Thomas J. Garite, MD
Alternatively symptoms 0f food poisoning purchase lithium online pills, these infants may be examined carefully medicine zofran order 150 mg lithium free shipping, preferably monthly treatment urticaria discount lithium 150 mg with visa, until their nontrepone mal serologic test results are negative medications 4h2 order genuine lithium on-line. Some experts, however, would treat with penicillin G benzathine as a single intramuscular injection if follow-up is uncertain. Lyme Disease Lyme disease is caused by a spirochete (Borrelia burgdorferi) transmitted by the bite of a deer tick. The early localized stage of the disease is characterized by a distinctive bull?s-eye skin lesion (erythema migrans) that occurs in 60?80% of patients and nonspecific, flu-like symptoms. A late manifestation of Lyme disease is relapsing arthritis, usually pauciarticular and affecting large joints. Patients in the later stages of Lyme disease usually will be seropositive, but false-positive and false negative test results are common. Suspicion of early maternal infection is based on a history of exposure to tick bites, the presence of the distinctive erythema migrans rash, and nonspecif ic, flu-like symptoms. Because congenital infection occurs with other spirochetal infec tions, there has been concern that an infected pregnant woman could transmit B burgdorferi to her fetus. No causal relationship between maternal Lyme disease and congenital abnormalities caused by B burgdorferi has been documented. Recommended treatment of suspected early disease in pregnant women is amoxicillin, 500 mg three times per day, for 2?3 weeks. For women who are allergic to penicillin, erythromycin is recommended for 2?3 weeks. For patients who are unable to tolerate erythromycin, cefuroxime axetil is an alternative for patients with immediate and anaphylactic hypersensitivity to penicillin who have undergone penicillin desensitization. If entrance into such areas is necessary, long-sleeved shirts and long pants tucked in at the ankle are helpful. Prophylactic antibiotic therapy for deer tick bites is not rec ommended routinely. Perinatal Infections 433 Parasitic Infections Malaria Although malaria mainly is confined to tropical areas of Africa, Asia, and Latin America, international travel and migration have made malaria a disease to con sider in developed countries. Malaria infection may be more severe in pregnant women and also may increase the risk of adverse outcomes of pregnancy, including spontaneous abortion, stillbirth, preterm birth, and low birth weight. Because of the risk to both the woman and the fetus, and because no chemoprophylactic regimen is completely effective, pregnant women (or women likely to become pregnant) should avoid travel to malaria-endemic areas. If travel to a malaria-endemic area is necessary, appropriate consultation should be sought for chemoprophylaxis recommendations based on the malaria species and drug-resistance patterns prevalent in that area. Definitive diagnosis (of the mother and the infant) relies on identifica tion of the parasite on stained blood films. Treatment of infection is based on the infecting species, possible drug resistance, and severity of disease. If malaria is a diagnostic consideration in a pregnant woman or newborn, consultation with appropriate specialists is recommended for optimal patient management. Infection is acquired by foodborne transmission (consuming cysts in undercooked meat of infected animals or insect contamination of food), zoonotic transmission (by contact with oocysts from the feces of infected cats or by contact with con taminated soil or water), or through mother-to-child transmission during preg nancy. Congenital infection is more common after maternal infection in the third trimester; however, the sequelae from first-trimester fetal infection are more severe. Congenitally infected infants are healthy appearing at birth in 70?90% 434 Guidelines for Perinatal Care of cases. Signs of congenital infection at birth may include maculopapular rash, generalized lymphadenopathy, hepatosplenomegaly, chorioretinitis, hydroceph aly, microcephaly, and intracranial calcifications. Because the presence of antibodies before pregnancy indicates immunity, the appropriate time to test for immunity to toxoplasmosis in women at risk is before conception. The diagnosis of maternal infection is based on serologic test results for the detection of Toxoplasma-specific antibodies. Both immunoglobulin G (IgG) and IgM testing should be used for the initial evaluation of patients suspected to have toxoplasmosis. A positive IgG titer indicates infection with the organ ism at some time in the past. A negative IgM test essentially