THE EFFECT OF THE POST-TRAUMATIC STRESS DISORDER RELATED TO THE UNITED STATES SOLDIER IN VIETNAM’S WAR

After returning from the war, many Vietnam veterans suffered from Post-Traumatic Stress Disorder, which is characterized by persistent emotional problems including anxiety and depression. The Department of Veterans Affairs estimated that 20,000 Vietnam veterans committed suicide in the war’s aftermath. Throughout the 1970s and 1980s, unemployment and rates of prison incarceration for Vietnam veterans, especially those having seen heavy combat, were significantly higher than in the general population.                                                                 
Having felt ignored or disrespected both by the Veterans Administration (now the Department of Veterans Affairs) and by traditional organizations such as the Veterans of Foreign Wars and the American Legion, Vietnam veterans have formed their own self-help groups. Collectively, they forced the Veterans Administration to establish storefront counseling centers, staffed by veterans, in every major city. The national organization, Vietnam Veterans of America (VVA), has become one of the most important service organizations lobbying in Washington, D.C.        

Stroke Hemoragik

TINJAUAN PUSTAKA

STROKE HEMORHAGIK

Kepaniteraan Klinik Ilmu Penyakit Saraf

RS. OTORITA BATAM

2009

I. PENDAHULUAN
Stroke adalah terminologi klinis untuk gangguan sirkulasi darah non traumatik yang terjadi secara akut pada suatu daerah fokal area di otak berlangsung lebih dari 24 jam atau menyebabkan kematian dan disebabkan oleh sebab vaskular.
Secara global, strok adalah penyebab kematian terbanyak kedua di dunia. Selain sebagai salah satu sebab utama kematian, strok juga menyebabkan  kecacatan pada banyak pasien yang bertahan hidup sehingga mereka membutuhkan bantuan keluarga, sistem kesehatan dan institusi sosial lainnya.

Adenomyosis

ADENOMYOSIS

Definisi

                Adenomiosis adalah pertumbuhan jinak dari endometrium kedalam otot uterus, terkadang disertai dengan pembesaran (hipertrofi) kemudian. Jika kelainan ini berupa nodul seperti tumor yang berbatas tegas disebut adenomyoma. [1] Adenomiosis pertama kali dideskripsikan oleh Rokitansky pada tahun 1860 dan kemudian disempurnakan lebih lanjut oleh Von Recklinghausen tahun 1896.

KEJANG DEMAM PADA ANAK

KEJANG DEMAM

DEFINISI

Kejang demam adalah bangkitan kejang yang terjadi pada kenaikan suhu tubuh ( suhu rectal diatas 38°C ) yang disebabkan oleh suatu proses ekstrakranium.¹ Kejang demam merupakan kelainan neurologis yang paling sering dijumpai pada anak-anak, terutama pada golongan umur 3 bulan sampai 5 tahun. Menurut Consensus statement on febrile seizures (1980), kejang demam adalah kejadian pada bayi atau anak yang berhubungan dengan demam tetapi tidak pernah terbukti adanya infeksi intrakranial atau penyebab tertentu. Anak yang pernah kejang tanpa demam dan bayi berumur kurang dari 4 minggu tidak termasuk dalam kejang demam. Kejang demam harus dibedakan dengan epilepsi,yaitu yang ditandai denagn kejang berulang tanpa demam.^1,2,3

Stevens-Johnson Syndrome

Introduction

Background

First described in 1922, Stevens-Johnson syndrome (SJS) is an immune-complex–mediated hypersensitivity complex that is a severe expression of erythema multiforme. It is known by some as erythema multiforme major, but disagreement exists in the literature. Most authors and experts consider Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) different manifestations of the same disease. For that reason, many refer to the entity as SJS/TEN. SJS typically involves the skin and the mucous membranes. While minor presentations may occur, significant involvement of oral, nasal, eye, vaginal, urethral, GI, and lower respiratory tract mucous membranes may develop in the course of the illness. GI and respiratory involvement may progress to necrosis. SJS is a serious systemic disorder with the potential for severe morbidity and even death. Missed diagnosis is common.

[New Information] Adult Immunization Schedule for 2010 Issued From ACIP

January 6, 2010 — The Advisory Committee on Immunization Practices (ACIP) of the US Centers for Disease Control and Prevention has issued clinical guidelines for the adult immunization schedule for 2010, according to a report in the January 5, 2010, issue of the Annals of Internal Medicine.

The American Academy of Family Physicians, American College of Obstetricians and Gynecologists, and American College of Physicians have also approved this adult immunization schedule for 2010.

UKDI 2010

National medical examination competence Schedule 2010

The meaning of the medicine logo (Caduceus)

The caduceus ☤ (pronounced /kəˈdjuːsiəs, -ʃəs/, from Greek kerykeion κηρύκειον) is typically depicted as a short herald's staff entwined by two serpents in the form of a double helix, and is sometimes surmounted by wings. This staff was first borne by Iris, the messenger of Hera. It was also called the wand of Hermes when he superseded Iris in much later myths.

In later Antiquity the caduceus might have provided the basis for the astrological symbol representing the planet Mercury and in Roman iconography was often depicted being carried in the left hand of Mercury, the messenger of the gods, guide of the dead and protector of merchants, shepherds, gamblers, liars and thieves.^[

The caduceus is sometimes erroneously used as a symbol for medicine, especially in North America, due to confusion with the traditional medical symbol, the rod of Asclepius, which has only a single snake and no wings.

Dermatological Descriptive Terms

Before you enter dermato-venereology station, you must know the basic terms of dermatology, here is the list, I hope you can use it..

