Outpatient Cervical Ripening with Balloon Catheters: A Systematic Review and Meta-analysis

Objective: To evaluate whether outpatient cervical ripening with a balloon catheter results in a shorter amount of time in the labor and delivery unit when compared with use in the inpatient setting. Data sources: PubMed, Scopus, Cochrane Library, and ClinicalTrials.gov were searched from their inception until December 2020. No restrictions for language or geographic location were applied. Methods of study selection: Using a predefined protocol and search strategy, 1,152 titles were identified and screened. Randomized controlled trials that compared outpatient and inpatient cervical ripening with balloon catheters were included. Tabulation, integration, and results: Data extraction and risk of bias assessments were performed by two reviewers. Meta-analysis was performed to produce mean difference for continuous data and risk ratio (RR) for dichotomous data, both with a 95% CI. The primary outcome was the amount of time from admission to the labor ward until delivery. Additional secondary maternal and neonatal outcomes were evaluated. Eight trials (740 patients) were included; six studies (571 patients) reported on our primary outcome. Compared with the inpatient group, outpatient balloon cervical ripening was associated with significantly less time in the labor and delivery unit (outpatient 16.3±9.7 hours vs inpatient 23.8±14.0 hours; mean difference -7.24 hours, 95% CI -11.03 to -3.34). There were no differences in total induction time or total hospital admission. The outpatient group was significantly less likely than the inpatient group to undergo cesarean delivery (21% vs 27%), RR 0.76 (95% CI 0.59-0.98). There were no differences in other maternal or neonatal outcomes. There were no deliveries outside of the hospital and no stillbirths. Conclusion: Outpatient balloon cervical ripening in low-risk patients is associated with a decreased amount of time from admission to labor and delivery until delivery by more than 7 hours and a significant 24% decreased risk of cesarean delivery. Outpatient balloon cervical ripening is a safe alternative for low-risk patients and has the potential for significant benefits to patients, and labor and delivery units. Systematic review registration: PROSPERO, CRD42019140503

Physical Examination-Indicated Cerclage

OBJECTIVE: To estimate the effectiveness of physical examination-indicated cerclage in the setting of second-trimester cervical dilatation by systematic review and meta-analysis of published studies. DATA SOURCES: We searched MEDLINE, EMBASE, Scopus, ClinicalTrials.gov, Web of Science, and the Cochrane Library for studies published between 1966 and 2014 that evaluated cervical cerclage for the treatment of cervical insufficiency. METHODS OF STUDY SELECTION: The search yielded 6,314 citations. We included cohort studies and randomized controlled trials comparing cerclage placement with expectant management of women with cervical dilatation between 14 and 27 weeks of gestation. Two investigators independently reviewed each citation for inclusion or exclusion and discordant decisions were arbitrated by a third reviewer. Summary estimates were reported as the mean difference and 95% confidence interval (CI) for continuous variables or relative risk and with 95% CI for dichotomous outcomes. Fixed- and random-effects meta-analysis was used, depending on heterogeneity. TABULATION, INTEGRATION, AND RESULTS: Ten studies met inclusion criteria and were included in the final analysis. One was a randomized controlled trial, two were prospective cohort studies, and the remaining seven were retrospective cohort studies. Of the 757 women, 485 (64%) underwent physical examination-indicated cerclage placement and 272 (36%) were expectantly managed. Cerclage was associated with increased neonatal survival (71% compared with 43%; relative risk 1.65, 95% CI 1.19-2.28) and prolongation of pregnancy (mean difference 33.98 days, 95% CI 17.88-50.08). CONCLUSION: Physical examination-indicated cerclage is associated with a significant increase in neonatal survival and prolongation of pregnancy of approximately 1 month when compared with no such cerclage. The strength of this conclusion is limited by the potential for bias in the included studies

A Comparison of Patients\u27 and Nurses\u27 Perceptions of Patient Stressors in Critical Care

The purpose of this study was. to compare critical care unit (CCU) nurses\u27 and patients\u27 perceptions of stress factors for patients in the CCU environment. The research questions were: 1. Which stressors do hospitalized CCU patients perceive to be the most significant? 2. What do nurses report as their perception of the most significant patient stressors in CCUs? 3. What is the relationship between the patients\u27 reports of perceived stressors and CCU nurses reports of patients\u27 perceived stressors. This comparative-descriptive study included a sample of 40 patients transferred from CCUs and 40 Registered Nurses employed in CCUs. A convenience sample was obtained from nine CCUs in three hospitals in a metropolitan area of the southeastern United States. Data were collected using a Personal Data Questionnaire and the Intensive Care Unit Environmental Stressor Scale (ICUESS). The ICUESS was designed to assess the level of perceived stressfulness of both patients and nurses in the critical care unit environment. Data were collected from the nurses by requesting them to complete the instruments following a shift worked in a CCU. Nurses were asked to complete the ICUESS by indicating the responses that they thought most CCU patients would indicate. Patient data were collected within 72 hours following transfer from a CCU. Comparison of group results from the ICUESS were analyzed using the Mann Whitney U Test and the independent T test. It was found that nurses reported higher levels of stress for patients than did the patients themselves on all of the items on the ICUESS. Comparison of all items was significant at the level 0.05 when analyzed by both parametric and nonparametric statistical methods. The results were consistent among the three hospitals and types of CCUs. Findings support those of previous studies in that nurses consistently perceive environmental stimuli as being more stressful than do patients. Findings of the study need to be made available to CCU nurses, to facilitate nursing focus on identified high patient stressors and minimize concern of the nurses about other environmental stimuli

A Case of Adams–Oliver Syndrome

Adams–Oliver syndrome (AOS) is a rare congenital disorder with unknown etiology commonly presented with aplasia cutis and terminal limb defects. Central nervous and cardiopulmonary systems may also be affected. It is commonly inherited as an autosomal dominant disorder but autosomal recessive and sporadic cases have also been reported. Here, we present a 10-year-old boy with extensive aplasia cutis congenita and limb anomalies as well as mild pachygyria and focal acrania in neuroimaging. No other internal organ involvement was obvious in this patient. Family history was negative for this syndrome. AOS is a multisystem disorder, and so it is crucial to investigate for internal organ involvements

Disseminated primary herpes simplex infection imitating preterm prelabor rupture of membranes – a case report

Background: We describe a case of primary herpes simplex virus (HSV) infection imitating preterm prelabor rupture of membranes (PPROM) and review the intricacies of establishing the diagnosis. Case presentation: At 18 weeks of gestation, a patient was referred for suspected PPROM following leakage of fluid and a positive nitrazine test. The patient had a swollen inguinal lymph node, intermittent fevers, transaminitis, labial lesions, and cervical ulceration with vaginal discharge. Amniotic fluid volume was normal. An HSV PCR test was positive. Intravenous acyclovir followed by oral valacyclovir resulted in resolution of symptoms. Conclusion: Discharge from HSV cervicitis can present as nitrazine-positive pooling, imitating PPROM. A high index of suspicion is warranted, especially when the amniotic fluid volume is normal and arborization is not seen on microscopic exam