excludes recent infection, but a positive IgM test is difficult to interpret because Toxoplasma specific IgM antibodies may be detected for as long as 18 months after acute acquired infection. In addition, false-positive test results are common with commercially available kits. Before making treatment recommendations, con firmation of diagnosis should be made based on results obtained in a reference laboratory. Identification of acute mater nal infection necessitates immediate institution of treatment until results of fetal testing are known. Spiramycin, which concentrates in the placenta, may reduce the risk of fetal transmission by 60%, but as a single agent, it does not treat established fetal infection. Food and Drug Administration after serologic confirmation at a reference laboratory; it is recommended for pregnant women at risk unless fetal infec tion is documented. If fetal infection is established, pyrimethamine, sulfon amides, and folinic acid are added to the regimen because they more effectively eradicate parasites in the placenta and in the fetus than spiramycin alone. With treatment, even early fetal infection with toxoplasmosis can result in successful pregnancy outcomes. Congenital toxoplasmosis can be diagnosed serologically by the detection of anti?toxoplas ma-specific IgM or immunoglobulin A antibodies soon after birth or by the persistence of anti-toxoplasma IgG beyond 12 months of age. If the diagnosis is suspected (but unconfirmed) at the time of birth, ophthalmologic, auditory, and neurologic examinations should be performed. For healthy appearing infants and those with clinical signs of congenital toxoplasmosis, pyrimethamine and sulfadiazine (supplemented with folinic acid) are recommended for approximately 1 year. Infants with congenital toxoplas mosis should be managed in consultation with infectious disease specialists. Acyclovir prophylaxis to pre vent herpes simplex virus recurrence at delivery: a systematic review. Update on immunization and pregnancy: tetanus, diphtheria, and pertussis vaccination. However, when coloni zation with certain organisms occurs, the outcome may be devastating for the neonate, the mother, or both. Many of the nosocomial infections that occur in intensive care units are caused by pathogens acquired from the hospital environ ment (ie, health care-associated infections). Health care-associated infections result in increased morbidity and mortality, prolonged lengths of hospital stay, and increased medical costs. Definition of Health Care-Associated Infection Health care-associated infection is defined as an infection that is acquired in the hospital while receiving treatment for other conditions. This definition should be applied consistently to allow uniform reporting and analysis of health care associated infections. The infection-control committee of each hospital should work with perinatal care personnel to ensure that appropriate surveillance of health care-associated infection is being performed. For obstetric patients, a health care-associated infection can be defined broadly as one that is not present or incubating when the patient is admitted to the hospital and occurs more than 48 hours after hospitalization. Many cases of urinary tract infection that occur postpartum are health care-associated. Risk factors associated with health care associated infection in the infant include preterm birth, the presence of invasive devices (intravascular catheters, endotracheal tubes, orogastric tubes, urinary catheters, drains), exposure to broad-spectrum antibiotic agents, parenteral nutrition, overcrowding and poor staffing ratios, administration of steroids and histamine-2 receptor blockers, and acuity of underlying illness. This includes cleaning and decontamination of the environment, using meticulous patient care tech niques, practicing hand hygiene, promoting breastfeeding (unless contraindi cated because of maternal infection; see also Contraindications to Breastfeeding in Chapter 8), limiting the number of invasive procedures (eg, central lines), limiting the number of visitors, grouping together (cohorting) infants colonized with the same pathogen, the judicious use of antimicrobial therapy. Labor and Delivery Admission Policy the pediatric health care provider should be notified of all mothers admitted to the antepartum obstetrics unit who are colonized with or are chronic car riers of a potentially infectious organism that may be transmitted vertically to the neonate (eg, human immunodeficiency virus, hepatitis B or hepatitis C virus, herpes simplex virus, influenza, methicillin-resistant staphylococcus, vancomycin-resistant enterococcus) or may be associated with a congenital infection. Both