The need for terminology

Dermatologists can sound erudite when they use the abundance of descriptive terms at their disposal. These terms are often simply describing the rash in Latin. Sometimes the words are of Greek derivation such as ichthyosis (meaning scales like a fish). Latin or Greek terminology may be used but the two should not be mixed.
The skin is affected by a vast number of insults and diseases including genetic and metabolic abnormalities as well as infections and yet there are a limited number of ways in which it can respond.Dermatological history and examination involves making an assessment of the condition, including describing it. Simply understanding dermatological terminology will facilitate diagnosis.

Hypertension

Hypertension means high blood pressure. This generally means:

• Systolic blood pressure is consistently over 140 (systolic is the "top" number of your blood pressure measurement, which represents the pressure generated when the heart beats)
• Diastolic blood pressure is consistently over 90 (diastolic is the "bottom" number of your blood pressure measurement, which represents the pressure in the vessels when the heart is at rest

Either or both of these numbers may be too high.

Kortikosteroid

        Kortikosteroid merupakan obat yang mempunyai khasiat dan indikasi klinis yang sangat luas. Kortikosteroid sering disebut sebagai life saving drug. Manfaat dari preparat ini cukup besar tetapi karena efek samping yang tidak diharapkan cukup banyak, maka dalam penggunaannya dibatasi termasuk dalam bidang dermatologi kortikosteroid merupakan pengobatan yang paling sering diberikan kepada pasien.^1,2 Kortikosteroid adalah derivat dari hormon kortikosteroid yang dihasilkan oleh kelenjar adrenal. Hormon ini dapat mempengaruhi volume dan tekanan darah, kadar gula darah, otot dan resistensi tubuh.^3,4

Obat AntiVirus

Obat AntiVirus

Siklus replikasi virus secara garis besar dapat dibagi menjadi 10 langkah: adsorbsi virus ke sel (pengikatan , attachment), penetrasi virus ke sel, uncoating (dekapsidasi), transkripsi tahap awal, translasi tahap awal, replikasi genom virus, trankripsi tahap akhir, assembly virus dan penglepasan virus. HIV juga mengalami tahapan-tahapan diatas dengan beberapa modifikasi yaitu pada transkripsi awal (tahap4) yang diganti dengan reverse transcription; translasi awal (tahap5) diganti dengan integrasi; dan tahap akhir (assembly dan penglepasan) terjadi bersamaan sebagai proses “ budding “ dan diikuti dengan maturasi virus. Semua tahap ini dapat menjadi target intervensi kemoterapi.

Childbirth Stations of Presentation

Cesarean Birth (C-section) Delivery & Birth

3D Medical Animation: Birth of Baby (Vaginal Childbirth)

Link between Alzheimer’s and heart failure found

Researchers at Johns Hopkins University have reported evidence for a link between Alzheimer’s diseases and chronic heart failure, stemming from studies in animals and humans.

The team of scientists (more specifically biochemists and cardiologists) from the U.S., Canada, and Italty were led by the researchers from Johns Hopkins in a study that found three changes in the chemical make-up of a key structural protein. The protein, named desmin, was studied in the heart muscle cells of dogs. The build-up of harmful protein is a key in both Alzheimer’s disease and chronic heart failure.

Protein clusters, in regards to heart disease, come in the form of desmin amyloid proteins, very similar to the beta-amyloid plaques found in the brain of Alzheimer’s patients. Scientists believe that these plaques are responsible for the onset of Alzheimer’s disease. Now, the discovery of the altered desmin protein in heart muscle cells has linked chronic heart failure with Alzheimer’s disease through these misshapen lumps of protein.

In 2005, desmin proteins and amyloid-like debris were found in mice altered to develop chronic heart failure. However, until now, there was no link between the changes in desmin and the effect on organ function.

Now, the team of scientists and researchers have found results that detail the chemical changes of desmin, allowing them to study the link between the changes and malformations in the process of heart failure. The results aalso suggest that dangerous desmin-like amyloids may form in response to stress placed on the heart.

The study and analysis was presented the American Heart Association’s annual Scientific Sessions in Orlando, Florida. The new finding is big news for researchers of heart failure, as it helps them pinpoint the biological cause of heart disease, and whether it is an amyloid-related disease like Alzheimer’s.

Researchers are now planning to analyze each change in the chemical make-up of the desmin protein, in hopes of discovering the biological impact of each.

from: http://www.physician.com/link-between-alzheimers-and-heart-failure-found.html

Dokter Stres Penyebab Tertinggi Kesalahan Medis

Jakarta, Jangan dikira seorang yang berprofesi dokter selalu sehat dan bisa mengatasi masalahnya. Studi menemukan bahwa penyebab kesalahan medis tertinggi pada pasien berasal dari dokter yang stres dan lelah.


Kelelahan, stres dan gejala depresi lainnya ternyata merupakan penyebab dokter menjadi 'error'. Bahkan studi yang dipimpin oleh Dr Colin P West, internis dari Mayo Clinic in Rochester, Amerika menemukan bahwa faktor-faktor error tersebut meningkatkan angka kesalahan medis hingga 3 kali lipat.

Kesalahan medis adalah isu penting saat ini. Menurut laporan dari Institute of Medicine, hampir 100.000 orang di Amerika meninggal setiap tahunnya karena kesalahan medis.

West dan rekannya melakukan survei dari tahun 2003 hingga 2008 terhadap para dokter yang melakukan medical error atau kesalahan medis pada pasiennya. Dari 378 dokter yang disurvei, sebanyak 39 persen dokter mengaku melakukan kesalahan karena faktor kelelahan, depresi, stres, rendahnya kualitas hidup dan kurang tidur.

