The European Cerebral Palsy Study Group looked at the correlation of MRI findings and clinical outcomes. MRI scans plus detailed clinical assessments were carried out on over 400 children from the age of 2 years on and it was found that the scans could provide information about the timing and extent of their lesions (Bax et al JAMA 2006;296:1602-8).
The commonest finding was that of white matter damage of immaturity with nearly 90% of the subjects having defined structural abnormalities which would allow clear prognoses to be made. The authors strongly advocate MRI scan for all children with CP.
The possibility of obstetric mishaps being the cause of CP in their study group was small which is in keeping with all similar studies. The most frequent cause was infection which obstetrically is associated with preterm labour and placental damage. When this leads to preterm delivery, the hypoxic insult can result in white matter damage. This mechanism is also thought to account for the cortical damage of those born at term with CP, the infection being either clinical or sub-clinical at an early stage of the pregnancy. Multiple pregnancies are an at-risk group accounting at least 10%, with the same numbers attributable to cerebral malformations and genetic or metabolic disorders.
Only 20% of those born after 34 weeks gestation could be considered to have CP on the basis of an intrapartum mishap. Such mishaps are unlikely to be the result of obstetric mismanagement and the proportion amenable to intervention low. The authors agree with previous findings that asphyxiated encephalopathic infants are not necessarily the result of labour malpractice or lack of vigilance in pregnancy. They suggest the treatment of infections in pregnancy, the reduction in assisted reproduction twin pregnancies and the better, earlier diagnoses of CP are the preventative measures that will reduce the burden of CP. See also the editorial by Msall (pp 1650-2).
22 December, 2006
18 December, 2006
Cord blood collection
Should cord blood be collected for the future benefit of the child? The current debate about stem cell research has focused attention on cord blood and commercial firms are cashing in by offering to collect and store cord blood for future purposes.
Companies are advertising collection as a biological insurance whereby the blood is kept for possible transfusion if the child develops leukaemia or some metabolic disease. Claims, which are presently speculative, suggest that future medical advances will use the blood to cure diseases such as diabetes, breast cancer, ovarian and testicular cancer, melanoma, rheumatoid arthritis or for the regeneration of damaged heart valves. More accurate predictions would be that better treatments for childhood leukaemias will be found that do not require autologous cells. In any event, donor cord blood can be used.
The scientific arguments are in fact pseudoscience in that they talk about future “yet to be discovered” developments. Maybe there will be inventions that will need the patient's own cord blood, but research will be extremely difficult as trials testing “own versus other” blood will be a recruiting nightmare. At present, the likelihood of stored blood being used is very low - quoted at between 1 in 1 400 and 1 in 20 000 (Edozien BMJ 2006;333:801-4).
The Royal College of O&G says storage cannot be recommended because of insufficient scientific evidence and logistic problems. The American and Canadian Colleges are also critical of the process, as are midwifery, paediatric and ethical bodies. There are also medico-legal issues, like whose responsibility is it to take the blood, ensure it is free of contamination, correctly consent its collection, labelling, storage and testing for viral and other dangers? To whom does the blood belong - mother or child? Does the collection process take priority over other labour ward procedures?
It is clear that it cannot be a routine practice, but should those with sufficient resources be advised to pay for it? Parents-to-be want the best for their unborn child and can be considered vulnerable to promotion of this “just in case” philosophy. Yes, personal cord blood may be useful in future situations but at present it is more likely that other measures will overtake autologous transfusions. Medical science says “no” right now but there are other sciences and other beliefs, so it is up to individuals to decide whether recommending cord collection is medical paternalism or sound advice.
Companies are advertising collection as a biological insurance whereby the blood is kept for possible transfusion if the child develops leukaemia or some metabolic disease. Claims, which are presently speculative, suggest that future medical advances will use the blood to cure diseases such as diabetes, breast cancer, ovarian and testicular cancer, melanoma, rheumatoid arthritis or for the regeneration of damaged heart valves. More accurate predictions would be that better treatments for childhood leukaemias will be found that do not require autologous cells. In any event, donor cord blood can be used.
The scientific arguments are in fact pseudoscience in that they talk about future “yet to be discovered” developments. Maybe there will be inventions that will need the patient's own cord blood, but research will be extremely difficult as trials testing “own versus other” blood will be a recruiting nightmare. At present, the likelihood of stored blood being used is very low - quoted at between 1 in 1 400 and 1 in 20 000 (Edozien BMJ 2006;333:801-4).
The Royal College of O&G says storage cannot be recommended because of insufficient scientific evidence and logistic problems. The American and Canadian Colleges are also critical of the process, as are midwifery, paediatric and ethical bodies. There are also medico-legal issues, like whose responsibility is it to take the blood, ensure it is free of contamination, correctly consent its collection, labelling, storage and testing for viral and other dangers? To whom does the blood belong - mother or child? Does the collection process take priority over other labour ward procedures?