group A streptococci and group B streptococci are pathogens that may be indigenous to the female genital tract, and both may cause serious, life-threatening infection in the mother and newborn. There are national guide lines for the management of group B streptococci colonization in the mother (see also Group B Streptococci in Chapter 10). Nursery Admission Policies Infants transferred from another hospital and those who require rehospitaliza tion a few days after being discharged home ideally should be admitted to the newborn unit. Infants with suspected infectious diseases should be admitted to specialized areas where additional transmission precautions (airborne, contact, droplet) can be provided to minimize the risks of spreading the infection to others. Routine culturing of infants respiratory or gastrointestinal tract or skin for surveillance purposes is not recommended, but cultures from lesions or sites of infection should be taken to identify the etiology.
Early Resolution of Type 2 Diabetes Seen After Roux en-Y Gastric Bypass and Vertical Sleeve Gastrectomy symptoms nerve damage purchase lithium with american express. Weight loss prior to bariatric surgery is not a pre-requisite of excess weight loss outcomes in obese patients medicine valley high school purchase lithium 300 mg without a prescription. Gender influence on long-term weight loss after three bariatric procedures: gastric banding is less effective in males in a retrospective analysis medicine 4211 v order 300 mg lithium with amex. Impact of restrictive (Sleeve Gastrectomy) vs hybrid bariatric surgery (roux-en-y gastric bypass) on lipid profile medicine quiz generic lithium 300 mg free shipping. Sleeve gastrectomy and Roux-en-Y gastric bypass are equally effective in correcting insulin resistance. Laparoscopic sleeve gastrectomy and laparoscopic gastric bypass are equally effective for reduction of cardiovascular risk in severely obese patients at one year of follow-up. Laparoscopic gastric bypass versus laparoscopic adjustable gastric banding: A comparative study of 1,200 cases. Bariatric surgery for obese children and adolescents: a systematic review and meta-analysis. Incidence of type 2 diabetes after bariatric surgery: population-based matched cohort study. Laparoscopic gastric bypass is superior to adjustable gastric band in super morbidly obese patients: A prospective, comparative analysis. Laparoscopic Roux-en-Y gastric bypass versus laparoscopic adjustable gastric banding: Five years of follow-up. Bariatric surgery for morbid obesity: pre-operative assessment, surgical techniques and post-operative monitoring. Observations regarding quality of life and comfort with food after bariatric surgery: Comparison between laparoscopic adjustable gastric banding and sleeve gastrectomy. Long-term cardiovascular risk and coronary events in morbidly obese patients treated with laparoscopic gastric banding. Comparative long-term mortality after laparoscopic adjustable gastric banding versus nonsurgical controls. Better weight loss, resolution of diabetes, and quality of life for laparoscopic gastric bypass vs banding: results of a 2-cohort pair-matched study. Preoperative weight loss is not a predictor of postoperative weight loss after laparoscopic Roux-en-Y gastric bypass. The comparative effectiveness of sleeve gastrectomy, gastric bypass, and adjustable gastric banding procedures for the treatment of morbid obesity. Use of individual surgeon versus surgical team approach: surgical outcomes of laparoscopic Roux-en-Y gastric bypass in an Asian Medical Center. Predictive factors of outcome after gastric banding: a nationwide survey on the role of center activity and patients behavior. Complications after laparoscopic adjustable gastric banding for morbid obesity: experience with 1,000 patients over 7 years. Effect of gastric bypass and gastric banding on proneurotensin levels in morbidly obese patients. Five-year outcomes of laparoscopic adjustable gastric banding and laparoscopic Roux-en-Y gastric bypass in a comprehensive bariatric surgery program in Canada. A case-controlled matched-pair cohort study of laparoscopic Roux-en-Y gastric bypass and Lap-Band? Serum vitamin D increases with weight loss in obese subjects 6 months after roux-en-y gastric bypass. Nutritional consequences of adjustable gastric banding and gastric bypass: A 1-year prospective study. Surgical vs Medical Treatments for Type 2 Diabetes Mellitus: A Randomized Clinical Trial. The relationship of surgeon and hospital volume to outcome after gastric bypass surgery in Pennsylvania: A 3-year summary. Mid-term results of laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass in adolescent patients. Clinical efficacy of