Diantara faktor-faktor tersebut, West menemukan faktor stres dan lelah sebagai penyebab tertinggi kesalahan medis. "Stres dan lelah menyebabkan fungsi otak tidak bekerja maksimal dan akhirnya salah mendiagnosa penyakit bahkan bisa menyebabkan kematian," ujar Dr David J Birnbach dari University of Miami seperti dilansir Health24, Jumat (25/9/2009).

Masalahnya adalah dengan waktu kerja yang sangat padat, tidak ada sistem yang bisa memonitor kesehatan dokter itu sendiri, apakah ia kelelahan, kurang tidur, stres atau ada masalah lainnya. "Dokter juga perlu sistem yang mengontrol kesehatannya apalagi untuk dokter-dokter yang sudah berusia 65 atau 70 tahun," ujar David.

Dalam Journal of the American Medical Association, para dokter disarankan melakukan meditasi, sadar olahraga dan juga memahami pentingnya menjalankani profesi dokter dengan sungguh-sungguh. Dengan begitu, rasa lelah fisik maupun batin pun bisa diatasi dan pasien pun tidak menjadi korban kesalahan medis.

"Intinya adalah mengatur jam biologis tubuh dan segera mengatasi rasa lelah agar bisa menyembuhkan pasien dengan aman," ujar David.

MANAGEMENT OF LABOR and OBSTRUCTED LABOR

MANAGEMENT OF LABOR and
OBSTRUCTED LABOR

by: Yoshua Viventius
medical student@ 6th grade

Definitions

In order to assess progress in labor, we need to be confident in our definition of active labor and abnormal progress.

Labor Is:
Regular, Frequent Uterine Contractions
+
Cervical Change
(dilatation and effacement)


First stage:

• Latent Phase: is the presence of uterine activity resulting in progressive effacement and dilatation of the cervix preceding the active phase. Latent phase is complete when a primiparous woman reaches 3-4 cm dilatation and cervical length of 0-0.5 cm and a multiparous woman reaches 4-5 cm and cervical length 0.5-1.0 cm. The onset of the latent phase is often difficult to define. It can be difficult to separate from false labor and the true length of this stage is often assessed retrospectively.

• Active phase requires the presence of regular painful contractions leading to more rapid cervical dilatation after 3-4 cm dilatation in a primiparous woman, or 4-5 cm dilatation in a multiparous woman.

Second Stage: (divided into two components)

• Passive: Early descent occurs during the time from full dilatation until an urge to push is felt (about station+2).
• Active: The second component is usually associated with maternal expulsive effort and is the time from the onset of the urge to push until delivery.

Inadequate progress of labor is associated with increases in maternal stress, maternal infection, postpartum hemorrhage and the need for neonatal resuscitation. Tools such as partograms are essential to demonstrate and highlight inadequate progress in labor.

In evaluating the cause of dystocia, we can refer to the three Ps: Powers, Passenger, and Passage. The powers are the most likely to be responsible for dystocia, and are the most readily evaluated and influenced. Ineffective contractions, usually early in labor, are responsible for approximately 2/3 of dystocias in nulliparous women.

Use of the Partograph in Labor

Why the Partograph?

The delivery of a healthy baby and maintenance of a safe delivery for the mother are two goals of all maternity health care givers. A simple instrument called a partograph can aid this basic human right of safe passage. The partograph has been shown to reduce prolonged labor, the need for augmentation, emergency caesarian section and intrapartum stillbirth rates. It should be used in all labor wards and centers for maternity care. The following recommendations are adapted from the World Health Organization recommendations on the use of the partograph: (see Appendix 1A and 1B)


When should one use the partograph?

A partograph should be started on women in labor who have NO complications that require immediate action. Start ONLY when the woman is in labor—this means two contractions in ten minutes (lasting 20 seconds or more) in the latent phase (cervical dilatation of 0-2 cm). In the active phase (cervical dilatation of 3-10 cm), the contractions should be one per ten minutes (lasting 20 seconds or more).

What does the partograph involve?

The partograph demands the assessment of several observations—the first relate to progress of labor (cervical dilatation, descent of the fetal head and uterine contractions). The second set of observations focuses on the fetus: fetal heart rate, membranes and liquor and moulding of the fetal head.

The DILATATION is plotted with an ‘X’. After the first vaginal examination, repeat exams are every four hours (with a more frequent assessment if the woman is multiparous or in advanced labor).

Descent is assessed abdominally in fifths above the pelvic brim. An abdominal examination should be done before the pelvic assessment. Contractions are observed for frequency and duration. The number of contractions in ten minutes is recorded with three ways of shading on the partograph: a) less than 20 seconds b) 20-40 seconds and c) greater than 40 seconds.

Membranes are denoted as:

I=intact C=ruptured and clear M=meconium A=ruptured but absent liquor

Things to remember:

Satisfactory progress means the plot of cervical dilatation will remain ON or LEFT of the ALERT LINE.

The latent phase should not last beyond eight hours. If a mother is admitted in latent phase, start plotting at time zero hours. Once in the active phase, plotting of dilatation is transferred to the ALERT line. If a patient is admitted already in the active phase, dilatation is plotted immediately on the ALERT line.


Listen to fetal heart rate after peak of contractions with a woman on her left side. The fetal heart rate should be 120-160 beats per minute. Record the fetal heart rate every 30 minutes during the first stage of labor. Increasing moulding with a high fetal head is a sign of cephalopelvic disproportion.

Actions on the Partogram:

The Alert Line:

A laboring mother should be referred from a health center to a hospital when the cervical dilatation moves to the RIGHT of the ALERT line. Amniotomy may be performed if the membranes are still intact—she may be observed for a short time prior to transfer. In hospital, movement to the RIGHT of the ALERT line should signal the need for an amniotomy and close observation.

