The clinical value of determination of fetal sex by ultrasound is in deciding whether to carry out prenatal invasive testing in pregnancies at risk of sex-linked genetic abnormalities, because invasive testing would be necessary only in pregnancies with male fetuses. Our results suggest that a final decision on invasive testing for sex-linked conditions should be undertaken only after 12 weeks of gestation.
Operator-dependant factors except gender, had little correlation with symptoms suffered, whilst the number of days worked per week, not taking regular breaks each day, revealed positive correlation. The results suggest that symptoms are both operator and workplace dependent. Though 65.6 % respondents suffered from RSI, less than half (30.5 %) resorted to supportive measures like physiotherapy.
A 32 year old woman attended the accident and emergency department with a two day complaint of vaginal bleeding and cramping lower abdominal pain, and a brown vaginal discharge since her last menstrual period which was 24 days prior to presentation. She had discontinued the combined oral contraceptive pill two months prior to her last menstrual period. Her urine pregnancy test (Guest Medical, UK) was positive. On abdominal examination, there was tenderness noted in the right iliac fossa. Vaginal examination revealed no cervical excitation but there was right adnexal tenderness. A transabdominal and transvaginal ultrasound scan (Diagnostic Sonar, multifrequency abdominal probe and 6.5 Hz transvaginal probe) revealed an empty uterus with an endometrial thickness of 11 mm. There was a right-sided ovarian cyst measuring 77 Â 54 Â 66 mm and a small amount of free fluid in the pouch of Douglas. Her serum h-hCG quantitative assay (Immulite 2000, immunoassay calibrated to WHO 3rd International Standard) at that point was 2830 IU/mL. A diagnostic laparoscopy was performed the following day to exclude an ectopic pregnancy.At laparoscopy, the finding of a right ovarian cyst was confirmed, with normal tubes, uterus and left ovary. A laparoscopic right ovarian cystectomy was performed as this was presumed to be the cause of her pain. A repeat h-hCG level the following day (48 hours after admission) was 3116 IU/mL. A repeat ultrasound scan two days later (four days after admission) showed what was presumed to be a viable intrauterine pregnancy, which was high within the uterine fundus. The possibility of a cornual pregnancy was raised. It was decided to rescan her in two weeks.A repeat ultrasound scan two weeks later revealed a left-sided cornual ectopic pregnancy, with a 25 mm gestational sac containing a 6 mm fetal pole. There was a large vascular signature from the surrounding decidual reaction, no fetal heart activity was seen and there was no free fluid in the pouch of Douglas. The serum h-hCG level at this stage was 15,208 IU/mL. Management options were discussed with the patient and she opted for surgical management.The following day, a laparoscopy and hysteroscopy were performed. The laparoscopy confirmed the diagnosis of a left-sided cornual ectopic pregnancy. A dilute solution of vasopressin (20 units in 20 mL of normal saline) was injected around the pregnancy. A hysteroscopy (5 mm, 30j forward angled scope) with normal saline showed a pregnancy beyond the left tubal ostium. The hysteroscope was advanced beyond the dilated left ostium and the sac was ruptured. The fetus was seen floating in the irrigation fluid. The hysteroscope was then withdrawn and a No. 6 flexible suction cannula (Rocket Medical, UK) inserted into the uterine cavity. Under transabdominal ultrasound guidance, the flexible suction cannula was advanced into the cornual gestation. Suction was then applied under direct laparoscopic control to ensure that the cannula did not perforate the uterine cornu. The suction evacuation yielded products of conc...
Background Reducing the rate of stillbirth is an international priority. At least half of babies stillborn in high-income countries are small for gestational-age (SGA). The Growth Assessment Protocol (GAP), a complex antenatal intervention that aims to increase the rate of antenatal detection of SGA, was evaluated in the DESiGN type 2 hybrid effectiveness-implementation cluster randomised trial (n = 13 clusters). In this paper, we present the trial process evaluation. Methods A mixed-methods process evaluation was conducted. Clinical leads and frontline healthcare professionals were interviewed to inform understanding of context (implementing and standard care sites) and GAP implementation (implementing sites). Thematic analysis of interview text used the context and implementation of complex interventions framework to understand acceptability, feasibility, and the impact of context. A review of implementing cluster clinical guidelines, training and maternity records was conducted to assess fidelity, dose and reach. Results Interviews were conducted with 28 clinical leads and 27 frontline healthcare professionals across 11 sites. Staff at implementing sites generally found GAP to be acceptable but raised issues of feasibility, caused by conflicting demands on resource, and variable beliefs among clinical leaders regarding the intervention value. GAP was implemented with variable fidelity (concordance of local guidelines to GAP was high at two sites, moderate at two and low at one site), all sites achieved the target to train > 75% staff using face-to-face methods, but only one site trained > 75% staff using e-learning methods; a median of 84% (range 78–87%) of women were correctly risk stratified at the five implementing sites. Most sites achieved high scores for reach (median 94%, range 62–98% of women had a customised growth chart), but generally, low scores for dose (median 31%, range 8–53% of low-risk women and median 5%, range 0–17% of high-risk women) were monitored for SGA as recommended. Conclusions Implementation of GAP was generally acceptable to staff but with issues of feasibility that are likely to have contributed to variation in implementation strength. Leadership and resourcing are fundamental to effective implementation of clinical service changes, even when such changes are well aligned to policy mandated service-change priorities. Trial registration Primary registry and trial identifying number: ISRCTN 67698474. Registered 02/11/16. https://doi.org/10.1186/ISRCTN67698474.
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