laparoscopic sleeve gastrectomy vs laparoscopic gastric bypass in obese type 2 diabetic patients: A retrospective comparison. Analysis of weight loss after bariatric surgery using mixed-effects linear modeling. Impact of surgeon experience and buttress material on postoperative complications after laparoscopic sleeve gastrectomy. Is sleeve gastrectomy as effective as gastric bypass for remission of type 2 diabetes in morbidly obese patients? Metabolic and nutritional status changes after 10% weightloss in severely obese patients treated with laparoscopic surgery vs integrated medical treatment. Roux-en-Y divided gastric bypass results in the same weight loss as duodenal switch for morbid obesity. Bariatric surgery complications before vs after implementation of a national policy restricting coverage to centers of excellence. Metabolic and psychosocial effects of minimal invasive gastric banding for morbid obesity. Changes in body composition with weight loss: obese subjects randomized to surgical and medical programs. Surgical vs Conventional Therapy for Weight Loss Treatment of Obstructive Sleep Apnea: A Randomized Controlled Trial. A Comparison of Laparoscopic Adjustable Gastric Banding and Biliopancreatic Diversion in Superobesity. Benefits and complications of the duodenal switch/biliopancreatic diversion compared to the Roux-en-Y gastric bypass. Neonatal outcomes in pregnancies after bariatric surgery: a retrospective multi-centric cohort study in three French referral centers. Laparoscopic sleeve gastrectomy in patients with preexisting gastroesophageal reflux disease : a national analysis. Does patient compliance with preoperative bariatric office visits affect postoperative excess weight loss? Do support groups play a role in weight loss after laparoscopic adjustable gastric banding? Weight loss and metabolic improvement in morbidly obese subjects implanted for 1 year with an endoscopic duodenal-jejunal bypass liner. Pregnancy after laparoscopic bariatric surgery: Comparative study of adjustable gastric banding and Roux-en-Y gastric bypass. Effect of bariatric surgery-induced weight loss on renal and systemic inflammation and blood pressure: A 12-month prospective study. Annual medical spending attributable to obesity: Payer and service-specific estimates. Obstructive sleep apnea after weight loss: a clinical trial comparing gastric bypass and intensive lifestyle intervention. Procedure-related morbidity in bariatric surgery: A retrospective short and mid-term follow-up of a single institution of the American College of Surgeons Bariatric Surgery Centers of Excellence. Laparoscopic sleeve gastrectomy compared to a multidisciplinary weight loss program for obesity-effects on body composition and protein status. Laparoscopic adjustable gastric band versus laparoscopic Roux-en Y gastric bypass: ends justify the means? Efficacy of surgery in the management of obesity-related type 2 diabetes mellitus. Bypass of the duodenum improves insulin resistance much more rapidly than sleeve gastrectomy. Does establishing a bariatric surgery fellowship training program influence operative outcomes? Laparoscopic Roux-en-Y gastric bypass in adolescents with morbid obesity-surgical aspects and clinical outcome. Impact of routine and long-term follow-up on weight loss after laparoscopic gastric bypass. Perioperative safety and volume: Outcomes relationships in bariatric surgery: A study of 32,000 patients. Roux-en-Y Gastric Bypass Surgery or Lifestyle With Intensive Medical Management in Patients With Type 2 Diabetes: Feasibility and 1-Year Results of a Randomized Clinical Trial. Superior weight loss and lower HbA1c 3 years after duodenal switch compared with Roux-en-Y gastric bypass A randomized controlled trial. A prospective randomized study between laparoscopic gastric banding and laparoscopic isolated sleeve gastrectomy: Results after 1 and 3 years.
Comparison of surgery medicine merit badge buy lithium discount, Ivan et al published a meta-analysis of tumour control external beam radiation therapy rates and treatment-related morbidity for glomus and radiosurgery jugulare tumours with 869 patients meeting the inclusion criteria medicine 2 discount lithium 150 mg visa. The majority of reports are single centre subtotal resection in addition to postoperative retrospective series with variable follow-up treatment writing order cheap lithium on-line. In addition medicine emoji order 300 mg lithium otc, radiosurgery in 97 patients and radiosurgery alone comparison between surgically and non-surgically in 339 patients. Tumour control rates were 86%, 69%, treated patients is difficult as historically, non-surgical 71% and 95% respectively. The meta-analysis also approaches