The Action Line:

If the patient’s partograph crosses the ACTION line in a central hospital, active intervention is required. Initially this would include: the start of an intravenous line, bladder catheterization, analgesia and augmentation using oxytocin. These measures would be carried out as long as there was no evidence of fetal distress or obstructed labour.

A vaginal examination should be carried out in three hours, then in two more hours (and every two hours thereafter). The dilatation rate should be 1cm/hour minimum. CHECK the FETAL HEART rate every half hour at minimum when oxytocin is being infused. If these measures are not successful, a cesarian section would be carried out.

Prolonged Latent Phase:

In the case of a woman with a prolonged latent phase (>8 hours), a full assessment must be carried out. Is she truly in labor—if not, abandon the partograph. One may consider an amniotomy plus oxytocin infusion if there is no evidence of fetal distress and the contraction pattern is not satisfactory. A final option is cesarian section—especially if evidence of obstruction or need for imminent delivery.

Antibiotics should be given if the membranes have been ruptured for more than 12 hours.

Fetal distress should be managed aggressively: if the woman is in a health centre, transfer to hospital (for operative delivery) immediately. If the woman is in hospital, stop oxytocin, turn on left side, examine for cord prolapse and hydrate. If the fetal distress does not resolve, an immediate cesarian section is needed.


Etiology of Dystocia


POWERS ineffective contractions
maternal expulsive efforts (second stage)
fetal position

PASSENGER
fetal attitude
fetal size
fetal abnormalities e.g. hydrocephalus

PASSAGE
bony pelvis abnormality

soft tissue causes:
tumours
full bladder/full rectum
vaginal septum


The diagnosis of true or absolute cephalopelvic disproportion (CPD) should be limited to the uncommon instances of real disproportion i.e. inability of the well flexed head (sub-occipito bregmatic presentation) to pass through the bony pelvis. Other presentations may lead to relative cephalopelvic disproportion.

If the woman is making satisfactory progress in labor then the interaction of the three P’s must be adequate. These three variables act together and should generally not be assessed in isolation.



If progress is inadequate, attention should be directed to:

1. Adequate Powers:
Contractions that are…
1) Regular
2) Progressive, which lead to cervical dilatation
3) Frequent ( 2-3 minutes)

2. The Passenger should be assessed for size and malposition. Inadequate powers in active labor may be responsible for malposition. A normal sized infant may present an excessively large diameter to the pelvis because the head is not flexed.

3. The Passage: Clinical examination of the passage may reveal prominent spines or sacrum, a narrow pubic arch or a space-occupying mass in the pelvis. A trial of labor is the only real assessment of the pelvic adequacy.


Prevention and Management of Dystocia

1) Prevention

Accurate Diagnosis of Labor

Some cesarean sections performed for dystocia in nulliparous patients are done in the latent phase of labor. It is likely that at least a portion of these women were not in true labor at the time of labour management interventions or at the time of cesarean section. Appropriate management, of suspected early labor, could result in a decrease in the cesarean section rate.

Management of Prolonged Latent Phase

Different definitions of prolonged latent phase exist including greater than 20 hours in a primip, or a time limit of six hours from admission to health center to 3 cm dilatation. If women are not admitted until they are in active labor, this latter definition becomes irrelevant. Regardless, it is important to separate this entity from false labor.

Management is controversial due to the limited number of published studies.
• The patient should preferably not be admitted to the labor and delivery area.
• Observation, rest and analgesia are favoured over a more active approach of amniotomy and oxytocin induction.

Labor Preparation

For nulliparous women who have attended prenatal education, there may be more rapid progress in labor. Some studies have shown a benefit and others show no difference, but all studies show that women who were prepared for labor had a more positive experience. Trials also show that prenatal education decreases the amount of analgesia used during labor.

Birth Companion

There is now strong evidence that the presence of a supportive companion results in faster progress and less dystocia. This companion should have experience with labouring women, but is not necessarily trained in a health discipline.


Ambulation

It is important to recognize the women’s choice of labor position. Ambulation and upright posture reduces the amount of pain perceived by women in labor. The use of a birth stool often helps if the woman does not want to walk. Upright posture in labor may be useful in reducing backpain and the need for epidural anesthesia. Static supine position may result in aorto-caval compression, hypotension and non-reassuring fetal monitoring.


Analgesia

Some patients in labor reach the limit of their pain tolerance. Furthermore, patients experiencing excessive pain or anxiety have high endogenous catecholamines. This produces a direct inhibitory effect on uterine contractility and establishes a vicious circle of poor uterine progress leading to increased anxiety, leading to increased catecholamines, leading to further impairment of progress. The relief of pain by effective analgesia may allow release of the uterus from the constraints of the endogenous catecholamines and enhance progress in labor. High endogenous catecholamine levels may also adversely affect uterine blood flow and therefore fetal oxygenation.


Amniotomy (ARM*)

Routine early use of amniotomy after 3 cm dilatation shortens the average length of labor, but does not in itself reduce the incidence of dystocia or cesarean section. Early amniotomy at less than 3 cm dilatation may increase the incidence of dystocia.
• ARM: Artificial Rupture of the Membranes


Fetal Size

Fetal size does not significantly affect the progress of labor in first and second stage.


