Current opinion in obstetrics & gynecology
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Curr. Opin. Obstet. Gynecol. · Feb 1993
ReviewPreterm labor, premature rupture of membranes, and cervical incompetence.
Prematurity continues to account for 75% of perinatal morbidity and mortality in the United States. The search for accurate clinical methods to predict prematurity and the critical evaluation of treatment strategies for premature labor dominate the recent medical literature. ⋯ Laboratory investigations into the role of subclinical genital infections as causes of prematurity continue to show promise. Despite these recent scientific advances, the effective prevention and treatment of prematurity continues to elude our clinical efforts.
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Epidural analgesia remains the mainstay for providing pain relief during labor. The search continues to find the ideal combination of analgesic agents and administration techniques that will provide excellent pain relief for the mother yet minimize side effects to the mother and fetus. This article reviews recent studies of epidural analgesia, including the increased use of epidural opioids, patient-controlled epidural analgesia, and the complications of epidural analgesia (including effects on gastric emptying, maternal temperature control, and hemodynamic changes to the mother and fetus). Intrathecal (spinal) analgesia, especially using opioids, is also discussed.
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Pelvic inflammatory disease is a common serious complication of the sexually transmitted pathogens Neisseria gonorrhoeae and Chlamydia trachomatis. There are more than 800,000 cases of pelvic inflammatory disease annually accounting for approximately 200,000 hospital admissions for acute and chronic infections. Early accurate diagnosis and treatment are essential to prevent the serious sequelae including ectopic pregnancy, tubal disease infertility, chronic pain, and disability requiring multiple hospitalizations and surgery. ⋯ In a small prospective randomized study, oral ofloxacin was as effective as cefoxitin plus doxycycline for outpatient treatment of chlamydial and gonococcal pelvic inflammatory disease. Treatment of tuboovarian abscess appears to be successful with single agent and combination therapy. Risk factors for developing postabortion endometritis continue to be identified, and the most efficacious prophylactic antibiotic regimen has not been determined to date.
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Human embryo cryopreservation is widely applied by programs of assisted reproductive technology. However, recent surveys have shown that relatively few in vitro fertilization programs in the United States substantially increase their per retrieval delivery rates through cryopreservation. ⋯ Although interest in oocyte cryopreservation remains high, experimental evidence shows that cryoinjury to human oocytes results in chromosome sorting defects, reduced fertilization, and compromised embryonic development. Micromanipulation of mammalian oocytes appears to have no deleterious effect on subsequent cryopreservation.
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Decisions about the role of cesarean section, forceps, and vacuum delivery in obstetrics continue to be a challenging part of daily obstetric practice. Five interesting papers on this topic are reviewed, including a comparison of international rates of cesarean sections and vaginal births after cesarean section, the method of choice for the delivery of the low-birth-weight fetus presenting as vertex, the advantages of a prelabor cesarean section for a fetus diagnosed with meningomyelocele, and the appropriate role for the midforceps delivery in the 1990s.