were considered for advanced lesions, examined the rates of cranial neuropathy following recurrent disease or poor surgical candidates. Tumour control was achieved in surgery have advanced rapidly and older series are 78% of patients. Oncologic outcome in as the primary treatment for new and recurrent surgical management of jugular paraganglioma paragangliomas: is open surgical resection still and factors influencing outcomes. A meta-analysis of tumor control rates and Which paragangliomas of the head and neck have treatment-related morbidity for patients with a higher rate of malignancy? Clin Otolaryngol 2007; Irradiated paragangliomas of the head and neck: 32(1): 7?11. Does catecholamine secretion from and neck paragangliomas influences the head and neck paragangliomas respond to treatment proposal. Radiosurgery Does intervention improve the natural course of of glomus jugulare tumors: a meta-analysis. A series of 108 patients seen in a Int J Radiat Oncol Biol Phys 2011; 81(4): 32-year period. Regression and vagal paragangliomas: Systematic study of and local control rates after radiotherapy for management with surgery and radiotherapy. They are most common in 1 embolisation within 24?48 hours of surgery is utilised adolescent boys with a median age of 14 years old. Surgical excision are most commonly nasal obstruction and recurrent should aim for clear margins, as inadequate margins epistaxis. Other reported symptoms include nasal are associated with significant failure rates. Potential surgical nodular mass is typically seen in the roof of the approaches are reviewed elsewhere. Biopsy is not usually adjunct in a combined surgical approach and, in some required and carries a high risk of bleeding. Excision of resorption, rather than the cellular infiltration 1 lesions with extensive spread is associated with higher characteristic of malignant processes. One routes of invasion of the skull base have been series of 16 cases correlated a recurrence rate of 37. No clear dose?response relationship has been demonstrated, with doses in the range of 35?45 Gray (Gy) commonly used. Only a few cases of second 9,16 treatment modality if the disease is deemed malignancies have been described. Cataract has 2,9,16,19 incompletely resectable without excess been reported more commonly. Juvenile nasopharyngeal Nasopharyngeal angiofibromas: selecting a angiofibroma: current treatment modalities and surgical approach. Arch Otolaryngol the role of radiation in the treatment of advanced Head Neck Surg 1986; 112(11): 1191?1193. Int J Pediatr Otorhinolaryngol 2006; in the treatment and follow-up of advanced 70(9): 1619?1627. Evaluation of response following irradiation of Radiographic staging of juvenile angiofibroma. Intensity-modulated radiation therapy, Long-term follow-up of juvenile nasopharyngeal protons, and the risk of second cancers. Approximately 3?4% of pleomorphic tumours, positive margins or multifocal recurrences. High local control rates of transformation; the duration of a lesion may increase >90% following tumour spill or close margins without its likelihood of transformation. The dose is significant (50 Gray [Gy]) so there is a small risk majority arise in the parotid, for which surgery entails a of long-term tissue damage in the radiation field with superficial or total parotidectomy with facial nerve potential for developing a radiation-induced cancer dissection and preservation. It has been shown abuts the main trunk or branches of the facial nerve, that both benign and malignant tumours can develop surgery may be a more limited enucleation or capsular after radiation exposure, although the risk is very low dissection. Outcomes after surgery and adjuvant radiotherapy for pleomorphic adenoma (adapted from Mendenhall et al)1,7?10 No of Untreated/ Radiotherapy Follow-up Local control patients locally dose recurrent Dawson and Orr 311 50?60 Gray (Gy) Minimum 92% at 20 years (1985)7 in 20?25 10 years fractions or brachytherapy Ravasz et al (1990)8 78 62/16 50 Gy in 25 Median 11 years Previously untreated fractions + 100%, locally recurrent 10?25 Gy boost 94% Barton et al (1992)9 187 115/72 50 Gy in 15?16 Median 14 years Previously untreated fractions or 99%, locally recurrent brachytherapy 88% Liu et al (1995)10 55 55/29 45 Gy in 20 Median 12. Although higher doses similar to those recommended for patients who are at a higher used for malignant salivary disease have been risk of recurrence, as indicated by incompletely used, doses of the magnitude of 50 Gy in 25 resected tumours, positive margins or multifocal fractions over five weeks have been commonly recurrences (Grade C). For parotid pleomorphic recommendations used within this review are based adenomas the target