Management

If an arrest disorder is diagnosed, management is as follows:
• Arrest without CPD
- amniotomy
- consider oxytocin augmentation if contractions are inadequate
• Arrest with true CPD
- cesarean section

Oxytocin

In the event of unsatisfactory progress (<0.5cm/hr x 4 hours or arrest of descent for over 1 hour) in the active phase of labor, oxytocin is indicated. Before the use of oxytocin, consideration should be given to the appropriate use of analgesia, hydration, rest and amniotomy.Oxytocin should be used to achieve adequate contractions before operative delivery is considered.Concern is sometimes raised about the use of oxytocin. The principal complications that cause apprehension are fetal compromise and uterine rupture due to uterine hyperstimulation. Judicious use of oxytocin should not result in complications.Fetal hypoxia may occur accompanying spontaneous contractions. Judicious use of oxytocin produces contractions with intrauterine pressures equivalent to spontaneous labor. If the fetus develops signs of fetal hypoxia with these contractions, this is due to pre-existing uteroplacental insufficiency and not to the oxytocin. Inappropriate use of oxytocin may produce hyperstimulation and decrease transplacental oxygen transport to the fetus. In the primigravida rupture of the uterus in association with oxytocin is almost unknown. However care must be taken in the multipara and those with previous uterine surgery.All labor and delivery units must be prepared to manage uterine hyperstimulation whether it is associated with oxytocin use or not. Management of uterine hyperstimulation is outlined in the section on induction of labor. The following are possible complications, their mechanism of occurrence and preventative management, with the use of oxytocin.Adverse Effects of Oxytocin and Their PreventionAdverse Effects Mechanism PreventionFetal compromise Hyperstimulation Correct doseUterine rupture Hyperstimulation Correct doseEach woman’s uterus varies in its sensitivity to oxytocin. Even in the same uterus, the sensitivity may change during the course of labor. The dose must be sufficient to achieve adequate contractions. Protocols or guidelines for the administration of oxytocin vary but suggest starting with a low dose and small increments at intervals of 30 minutes. Starting incremental dosages for augmentation may be less than those for induction.Augmentation of LaborInitial dose of oxytocin 1-2mU/minIncrease interval Every 30 minutesDosage increment 1-2mUUsual dose for good labor 2-12mU/minIt is important to allow adequate time for oxytocin to work. This is especially true if it is started when the cervix is less than 5 cm dilated. Do not expect to see immediate progress.For the conversion to the equivalent to drops per minute (20 drops=1ml):Oxytocin Normal Saline Drops10 unites 500 ml 1mu = 1 drop5 unites 1 lt 1mu = 4 drops10 unites in 1 lt 1mu = 2 dropsActive Management of LaborActive management of labor encompasses the following principles:• Rigorous diagnosis of labor• Close surveillance of progress of labor by partogram• Continuous support in labor• Early intervention to correct inadequate progress of labor:• ARM• OxytocinThis has been shown to reduce the incidence of dystocia and cesarean sections. Management of the Prolonged Second Stage Setting an arbitrary time limit for the second stage in the absence of suspected fetal compromise, is not well founded. Women should not be encouraged to push until the head has descended to the pelvic floor and they feel the urge to do so. If no urge to push occurs after one hour of second stage, reassess the contractions and consider the use of oxytocin if contractions are inadequate. A lack of descent in the absence of moulding or caput is likely due to inadequate contractions.Summary

Prevention of Dystocia
• Avoid unnecessary induction
• Admit only women in active labor
• Encourage ambulation and upright posture
• Encourage the use of prenatal education
• Continuous support of laboring women
• Use appropriate analgesia

Management of Dystocia
• Appropriate assessment of adequate progress in labor
• Appropriate intervention when necessary
 Amniotomy
 Analgesia
 Rest
 Ambulation
 Augmentation
 Cesarean sections


OBSTRUCTED LABOR

Definitions

“Failure of descent of the fetus in the birth canal for mechanical reasons in spite of good uterine contractions”. (Philpott, 1982)

Incidence
1 - 3%

Risks Associated with Neglected Obstructed Labor

Fetal:
• Asphyxia
• Sepsis
• Death

Maternal:
• Sepsis
• Uterine rupture
• Hemorrhage
• Fistula (Vesico-vaginal, recto-vaginal)
• Death

Etiology of Obstructed Labor

Fetal - Pelvic Disproportion:

Malpresentations
- Face
- Brow
- Shoulder/arm presentation - Transverse lie
- Breech
- Compound presentation

Malposition- Persistent occipito posterior
- Persistent occipito transverse

Malformations
- Hydrocephalus
- Abdominal tumors (eg. Wilms Tumor)
- Cystic Hygroma
-Conjoined twins


Maternal

•Small pelvis
- Childhood malnutrition
- Contracted or deformed bony pelvis

•Soft tissue tumors of the pelvis
- Uterine fibroids
- Ovarian tumors
- Rectal tumors


Clinical Features of Obstructed Labor

In most cases, prolonged labor preceeds obstruction. However, in the grand multiparous patient labor may be quick and relatively silent, and in the presence of a malpresentation, such as a transverse lie, obstructed labor may rapidly occur.

Clinical Presentation of a Patient with Obstructed Labor:

Dehydration

Dehydration is due to muscular activity in the absence of adequate fluid intake. Signs and symptoms will include hot and dry skin with loss of tissue turgor.

• Oliguria

Decreased urinary output occurs in association with the patient’s state of dehydration.

• Keto-acidosis

Metabolic acidosis develops, from accumulation of lactic acid produced by the prolonged contractions of uterine and skeletal muscles. With inadequate caloric intake, endogenous tissue breakdown occurs, and the catabolism of fat in the absence of carbohydrates leads to the production of ketones which further increases the acidosis. Dehydration exaggerates the acidaemia because anions accumulate due to the diminished urinary output. In a response to restore the acid base equilibrium, potassium is mobilized from the cells, which diminishes the activity of the involuntary muscles.

