Objective To examine the relationship between umbilical cord pH at term and serious neonatal outcomes.Design Observational cohort study. Methods Absolute risks, relative risks with 95% confidence intervals, and numbers needed to harm were calculated for different levels of arterial pH across the entire range.Main outcome measures Neonatal encephalopathy with seizures and/or death, encephalopathy within 24 hours of birth, 5-minute Apgar scores and neonatal unit admission.Results The median arterial pH was 7.22, interquartile range 7.17-7.27. The absolute risk of an adverse neurological outcome was significantly increased below 7.10 (0.36%) and was lowest between 7.26 and 7.30 (0.16%). Even below 7.00, the risk was only 2.95%. However, more than 75% of neonates with neurological outcomes examined, including seizures within 24 hours of birth, had a pH above 7.10. A small increase in risk was evident at higher pH levels.Conclusion The threshold pH for adverse neurological outcomes is 7.10 and the 'ideal' cord pH is 7.26-7.30. Above 7.00, however, neonatal acidaemia is weakly associated with adverse outcomes. Most neonates with neurological morbidity have normal cord pH values. Other variables must influence adverse outcomes and account for more of these than acidaemia. A better understanding of these is required before intrapartum fetal monitoring can improve.

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P = 0.002; 74.8 ± 7.6 to 70.4 ± 6.5 diastolic BP, P = 0.001). None of the women had a blood loss of >900 mL and no transfusions were required.These results agree with those from a previous randomized, controlled pilot study, leading to the conclusion that the use of sequential oxytocin and sublingual nitroglycerin seems to be effective and safe for retained placenta. One weakness of the present study is that no ultrasonography was performed when retained placenta was diagnosed. The authors recommended a large, randomized, placebo-controlled study of retained placenta using ultrasonography for diagnosis of the condition. COMMENTThere are many agents that can be used to assist in delivering a retained placenta. These methods range from oxytocics, ergometrine, or prostaglandins to induce uterine contractions, which shear off and expel the placenta to glyceryl trinitrate (nitroglycerin), amyl nitrate, and inhalational agents to relax the uterus and cervix to expedite mechanical techniques-controlled cord traction, Crede's maneuver or manual removal-of placental expulsion.I remember, many moons ago, in the late 1980s/early 1990s, writing the early protocols to be followed for dilution, handling and administration of intravenous glyceryl trinitrate miniboluses for women with retained placentae. The use of nitroglycerin to relax the uterus is not new.Since nitroglycerin is a potent nitric oxide (NO) donor, it works not only by inducing transient relaxation of the uterine body but also by relaxing the anchoring villi and, therefore, encouraging placental separation. Placental separation is known to commence from the lower pole of the placenta by a multiphasic process where the central mechanism involves retroplacental myometrial contractions, which produce placental separation.The importance of this paper is that (a) it shows that sublingual nitroglycerin 1 mg is as effective as the minibolus intravenous route; (b) the technique is effective and simple (study success rate: pilot 12/12, main 21/24); and (c) the protocol is safe in that, if the guidelines are followed, hypotension is not severe and bleeding is not markedly increased.It should be remembered that, despite the paper's title, this is not a study of the efficacy of sublingual nitroglycerin in retained placenta but of the efficacy of sequential oxytocin followed by single-dose sublingual nitroglycerin. The piece de resistance of the paper lies in the simple protocol itself especially since the success rate is high and can dramatically reduce the need for postpartum general anesthesia or introduction of major neuraxial blockade.The protocol bears presenting in synopsis here: minutes after delivery, 5 IU oxytocin intramuscularly/IV followed by Crede's maneuver; after 30 minutes of failure to deliver the placenta, 10 IU oxytocin followed by controlled umbilical cord traction; after a further 20 to 30 minutes, sublingual nitroglycerin 1 mg tablet. Once the tablet is absorbed and is no longer visible under the tongue, wait for 5 minutes before reapplying controlled c...

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We report higher prenatal/postnatal concordance rates in this series. A precise prenatal diagnosis is frequently difficult and often inaccurate. Prediction of lethality is much easier and often possible with accuracy. Parents need to be aware that the outcome of many skeletal dysplasias is poor.

Purpose Labour epidural analgesia (LEA) is an evolving field. Various neuraxial techniques and dosing regimens are available to the modern obstetric anesthesia provider, allowing for significant practice variability. To begin a search for consensus on optimal care, we sought to query fellowship training practices for LEA. Methods We conducted an electronic survey of institutions with American Council for Graduate Medical Education-accredited obstetric anesthesiology fellowship programs. We studied the frequency of epidural initiation techniques, including combined spinal epidural (CSE), dural puncture epidural, and epidural bolus. For maintenance techniques, we appraised the use of continuous epidural infusion, programmed intermittent bolus (PIEB), and patient-controlled epidural analgesia (PCEA). Results Of 40 institutions surveyed, we received 32 responses (80% response rate). Twenty-eight of 40 (70%) were included in the analysis. A plurality of institutions (12/28; 43%) preferred CSE, and among those who used

BackgroundPterygium is a fibrovascular growth of the bulbar conjunctiva and underlying subconjunctival tissue that may cause blindness. The mechanism of pterygium formation is not yet fully understood, but pterygium has some tumorlike features.ObjectivesThe objective of this study was to evaluate the association between arsenic exposure through drinking water and the occurrence of pterygium in southwestern Taiwan.MethodsWe recruited participants > 40 years of age from three villages in the arseniasis-endemic area in southwestern Taiwan (exposure villages) and four neighboring nonendemic villages (comparison villages). Each participant received an eye examination and a questionnaire interview. Photographs taken of both eyes were later graded by an ophthalmologist to determine pterygium status.ResultsWe included 223 participants from the exposure villages and 160 from the comparison villages. The prevalence of pterygium was higher in the exposure villages across all age groups in both sexes and increased with cumulative arsenic exposure. We found a significant association between cumulative arsenic exposure and the prevalence of pterygium. After adjusting for age, sex, working under sunlight, and working in sandy environments, we found that cumulative arsenic exposure of 0.1–15.0 mg/L-year and ≥ 15.1 mg/L-year were associated with increased risks of developing pterygium. The adjusted odds ratios were 2.04 [95% confidence interval (CI), 1.04–3.99] and 2.88 (95% CI, 1.42–5.83), respectively.ConclusionsChronic exposure to arsenic in drinking water was related to the occurrence of pterygium, and the association was still observed after adjusting for exposures to sunlight and sandy environments.