volume includes the whole on those proposed by the the Scottish Intercollegiate parotid bed (Grade D). Carcinoma ex pleomorphic recognition of focal carcinoma and atypical tumor adenoma: a clinicopathologic review. Current management of benign adenoma of the parotid gland: report of 126 cases parotid tumors the role of limited superficial and a review of the literature. Total conservative Recurrent pleomorphic adenoma of the parotid parotidectomy for primary benign pleomorphic gland. Laryngoscope 1994; rupture of pleomorphic adenomas to recurrence: 104(12): 1487?1494. Pleomorphic immunohistochemical features of 60 cases in adenoma: effect of tumor spill and inadequate Brazil. Salivary gland local excision and radiotherapy in pleomorphic tumors among atomic bomb survivors, 1950?1987. Radiotherapy tumors after childhood radiation treatment for in epithelial tumors of the parotid gland: case benign conditions of the head and neck: dose presentation and literature review. The inability to control oral secretions leads to neurological disease generally have a limited life the build up of excess saliva in the oropharynx and expectancy due to the underlying disorder. In addition, sialorrhea can have a major submandibular glands with separate ipsilateral fields. A wide variety of dose fractionation regimens were employed, varying from 6 Gray (Gy) in one Management fraction to 44 Gy in 22 fractions. Eighty-two per cent of treatments were reported to have a response, with Treatment for sialorrhea should be considered when 64% of treatments maintaining a durable satisfactory quality of life is adversely affected. The varied dose/fractionation regimens did are available to try to control sialorrhea by reducing not appear to affect the likelihood of response. The management of the condition Durable responses were associated with the use of varies with the underlying cause and age of patient. Late side-effects were Anti-cholinergic medication is often utilised as firstline uncommon and related mainly to thick saliva. Botulinum toxin can orthovoltage with a dose of 12 Gy in two fractions over be injected locally to reduce saliva production by one week. Of the 19 patients reported in this study, reducing cholinergic parasympathetic and post 14 had a satisfactory response to treatment. Several surgical procedures have been attempted, including salivary duct repositioning, Guy et al treated 16 patients with amyotrophic lateral denervation procedures and parotidectomy. There was an xerostomia in the treatment of head and neck association between the use of an electron energy cancers. In this study, patients were treated Postma et al reported a series with prospective with a lateral opposed pair of 6 MeV photons including assessment of outcomes. Seven patients were treated doses were 10 Gy in two fractions over three days with electrons and the remainder with orthovoltage (n=30) or 20 Gy in four fractions over ten days (n=20). More patients treated with the higher Acute adverse events included dry mouth and dose protocol had no or only mild salivation. The authors concluded that the 20 Gy in four reported to improve significantly one month post fractions regimen is an effective treatment, with the treatment and this was maintained for at least shorter fractionation of 10 Gy in two fractions an option one year; quality of life was found to improve in the for patients with poorer medical condition. Potential long-term consequences the submandibular glands produce more viscous of radiotherapy seromucous saliva, providing around 70% of basal saliva secretion.
Systematic reviews of observational studies investigating the longer-term associations of cesarean delivery provide conflicting results on risks and benefits for mother and baby [7?13] medicine grace potter lyrics order lithium online pills. Maternal preferences are an important influence on decisions about mode of delivery medications beginning with z buy lithium online. At present medications used for migraines generic lithium 300 mg with visa, evidence of longer-term complications of cesarean delivery has not been adequately synthesized to allow fully informed decisions about mode of delivery to be made medications to treat bipolar disorder order lithium in united states online. The aim of this systematic review and meta-analysis is to summarize the evidence about long-term risks and benefits of cesarean delivery for women, children, and the associations with future pregnancies. We developed and tested the search strategy in collaboration with a librarian experienced in literature searching. The search terms are described in S1 Table; searches began 23 March 2014, and the last search was 25 May 2017. After removal of