Adherence by midwives to the Dutch national guidelines on threatened miscarriage in general practice: a prospective study.
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OBJECTIVE: To determine the feasibility for midwives to adhere to Dutch national guidelines on threatened miscarriage in general practice. DESIGN: Prospective recording of appointments by midwives who agreed to adhere to the guidelines on threatened miscarriage. Interviews with the midwives after they had recorded appointments for one year. SETTING: Midwifery practices in The Netherlands. SUBJECTS: 56 midwives who agreed to adhere to the guidelines; 43 midwives actually made records from 156 clients during a period of 12 months. MAIN OUTCOME MEASURES: Adherence to each recommendation and reasons for non-adherence. RESULTS: The recommendation that a physical examination should take place on the first and also on the follow up appointment was not always adhered to. Reasons for non-adherence were the midwives' criticism of this recommendation, their lack of knowledge or skills, and the specific client situation. Adherence to a follow up appointment after 10 days, a counselling consultation after six weeks, and not performing an ultrasound scan was low. Reasons for non-adherence were mainly based on the midwives' criticism of these recommendations and reluctance on the part of the client. Furthermore, many midwives did not give information and instructions to the client. It is noteworthy that in 13% of the cases the midwife's policy was overridden by the obstetrician taking control of the situation after the midwife had requested an ultrasound scan. CONCLUSIONS: Those recommendations in the guidelines on threatened miscarriage that are most often not adhered to should be reviewed. To reduce conflicts about ultrasound scans and referrals, agreement on the policy on threatened miscarriage should be mutually established between midwives and obstetricians. (+info)
Do patients matter? Contribution of patient and care provider characteristics to the adherence of general practitioners and midwives to the Dutch national guidelines on imminent miscarriage.
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OBJECTIVE: To assess the relative contribution of patient and care provider characteristics to the adherence of general practitioners (GPs) and midwives to two specific recommendations in the Dutch national guidelines on imminent miscarriage. The study focused on performing physical examinations at the first contact and making a follow up appointment after 10 days because these are essential recommendations and there was much variation in adherence between different groups of providers. DESIGN: Prospective recording by GPs and midwives of care provided for patients with symptoms of imminent miscarriage. SETTING: General practices and midwifery practices in the Netherlands. SUBJECTS: 73 GPs and 38 midwives who agreed to adhere to the guidelines; 391 patients were recorded during a period of 12 months. MAIN MEASURES: Adherence to physical examinations and making a follow up appointment were measured as part of a larger prospective recording study on adherence to the guidelines on imminent miscarriage. Patient and care provider characteristics were obtained from case recordings and interviews, respectively. Multilevel analysis was performed to assess the contribution of several care provider and patient characteristics to adherence to two selected recommendations: the number of recommended physical examinations at the first contact and the number of days before a follow up appointment took place. RESULTS: In the multilevel model explaining variance in adherence to physical examinations, the care provider's acceptance of the recommendations was the most important factor. Severity of symptoms and referral to an obstetrician were significant factors at the patient level. In the model for follow up appointments the characteristics of the care provider were less important. Referral to an obstetrician and probability diagnosis were significant factors at the patient level. CONCLUSIONS: The study showed that characteristics of both the patient and care provider contribute to the variability in adherence. Furthermore, the contribution of the characteristics differed per recommendation. It is therefore advised that the contribution of both patient and care provider characteristics per recommendation should be carefully examined. If implementation is to be successful, strategies should be developed to address these specific contributions. (+info)
Pregnancy outcome of patients conceiving within one year after chemotherapy for gestational trophoblastic tumor: a clinical report of 22 cases.
