion of the CR-PGE2, and 1 hour of monitoring, those in the outpatient group were discharged home, to return with onset of labour or 12 hours later for an NST. If not already in labour 24 hours later, the women returned for inpatient induction. Vaginal examination was not repeated before 24 hours unless the patient was contracting and required analgesia. Inpatients remained on the antepartum ward but were otherwise treated similarly. The women in both groups reported ratings of satisfaction, pain, and anxiety over the telephone until they were in labour. RESULTS: There were 150 women randomized to outpatient and 150 women to inpatient induction of labour. The number of women who were in labour or who delivered by 24 hours in the outpatient group was 115 (0.77, 95% confidence interval [CI] 0.70-0.84) and in the inpatient group was 107 (0.72, 95% CI 0.64-0.79). The median times to labour were 9.8 hours (95% CI, 8.1-11.4) and 11.4 hours (95% CI, 10.1-12.7), and to delivery were 21.4 hours (95% CI, 19.2-23.5) and 20.7 hours (95% CI, 18.4-23.0), for the outpatient and inpatient groups, respectively. In the outpatient group, 56% of women reported high satisfaction during the initial 12 hours of induction compared to 39% in the inpatient group (p < 0.008). Ratings of pain and anxiety during the first 12 hours of induction were similar. In the outpatient group, women were at home for a median of 8 hours (95% CI, 6.7-9.4) before labour and delivery. There were no significant differences in adverse outcomes. CONCLUSIONS: This study suggests that outpatient induction of labour with intravaginal CR-PGE2 may be a reasonable option for selected low-risk women; however, further study is needed to confirm the safety of this approach.

A comparison of rates, risk factors, and outcomes of gestational diabetes between aboriginal and non-aboriginal women in the Saskatoon health district.

OBJECTIVE: To determine possible differences in gestational diabetes mellitus (GDM) between aboriginal and non-aboriginal people in the Saskatoon Health District. RESEARCH DESIGN AND METHODS: This was a prospective survey of all women admitted for childbirth to the Saskatoon Royal University Hospital between January and July 1998. We compared prevalence rates, risk factors, and outcomes of GDM between aboriginal and non-aboriginal women. RESULTS: Information was obtained from 2,006 women, of whom 252 aboriginal and 1,360 non-aboriginal subjects had been tested for GDM. The overall rates of GDM were 3.5% for women in the general population and 11.5% for aboriginal women. For those living within the Saskatoon Health District, GDM rates were 3.7 and 6.4%, respectively. Multivariate analysis demonstrated that aboriginal ethnicity, most notably when combined with obesity, was an independent predictor for GDM. Pregravid BMI > or = 27 kg/m(2) and maternal age > or = 33 years were the most important risk factors for GDM in aboriginal women, whereas previous GDM, family history of diabetes, and maternal age > or = 38 years were the strongest predictors for GDM in non-aboriginal women. CONCLUSIONS: There may be fundamental differences in GDM between aboriginal and non-aboriginal people. Because GDM contributes to an increased risk for type 2 diabetes in aboriginal women and their offspring, the impact of prevention and optimal treatment of GDM on the type 2 diabetes epidemic in susceptible populations are important areas for further investigation.

Process evaluation of the Saskatoon breastfeeding center.

A process evaluation of the Breastfeeding Center in Saskatoon was conducted to assess clients' characteristics and satisfaction. Fifty women completed a questionnaire immediately after visiting the center and were interviewed by telephone 2 to 4 weeks later; another 25 women telephoned the center for information and were interviewed by telephone 2 to 4 weeks after initial contact. Four visits were observed and timed. Respondents were generally very satisfied with all aspects of the center. All said they would use the center again and recommend it to others. Most of the respondents were still breastfeeding when interviewed and felt that the center had helped them do so. Observation of the visits revealed a consistent sequence of activities, with visits taking longer on average than the time allotted. The evaluation confirmed that the center was meeting its process objectives. This evaluation could be used as a model for other community-based breastfeeding centers.