duplicates, the abstracts were then screened for study inclusion criteria and full-text articles then assessed for eligibility. Where available, data for outcomes following operative vaginal delivery were included in the vaginal delivery group. Studies were excluded if they did not provide sufficient information to assess methods or data analysis. Authors were contacted to clarify ambiguities in published results, in particular figures for outcomes in cesarean delivery and vaginal delivery groups [17?19]. Where there was disagreement over eligibility for inclusion or assessment of study quality, this was referred to a meeting of all authors. We analysed the data in three groups of prespecified outcomes: maternal, childhood, and subsequent pregnancy outcomes. The primary outcome chosen for each database search was that which we felt patients would be most concerned about. As there were several other rele vant outcomes for each database search, we added these as secondary outcomes (see Table 1). Table displaying the primary and secondary outcomes specified for database searches of maternal, childhood, and subse quent pregnancy outcomes. Group Primary outcome Secondary outcomes Maternal outcomes Pelvic floor dysfunction (any of urinary incontinence, fecal incontinence, Maternal death uterine prolapse, or vaginal prolapse) Chronic pain (including pelvic pain) Dysmenorrhea Menorrhagia Sexual dysfunction (including dyspareunia) Healthcare usage Subfertility Childhood outcomes Asthma (up to 12 years and from 15 years) Wheeze (up to 5 years and 6?15 years) Allergy/Atopy/Hypersensitivity/Dermatitis Overweight (3?13 years) Obesity (up to 5 years, 6?15 years, and adulthood) Inflammatory bowel disease (up to 35 years) Subsequent pregnancy Perinatal death (from 22 weeks gestation to one week of age) Placenta previa outcomes Placenta accreta Placental abruption Uterine rupture Miscarriage Ectopic pregnancy Stillbirth Hysterectomy Postpartum haemorrhage Antepartum haemorrhage Preterm labour Fetal growth restriction (small for gestational age, low birth weight [<2,500 g]) Neonatal death doi. Heterogeneity was assessed using the chi-squared and I-squared tests, with random effects models used when substantial heterogeneity was present, i. This study period cutoff was chosen as cesarean delivery rates and obstetric care have changed signifi cantly since 1980. Post hoc protocol changes to methods Prior to analysis, we made the following changes to our methods from the published protocol. We clarified that the definition of prospective cohort study included studies if data had been collected prospectively, even if analysis was retrospective. We changed the threshold of hetero geneity that we would use random effects meta-analysis from chi-squared test p-value <0. In addition, at the data extraction stage, we made a decision to report both small for gestational age and low birth weight as secondary subsequent pregnancy outcomes in our analysis rather than fetal growth restriction as speci fied in our protocol. Results Electronic searches provided 30,327 citations and hand-searching of references provided a fur ther 57 papers. Sev eral studies had high or unclear risk of detection bias through inadequate blinding of outcome assessments, and many had a high risk of attrition bias caused by the inadequate handling of incomplete outcome data. The majority of studies were of acceptable quality, and many were adjusted for multiple confounding factors. No studies reported pelvic floor dys function as an outcome; therefore, the following individual outcomes were used: urinary incontinence, pelvic organ prolapse (to include uterine and/or vaginal prolapse), and fecal incontinence. Table summarizing the meta-analyses performed detailing the number of studies, number of participants, effect estimate of each outcome and statistical method used. Secondary outcomes: Menorrhagia and dysmenorrhea; chronic pain (including pelvic pain) and sexual dysfunction (including dyspareunia); and subfertility. There were no studies found investigating maternal death or healthcare usage as a long term association of cesarean delivery. Childhood outcomes Thirty-five manuscripts met the inclusion criteria (see S3 Table for characteristics) [17,19,44 76]. As studies had multiple cohorts and different follow-up periods, meta-analyses were divided according to age or duration of follow-up. Cesarean delivery was associated with increased risk of childhood asthma in another study that could not be included in the meta-analysis because results were not subdivided by duration of follow up [71]. Secondary outcomes: Wheeze; hypersensitivity/dermatitis/allergy/atopy; overweight/ obesity; and inflammatory bowel disease. Eight