Bursitis
When inflammation of a bursa is superficial, such as of the shoulder, knee, elbow, or Achilles tendon, the diagnosis of bursitis is easily accomplished. Deep bursae, such as those around the hip joint and the ischial tuberosity, do not present with obvious swelling; a diagnosis must be inferred from local tenderness and exacerbation of pain by activation of the associated muscles. In difficult cases, the temporary elimination of pain after the local instillation of an anesthetic is a useful diagnostic tool. Bursitis seldom shows up on plain radiographs, and expensive imaging studies are not routinely advocated. If possible, one should aspirate the bursa because the finding of synovial fluid helps confirm the diagnosis of bursitis. If the fluid is not clear (as is the case in most instances of "irritated" bursitis), it should be sent for culture and examined for the presence of crystals.
Wednesday, July 28, 2010
Breech Delivery
Breech Delivery
The rate of cesarean delivery for fetuses with intrapartum breech presentation now exceeds 90%. Of the remaining 10%, some are delivered vaginally before cesarean delivery can be performed. Only a small percentage of patients elect to undergo a trial vaginal breech delivery. Criteria for vaginal breech delivery at term include an adequate maternal pelvis, frank breech presentation without hyper-extension of the fetal head, and an estimated fetal weight between 2.5 and 4.0 kg. The practitioner should be experienced in managing vaginal breech delivery.
There is a critical shortage of patients for both residency training and maintenance of delivery skills in the management of vaginal breech deliveries. Furthermore, there are no prospective randomized trials with sufficient power to demonstrate differences in uncommon adverse neonatal outcomes. A large meta-analysis of breech presentation at term reviewed perinatal outcome in 24 studies according to the intended mode of delivery. The overall neonatal morbidity from trauma was significantly increased in the elective vaginal breech group with an odds ratio of 3.86 (95% confidence interval, 2.22-6.69). The authors concluded that until a large randomized trial can be performed, planned cesarean delivery should be strongly considered for persistent breech presentation at term.
Studies regarding the safety of preterm breech vaginal delivery are conflicting. Efforts to perform randomized, prospective trials with proper power have been resisted by patients, practitioners, and investigators alike. For example, the Maternal-Fetal Medicine Units Network of the National Institute of Child Health and Human Development declined to undertake a trial of cesarean versus vaginal breech delivery at 24-28 weeks of gestation because the trial would take 8-9 years to complete in an 11-member, multicenter network with 60,000 annual deliveries. Ironically, 82% of the faculty of the Maternal-Fetal Medicine Units Network agreed that such trials were needed, and 55% thought that residency training for vaginal breech delivery was inadequate. Because it seems unlikely that the question will be answered in the 1990s, only nonselective and retrospective data are available to justify vaginal breech delivery for the term and preterm infant. External cephalic version at term is an alternative to vaginal breech delivery that can decrease term breech presentation by at least 50%.
The rate of cesarean delivery for fetuses with intrapartum breech presentation now exceeds 90%. Of the remaining 10%, some are delivered vaginally before cesarean delivery can be performed. Only a small percentage of patients elect to undergo a trial vaginal breech delivery. Criteria for vaginal breech delivery at term include an adequate maternal pelvis, frank breech presentation without hyper-extension of the fetal head, and an estimated fetal weight between 2.5 and 4.0 kg. The practitioner should be experienced in managing vaginal breech delivery.
There is a critical shortage of patients for both residency training and maintenance of delivery skills in the management of vaginal breech deliveries. Furthermore, there are no prospective randomized trials with sufficient power to demonstrate differences in uncommon adverse neonatal outcomes. A large meta-analysis of breech presentation at term reviewed perinatal outcome in 24 studies according to the intended mode of delivery. The overall neonatal morbidity from trauma was significantly increased in the elective vaginal breech group with an odds ratio of 3.86 (95% confidence interval, 2.22-6.69). The authors concluded that until a large randomized trial can be performed, planned cesarean delivery should be strongly considered for persistent breech presentation at term.
Studies regarding the safety of preterm breech vaginal delivery are conflicting. Efforts to perform randomized, prospective trials with proper power have been resisted by patients, practitioners, and investigators alike. For example, the Maternal-Fetal Medicine Units Network of the National Institute of Child Health and Human Development declined to undertake a trial of cesarean versus vaginal breech delivery at 24-28 weeks of gestation because the trial would take 8-9 years to complete in an 11-member, multicenter network with 60,000 annual deliveries. Ironically, 82% of the faculty of the Maternal-Fetal Medicine Units Network agreed that such trials were needed, and 55% thought that residency training for vaginal breech delivery was inadequate. Because it seems unlikely that the question will be answered in the 1990s, only nonselective and retrospective data are available to justify vaginal breech delivery for the term and preterm infant. External cephalic version at term is an alternative to vaginal breech delivery that can decrease term breech presentation by at least 50%.
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