The clinical signs of keto-acidosis are: a rapid pulse in association with deep and rapid respiration and pyrexia. Acetone is present in the urine, and the bowel is frequently distended and atonic due to hypokalemia.

• Sepsis

Infection that is frequently established by the time-prolonged labor has reached the stage of obstruction, particularly if the membranes have been ruptured for a long time. The introduction of pathogens often occurs with un-sterile vaginal examinations or manipulations. Even in the absence of vaginal interventions, infection will develop in the birth canal in association with prolonged obstructed labor.

The clinical signs of infection are purulent vaginal discharge, pyrexia and tachycardia. In advanced cases, infections due to gas-forming organisms may produce a crackling sensation when the uterus is palpated.

When the fetus has been dead for several days, significant gas may be produced from putrefaction and the uterus becomes distended and tympanitic. The terminal signs of severe intrapartum infection are septic shock with circulatory collapse, hypotension, a rapid thready pulse with subnormal temperature.

State of the Uterus

In multigravid, the uterus reacts to obstruction by frequent and stronger contractions of the upper segment. Meanwhile, the lower segment continues to retract and already thinned by circumferential dilatation in the first stage of labor, elongates and becomes progressively thinner. As the contractions continue, progressive retraction and thinning of the lower segment continues and the junction ring between the lower and upper segment rises progressively, often up to the level of the umbilicus. This is called a pathological ring or Bandl’s Ring.

In the primigravid patient, obstruction will usually occur before full dilatation. If the obstruction is neglected the following sequence of events will occur:

• Prolonged uterine activity may lead to reduced intervillous blood flow and fetal asphyxia
• Fetal trauma associated with operative vaginal delivery
• Avascular pressure necrosis from the fetal presenting part. This develops in a ring formation at the obstruction site leading to sloughing of the lower uterine segment and cervix.

Palpation of the uterus and observation of contractions provides important information. In the early stages of obstruction the uterus may contract vigorously and frequently, with little relaxation between contractions. This is followed by a continuous spasm when the uterus is hard, uniformly convex, and tender to pressure - particularly over the distended lower uterine segment. The patient is usually not in constant pain but feels continuous discomfort.

In obstructed labor, asphyxia is likely to have caused intra-uterine fetal death by the time the patient presents for treatment. The asphyxia results from interference with placental exchange of gas between fetus and mother through the mechanism of strong repetitive uterine contractions over a long period of time or the development of a contracted uterus.

Ruptured Uterus

The clinical findings may vary from mild and non-specific to an obvious clinical crisis and abdominal catastrophe. The following signs and symptoms of impending, or early, uterine rupture are not consistent but can aid early detection:

- Persistent lower uterine segment pain and tenderness between contractions
- Swelling and crepitus of lower uterine segment
- Vaginal bleeding
- Maternal tachycardia, hypotension and syncope
- Haematuria
- Fetal heart rate abnormalities: tachycardia, variable and late deceleration. This is the most reliable
warning sign.

The classic signs and symptoms of complete uterine rupture are:

- Sudden onset of tearing abdominal pain
- Cessation of uterine contractions
- Vaginal bleeding
- Recession of the presenting part
- Absent fetal heart
- Signs of intra-abdominal hemorrhage associated with hypovolaemic shock.

The lower uterine segment may rupture with few dramatic signs and symptoms. The thin avascular scar of a previous lower uterine segment cesarean section may rupture with little bleeding and labor continue uneventfully- rupture of the uterus becoming apparent in the post partum period.


State of the Bladder

During labour, the bladder is normally displaced out of the pelvis and becomes palpable above the symphysis pubis. Compression between the back of the symphysis and the presenting part may prevent the patient from emptying her bladder and make catheterisation impossible. The bladder forms a tender swelling above the symphysis. This overlies the stretched lower uterine segment, and the transverse depression at the junction of the superior border of the bladder and the lower segment of the uterus may be confused with a pathological retraction ring.

Prolonged compression traumatizes the bladder, so blood stained urine is a fairly constant feature of obstructed labor but does not necessarily mean the uterus has ruptured.

Vaginal Findings

Obstructed labor often produces oedema of the lower vagina and vulva. Associated sepsis often leads to a thick offensive vaginal discharge. Bleeding is of significant concern, as it usually indicates the uterus has ruptured.

Cervical Findings

In cephalic presentations full cervical dilation will usually occur as the moulded fetal head is driven down through the cervix. With shoulder or compound presentations, a rim of cervix usually persists because the presenting part is arrested at a higher level.

By the time obstruction has occurred, the caput succedaneum makes identification of the presentation and position very difficult. In vertex presentations, a large caput on the apex of an extremely molded head may reach the outlet when the greatest diameter is still above the brim. Therefore, more reliance should be placed on the abdominal findings when deciding the level or station of the head.

Complications of Obstructed Labor

Maternal
- Ruptured Uterus
- Vesico-Vaginal Fistulae (VVF)
- Recto-Vaginal Fistulae (RVF)
- Pueperal sepsis


• Extensive sloughing heals by fibrosis leading to almost complete stenosis of the vagina and dyspareunia/ apareunia
• Osteitis pubis - infection of pubic bone after damage to the periosteum and superficial cortex by pressure necrosis

Fetal
- Asphyxia / cerebral palsy
- Neonatal sepsis
- Death

Treatment

• Prevention - In most cases, obstructed labor can be prevented by:

- Good nutrition in childhood
- Promotion of appropriate and accessible antenatal care with health care providers trained in history and
physical examination skills
- Use of a partogram in the health unit when the patient is in labor
- The development of appropriate and timely referral systems.

•The standard procedure for obstructed labor is cesarean section when the diagnosis has been made.