studies (n = 44,131) assessed allergies, hypersensitivity, dermatitis, or atopic condi tions, evaluating a variety of outcomes [51,59,61,63,67,69,75,77]. All studies had follow-up of up to 8 years except one [75], which had 31 years follow-up. There was no statistically significant asso ciation between mode of delivery and odds of hypersensitivity/allergy/dermatitis/atopy in the 2 meta-analysis (S13 Fig). Subsequent pregnancy outcomes There were 24 cohort studies assessing outcomes for pregnancy following cesarean delivery (see S4 Table for characteristics) [29,35,40,78?98]. The primary outcome of perinatal death (defined as the combination of stillbirth [as defined by the authors] and neonatal death [as defined by the authors]) was assessed in 2 studies (n = 91,429) [81,86,90,91,94,97]. There was no statistically sig nificant association between previous mode of delivery and preterm labour [85,86,90,91,94,97,98], small for gestational age [79,86,91,94,97], low birth weight (<2,500 g) [86,90,94,98] or neonatal death [81,86,91,94,97] (S30 Fig, S31 Fig, S32 Fig, S33 Fig). Non-prespecified outcomes Whilst searching for the outcomes defined in our protocol, we identified studies looking at the risk of additional outcomes, including childhood type 1 diabetes [17,99?102] and celiac disease [99,103]. These were not defined as outcome variables in our protocol, and we did not there fore systematically review the risks of these events. Discussion this systematic review and meta-analysis has highlighted the long-term risks and benefits of cesarean delivery for mother, baby, and subsequent pregnancies when compared to vaginal delivery in term (>37 weeks gestation) pregnancies. We found that cesarean delivery is associ ated with reduced rates of urinary incontinence and pelvic organ prolapse but has adverse associations with fertility, future pregnancy outcome, future pregnancy complications, and long-term childhood outcomes. In order to minimize publication bias, the database searches were comprehensive, without language or date restrictions, and efforts were made to include unpublished data through contacting authors. Despite the strengths of this systematic review, we recognize that the associations are based on predominantly observational data, which itself may be vulnerable to bias. Whilst this minimized bias, we have been unable to include some data from well-conducted prospective randomized trials. Examples include [6] and [104], both of which looked at neurodevelopmental outcomes at two years of age in chil dren delivered by planned cesarean delivery versus planned vaginal delivery. Neither study demonstrated statistically significant differences in the two delivery groups; therefore, includ ing these would not have substantially altered the conclusions of our review. Two independent reviewers assessed study quality using two bias assessment tools that cor related well. These biases are likely to have operated in different directions, with attrition bias reducing the observed difference between the treatment groups and detection bias magnifying it. Importantly, excluding studies of low quality did not change findings, suggesting that any bias will have had minimal effect. However, as with all meta-analyses of observational studies, some caution must be exercised in the interpretation of results. This is especially true in analyses where high levels of between study heterogeneity were observed (pelvic organ prolapse, subfertility, placenta previa, uterine rupture, preterm labour), likely to reflect differences in the definitions of outcomes and con founders, follow-up times, and parity in cohorts, or where there the range of confidence inter vals were very wide (placenta accreta, uterine rupture, hysterectomy, antepartum haemorrhage). Observational studies of the risks and benefits of cesarean delivery have multiple potential confounding factors. The majority of included studies adjusted for at least some of these (S2 Table, S3 Table, S4 Table). Studies assessing childhood outcomes frequently also adjusted for birth weight, breast feeding, maternal education, and maternal smoking. Studies assessing the association of cesarean delivery with subsequent pregnancy outcomes additionally adjusted for a range of maternal complications in previous pregnancy such as hypertension, diabetes and preterm labour. In this systematic review and summary meta-analysis of mainly observational data we were unable to adjust for confounding factors. However, it is worth noting that in the majority of studies included, multivariable analysis did not significantly alter findings of univariable analysis. Lithium 150 mg low price. 2 Signs a Man DEEPLY LOVES You...10 That He Does Not!. |