It is clear that it cannot be a routine practice, but should those with sufficient resources be advised to pay for it? Parents-to-be want the best for their unborn child and can be considered vulnerable to promotion of this “just in case” philosophy. Yes, personal cord blood may be useful in future situations but at present it is more likely that other measures will overtake autologous transfusions. Medical science says “no” right now but there are other sciences and other beliefs, so it is up to individuals to decide whether recommending cord collection is medical paternalism or sound advice.
06 December, 2006
Magnesium sulphate and eclampsia
Magnesium sulphate is given intravenously to prevent initial or subsequent eclamptic fits in peripartum women. Its efficacy in fit prophylaxis is unquestioned but when it should be commenced and stopped are challenging questions. Two American surveys help in the decision making process in high-risk hypertensive patients.
Alexander et al from Texas (Obstet Gynecol 2006;826-32) reviewed their unit's records when changing from an intramuscular to an intravenous regime and at the same time from treating all hypertensive women to treating only those qualifying for treatment according to strict criteria which would label them as severe preeclamptics. The criteria used were
* BP of 140/90 in a previously normotensive woman
* proteinuria of 2+ or greater on a catheter specimen
* serum creatinine more than 1.2mg/dl or platelets less than 100 000/ml
* aspartate transaminase of double the upper limit of normal
* persistent headache or visual disturbances
* persistent epigastric or right upper-quadrant pain.
As expected, the selective rather than broad spectrum use of magnesium resulted in more eclamptic fits but the numbers needed to treat and the side effects of magnesium therapy make an optimal policy difficult to set. If the net is too fine, it cannot be dragged through the water, and the authors speak of an “irreducible minimum” of unpreventable cases.
A second study from Ohio looked at the duration of magnesium treatment postpartum in mild preeclamptics. Ehrenberg & Mercer (pp833-8) randomly allocated women receiving prophylactic magnesium sulphate but who did not have severe disease, to have 12 or 24 hours of postpartum treatment. Women whose condition deteriorated after being selected to one or other arm of the trial were immediately excluded. Incidentally they found that chronic hypertensive and insulin-dependent diabetics were the most at-risk groups for such deterioration.
Of those not showing progressive disease, it seemed that 12 hours of treatment was sufficient and that carrying on the magnesium for a total of 24 hours had no advantage. Of course, lesser duration of treatment means fewer intensive nursing hours, less chance of side-effects and less maternal mobility, so this article provides useful practical information.
Alexander et al from Texas (Obstet Gynecol 2006;826-32) reviewed their unit's records when changing from an intramuscular to an intravenous regime and at the same time from treating all hypertensive women to treating only those qualifying for treatment according to strict criteria which would label them as severe preeclamptics. The criteria used were
* BP of 140/90 in a previously normotensive woman
* proteinuria of 2+ or greater on a catheter specimen
* serum creatinine more than 1.2mg/dl or platelets less than 100 000/ml
* aspartate transaminase of double the upper limit of normal
* persistent headache or visual disturbances
* persistent epigastric or right upper-quadrant pain.
As expected, the selective rather than broad spectrum use of magnesium resulted in more eclamptic fits but the numbers needed to treat and the side effects of magnesium therapy make an optimal policy difficult to set. If the net is too fine, it cannot be dragged through the water, and the authors speak of an “irreducible minimum” of unpreventable cases.
A second study from Ohio looked at the duration of magnesium treatment postpartum in mild preeclamptics. Ehrenberg & Mercer (pp833-8) randomly allocated women receiving prophylactic magnesium sulphate but who did not have severe disease, to have 12 or 24 hours of postpartum treatment. Women whose condition deteriorated after being selected to one or other arm of the trial were immediately excluded. Incidentally they found that chronic hypertensive and insulin-dependent diabetics were the most at-risk groups for such deterioration.
Of those not showing progressive disease, it seemed that 12 hours of treatment was sufficient and that carrying on the magnesium for a total of 24 hours had no advantage. Of course, lesser duration of treatment means fewer intensive nursing hours, less chance of side-effects and less maternal mobility, so this article provides useful practical information.
New JASS out
This month we have a focus on American health.If you are wondering about JASS' highlighting of American reproductive health, then reflect on the fact that the US spends more on health than the GNP of most developing countries. Their pharma behemoths dictate where drug research spending is directed - on which much of the rest of the world depends. Their administration's stance on drugs is vital - especially in women's health, but let's hope their moral lead is not one we all have to follow.
Our own government's policies on contraception, abortion, HIV, violence against women and obesity are all issues that directly affect our practice. We seem less and less able to influence political dictates which is leading to frustration and lowered morale.
It is good that the journals are speaking out for the profession rather than siding with our political masters.
There are practical summaries too. What to do about cord blood collection, acute uterine bleeding in gynaecology and postpartum, as well as facts to support our patients who wish to eat fish - and stay slim!
Our own government's policies on contraception, abortion, HIV, violence against women and obesity are all issues that directly affect our practice. We seem less and less able to influence political dictates which is leading to frustration and lowered morale.
It is good that the journals are speaking out for the profession rather than siding with our political masters.
There are practical summaries too. What to do about cord blood collection, acute uterine bleeding in gynaecology and postpartum, as well as facts to support our patients who wish to eat fish - and stay slim!
05 December, 2006
Subscribe to:
Posts (Atom)