•Prolonged or neglected obstructed labor (uterus intact)

1. If the fetus is still alive - The patient should be prepared for delivery with simultaneously attention to the sequelae of prolonged labor.

- Fluid electolyte imbalance
- Control of infections with broad spectrum antibiotics and tetanus prophylaxis

Method of delivery:
- Vacuum in cases of mild disproportion
- Forceps: which will require special skills for mid cavity operations
- Symphysiotomy (see Appendix 2)

2. With a dead fetus - If the fetus is dead, destructive operations may be considered, particularly if the mother’s condition is morbid. Resuscitation of the mother is essential before proceeding with a destructive procedure. This resuscitation should include:

- Correction of fluid and electrolyte imbalance
- Control infection
- Be prepared to prevent/treat post partum hemorrhage

• Ruptured Uterus

1. Prompt management of hypovolaemia

2. Laparotomy:
- Remove fetus and placenta

3. Secure hemostasis :
- Deliver the uterus out of the abdominal incision. Assistant’s hands may hold the uterus and with fingers and thumbs occlude the uterine vessels.
- Control the bleeding edges of the uterine laceration with ring forceps.
- Manual compression of the aorta will often enable the surgeon to identify the extent of the lacerations in the uterus.
- Uterine artery ligation should be considered to reduce blood loss before proceeding to definitive surgery.
- Internal iliac artery ligation may be necessary to control bleeding in the base of the broad ligament.

Before carrying out any surgical procedures on major vessels, identification of the course of the uretery should be undertaken in order to avoid ureteric injury. The integrity of the bladder should always be carefully reviewed, as the bladder wall may frequently be involved in a lower uterine segment rupture.

Surgical Options:

The choice of operative procedure is dependant on a number of factors including the patient’s condition, type of rupture, facilities available, and experience of the surgeon. 5
- Total hysterectomy
- Subtotal hysterectomy
- -Laceration repair and tubal ligation
- Laceration repair alone

Destructive Procedures

- Craniotomy
- Decapitation
- Evisceration
- Cleidotomy

In a series reported by Raksha Anura on 33 patients who underwent destructive operations, craniotomy was the most common destructive procedure and the main indication was hydrocephalus.5

The performance of destructive fetal operation will depend on local facilities and experience.

Before performing any destructive procedure, it is important to ensure the bladder is empty. The aim of the treatment is to deliver the mother by the safest possible method. The operative vaginal delivery and destructive procedures must be performed in an operating theatre where a set of laporatomy instruments are available for immediate use.


References:
1. Kwast B et al., World Health Organization partograph in management of labour. Lancet, 1994, 343:1399-1404.
2. WHO. “Preventing Prolonged Labour: A Practical Guide.” The Partograph. Geneva: Maternal Health and Safe Motherhood Programme, Division of Family Health, 1994.
3. SOGC “DYSTOCIA”. SOGC Policy Statement No. 40, October 1995
4. Keirse MJNC, Chalmers I. In: Chalmers, Enkin, Keirse (Eds). Effective Care in Pregnancy and Childbirth. Oxford University Press, Oxford, England, 1989.
5. Friedman EA. Labour: Clinical evaluation and management. Second edition (New York). Appleton Century Crofs. 1976. Studd JWW (Ed). The Management of Labour. Oxford: Blackwell Scientific Publications, 1985.
6. O’Driscoll K, Foley M, MacDonald D. Active management of labor as an alternative to caesarean section for dystocia. Obstet Gynecol 1984; 63: 485-90
7. Akoury HA, BrodieG, Caddick R, McLaughlin VD, Pugh PA. Active Management of Labor and Operative Delivery in Nulliparous Women. AM J Obstet Gynecol 1988;255

Guidelines on Labor Induction Revised

July 24, 2009 — On July 21, the American College of Obstetricians and Gynecologists (ACOG) issued revised guidelines on when and how to induce labor in pregnant women. The updated recommendations are published as a Practice Bulletin, "Induction of Labor," in the August issue of Obstetrics & Gynecology. The bulletin aims to guide physicians regarding their choice of induction methods that may be most suitable in specific settings and to elucidate the safety requirements, risks, and benefits of various regimens to induce labor.

Benefits vs Risks of Labor Induction

For the last 2 decades, the rate of labor induction in the United States has more than doubled, with more than 22% of all pregnant women in 2006 having labor induced. This increase in use necessitates a careful review of indications, risks, and benefits.

The goal of labor induction is to stimulate uterine contractions before the spontaneous onset of labor, resulting in vaginal delivery. The benefits of labor induction must be weighed against the potential maternal and fetal risks associated with this procedure. When the benefits of expeditious delivery are greater than the risks of continuing the pregnancy, inducing labor can be justified as a therapeutic intervention.

"There are certain health conditions, in either the woman or the fetus, where the benefit of inducing labor is clear-cut," coauthor Susan Ramin, MD, from the University of Texas Medical School in Houston, said in a news release. "And, there are some nonmedical situations in which induction also may be prudent, for instance, in rural areas where the distance to the hospital is just too great to risk waiting for spontaneous labor to happen at home."

Recommendations Based on Sound Evidence

Based on evidence from methodologically sound outcomes-based research, the bulletin attempts to review current methods for cervical ripening and for inducing labor and to summarize the efficacy of these approaches. Also highlighted are indications for and contraindications to inducting labor, pharmacologic characteristics of various agents used for cervical ripening, regimens used for labor induction, and the requirements for safe clinical use of these techniques.

The bulletin authors searched the MEDLINE database, the Cochrane Library, and ACOG's own internal resources and documents to identify pertinent English-language articles published between January 1985 and January 2009. Although articles reporting results of original research were given priority, review articles and commentaries were also consulted, as were guidelines published by organizations or institutions such as ACOG and the National Institutes of Health. However, abstracts of research presented at symposia and scientific conferences were excluded. Expert opinions from obstetrician-gynecologists were used when reliable research evidence was not available.