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OBJECTIVE: To determine the risk of pregnancy for patients who conceive within one year after successful chemotherapy for gestational trophoblastic tumor (GTT). METHODS: We followed up and analysed retrospectively 22 patients who conceived within one year after receiving chemotherapy for GTT from 1966 through 1996. RESULTS: Of 22 patients, 9 had term delivery, 1 had premature birth, 6 requested induced abortion, and 6 experienced therapeutic abortion because of repeated hydatidiform mole (1 patient), intrauterine death (1), inevitable abortion (1), or threatened abortion (3). The fetal wastage rate was 27.3% (6/22). The incidence of gestational trophoblastic disease (GTD), including hydatidiform mole, was 9.1% (2/22). The incidence of GTT was 4.5%. The average interval between completion of chemotherapy and pregnancy was 9.78 months in the group of term pregnancy and 6.50 months in the group of fetal wastage (P < 0.05). CONCLUSIONS: Patients conceiving within one year after successful chemotherapy for GTT are at higher risk for recurrence of GTD and fetal wastage. Therefore, patients with preserved fertility should practice contraception for at least one year after chemotherapy to get better pregnancy outcome. (+info)
Use of anti-D immunoglobulin in the treatment of threatened miscarriage in the accident and emergency department.
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BACKGROUND: The UK guidelines for the use of anti-D immunoglobulin for rhesus prophylaxis have been revised. Anti-D immunoglobulin is no longer recommended for Rh D negative women after a threatened miscarriage less than 12 weeks gestation. These patients are at risk of rhesus immunisation, and there should be a policy for their treatment in the accident and emergency (A&E) department. DESIGN: A retrospective study over a 17 month period was conducted looking at women less than 12 weeks gestation who presented to an A&E department with a threatened miscarriage. OBJECTIVES: To determine how many of these patients presented with heavy or repeated bleeding, or abdominal pain, and whether the guidelines for the use of rhesus prophylaxis were followed. RESULTS: 112 women fulfilled the criteria for inclusion. Nineteen patients were Rh D negative. Eighty three patients (74.1%) presented with either abdominal pain or heavy or recurrent bleeding. Rhesus status was recorded in the A&E notes in only 15 patients (13.3%). Ninety seven patients (86.6 %) were discharged without rhesus status being checked. Fifteen Rh D negative patients were discharged without being offered anti-D immunoglobulin. CONCLUSION: Many women who present to the A&E department with a threatened miscarriage of less than 12 weeks gestation have heavy or recurrent bleeding or associated abdominal pain. These patients have an increased risk of fetomaternal haemorrhage and the consequent development of haemolytic disease of the newborn is possible. It should be mandatory for the A&E department to record rhesus status. In the context of A&E medicine, anti-D immunoglobulin should still be offered to all non-immune Rh D negative women presenting with a threatened miscarriage less than 12 weeks gestation. (+info)
A case of twin pregnancy with complete hydatidiform mole and coexisting fetus following IVF-ET.
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Twin pregnancy consisting of complete hydatidiform mole (H-mole) and a coexisting fetus occurs with an estimated incidence of 1 per 22,000-100,000 pregnancies. The incidence of this unusual twin pregnancy with complete H-mole and a coexisting fetus after in vitro fertilization and embryo transfer (IVF-ET) is not thought to be greater than that of general population. We present an unusual twin pregnancy with complete H-mole and a coexisting fetus that occurred following IVF-ET, which was terminated at 21 weeks of gestation and developed into nonmetastatic gestational trophoblastic tumor. (+info)
Threatened miscarriage in general practice: diagnostic value of history taking and physical examination.
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BACKGROUND: Ultrasonography, the gold standard for establishing a diagnosis in first-trimester vaginal bleeding, is not always readily avaliable. Medical history and gynaecological examination are then used instead, to make a provisional diagnosis. AIM: To determine the diagnostic value of history taking and physical examination in first-trimester bleeding, to differentiate between patients requiring immediate further diagnostic examination from those in whom an expectant policy will initially suffice. DESIGN OF STUDY: Prospective population-based cohort study. SETTING: Seventy-four general practices in Amsterdam. METHOD: Two hundred and twenty-five patients with first trimester vaginal bleeding were referred for an early pregnancy assessment. The data from 204 patients were analysed. Two diagnostic models were constructed based on symptoms and the results of gynaecological examination to identify diagnostic subgroups relevant to clinical practice. RESULTS: Model 1, which separates viable pregnancies from other diagnoses, increased pre-test probability from 47% to a post-test probability of 70%. Model 2, which enabled the identification of complete miscarriages, resulted in a post-test probability of 41% of a complete miscarriage, given a pre-test sample probability of 25%. The tentative diagnosis of a general practitioner, based entirely on clinical judgement, turned out to be a poor predictor for the ultrasonographically confirmed diagnosis (pre-test probability of 47% changed to a post-test probability of 58%). CONCLUSION: This study shows that, in first trimester bleeding, neither statistical prediction models based on signs and symptoms, nor clinical judgement, are valid replacements for ultrasonographic assessment in establishing a diagnosis. (+info)
Ultrasound assessment of cervical length in threatened preterm labor.
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OBJECTIVE: More than 70% of women presenting with threatened preterm labor do not progress to active labor and delivery. The aim of this study was to investigate the hypothesis that in women with threatened preterm labor, sonographic measurement of cervical length helps distinguish between true and false labor. METHODS: We examined 216 women with singleton pregnancies presenting with regular and painful uterine contractions at 24-36 (mean, 32) weeks of gestation. Women in active labor, defined by the presence of cervical dilatation > or = 3 cm, and those with ruptured membranes were excluded. On admission to the hospital a transvaginal scan was performed to measure the cervical length. The subsequent management was determined by the attending obstetrician. The primary outcome was delivery within 7 days of presentation. RESULTS: In 173 cases the cervical length was > or = 15 mm and only one of these women delivered within 7 days. In the 43 cases with cervical length < 15 mm delivery within 7 days of presentation occurred in 16 (37%) including 6/14 (42%) treated with tocolytics and 10/29 (35%) managed expectantly. Logistic regression analysis demonstrated that the only significant contributor in the prediction of delivery within 7 days was cervical length < 15 mm (odds ratio = 101, 95% CI 12-800, P < 0.0001) with no significant contribution from ethnic group, maternal age, gestational age, body mass index, parity, previous history of preterm delivery, cigarette smoking, contraction frequency or use of tocolytics. CONCLUSIONS: In women with threatened preterm labor, sonographic measurement of cervical length helps distinguish between true and false labor. (+info)
Pregnancy outcome of threatened abortion with subchorionic hematoma: possible benefit of bed-rest?
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BACKGROUND: Bleeding in the first trimester of pregnancy is a common phenomenon, associated with early pregnancy loss. In many instances a subchorionic hematoma is found sonographically. OBJECTIVE: To evaluate the possible benefit of bed-rest in women with threatened abortion and sonographically proven subchorionic hematoma, and to examine the possible relationship of duration of vaginal bleeding, hematoma size, and gestational age at diagnosis to pregnancy outcome. METHODS: The study group consisted of 230 women of 2,556 (9%) referred for ultrasound examination because of vaginal bleeding in the first half of pregnancy, who were found to have a subchorionic hematoma in the presence of a singleton live embryo or fetus. All patients were advised bed-rest at home; 200 adhered to this recommendation for the duration of vaginal bleeding (group 1) and 30 continued their usual lifestyle (group 2). All were followed with repeated sonograms at 7 day intervals until bleeding ceased, the subchorionic hematoma disappeared, or abortion occurred. The groups were compared for size of hematoma, duration of bleeding, and gestational age at diagnosis in relation to pregnancy outcome (spontaneous abortion, term or preterm delivery). RESULTS: The first bleeding episode occurred at 12.6 +/- 3.4 weeks of gestation (range 7-20 weeks) and lasted for 28.8 +/- 19.1 days (range 4-72 days). The women who adhered to bed-rest had fewer spontaneous abortions (9.9% vs. 23.3%, P = 0.006) and a higher rate of term pregnancy (89 vs. 70%, P = 0.004) than those who did not. There was no association between duration of vaginal bleeding, hematoma size, or gestational age at diagnosis of subchorionic hematoma and pregnancy outcome. CONCLUSIONS: Fewer spontaneous abortions and a higher rate of term pregnancy were noted in the bed-rest group. However, the lack of randomization and retrospective design of the outcome data collection preclude a definite conclusion. A large prospective randomized study is required to confirm whether bed-rest has a real therapeutic effect. (+info)