Indications for Labor Induction

Possible indications for labor induction may include gestational or chronic hypertension, preeclampsia, eclampsia, diabetes, premature rupture of membranes, severe fetal growth restriction, and postterm pregnancy. However, physicians should decide whether labor induction is warranted on a case-by-case basis, after consideration of maternal and infant conditions, cervical status, gestational age, and other factors.

Contraindications to labor induction include transverse fetal position, umbilical cord prolapse, active genital herpes infection, placenta previa, and a history of previous myomectomy.

When labor induction is deemed necessary, the gestational age of the fetus should be determined to be at least 39 weeks, or there must be evidence of fetal lung maturity.

The first step in labor induction is cervical ripening using drugs or mechanical cervical dilators to dilate the cervix sufficiently before labor is induced. The next step is to induce labor using oxytocin, membrane stripping, rupture of the amniotic membrane, or nipple stimulation.

Misoprostol, which is approved for treatment of peptic ulcers, is often used off-label for cervical ripening as well as for labor induction. In women who have had any previous cesarean delivery, however, inducing labor with misoprostol may increase risk for uterine rupture and should therefore be avoided.

Clinical Recommendations

Specific clinical recommendations and conclusions, all based on good and consistent scientific evidence (level A), are as follows:

* For cervical ripening and labor induction, prostaglandin E (PGE) analogues are effective.
* When labor induction is indicated, low-dose or high-dose oxytocin regimens are appropriate.
* Regardless of Bishop score, the most efficient method of labor induction before 28 weeks of gestation appears to be vaginal misoprostol. However, infusion of high-dose oxytocin is also an acceptable option.
* For cervical ripening and induction of labor, an appropriate initial dose of misoprostol is approximately 25 µg, with frequency of administration not to exceed 1 dose every 3 to 6 hours.
* For induction of labor in women with premature rupture of membranes, intravaginal PGE2 appears to be safe and effective.
* In women with previous cesarean delivery or major uterine surgery, the use of misoprostol should be avoided in the third trimester because it has been linked to a greater risk for uterine rupture.
* The Foley catheter is a reasonable, effective option to promote cervical ripening and labor induction.

An additional clinical recommendation, based on limited or inconsistent evidence (level B), is that misoprostol, 50 µg every 6 hours, to induce labor may be appropriate in some situations. However, higher doses are linked to a greater risk for uterine tachysystole with fetal heart rate (FHR) decelerations and other complications.

"A physician capable of performing a cesarean should be readily available any time induction is used in the event that the induction isn't successful in producing a vaginal delivery," Dr. Ramin concluded. "These guidelines will help physicians utilize the most appropriate method depending on the unique characteristics of the pregnant woman and her fetus."

Obstet Gynecol. 2009;114:386-397.
Clinical Context

Labor induction occurs in more than 22% of pregnant women in the United States and has doubled in rate between 1990 and 2006, according to Martin and colleagues in the January 7, 2009, issue of National Vital Statistics Reports. Cervical ripening methods include mechanical dilation, synthetic PGE1, and PGE2. Mechanical dilation methods are hygroscopic dilators, osmotic dilators, Foley catheters, double-balloon devices, and extra-amniotic saline infusion. The PGE1 analogue, misoprostol, can be used for cervical ripening and labor induction. PGE2 is available as dinoprostone gel or as a vaginal insert. Methods of labor induction include oxytocin, membrane stripping, amniotomy, and nipple stimulation.

This guideline from the ACOG describes the indications for and contraindications to labor induction, methods for cervical ripening, methods for labor induction, and recommendations for use of these methods.



Study Highlights

* Indications for labor induction include abruptio placentae, chorioamnionitis, fetal demise, gestational hypertension, preeclampsia, eclampsia, premature rupture of membranes, postterm pregnancy, maternal medical conditions, and fetal compromise.
* Labor might be induced for logistic reasons if term gestation is confirmed.
* Contraindications to labor induction include vasa previa or complete placenta previa, transverse fetal lie, umbilical cord prolapsed, previous classic cesarean delivery, active genital herpes infection, and previous myomectomy entering the endometrial cavity.
* Criteria for cervical ripening or labor induction are assessment of gestational age and risk to mother or fetus; assessment of cervix, pelvis, fetal size, and presentation; FHR and uterine contraction monitoring; patient counseling; and capability for cesarean delivery.
* PGE analogues are effective methods for cervical ripening and inducing labor.
* An effective alternative for cervical ripening and inducing labor is a Foley catheter, which reduces the duration of labor and risk for cesarean delivery.
* Misoprostol initial dose is 25 µg every 3 to 6 hours intravaginally.
* Misoprostol doses of 50 µg every 6 hours might be indicated but are linked with the risk for uterine tachysystole with FHR decelerations.
* Buccal and sublingual misoprostol for cervical ripening or labor induction are not recommended because of lack of safety data.
* Misoprostol should be avoided in the third trimester in women with prior cesarean delivery or major uterine surgery because of an increased risk for uterine rupture.
* Dinoprostone can be administered intracervically or intravaginally.
* Uterine tachysystole with or without FHR changes occur more commonly with vaginal misoprostol vs vaginal or intracervical PGE2 and oxytocin.
* The management of uterine tachysystole and category III FHR tracing includes maternal repositioning, supplemental oxygen, subcutaneous terbutaline, and decrease or discontinuation of oxytocin.
* Cesarean delivery might be necessary for persistent tachysystole or FHR abnormalities.
* After PGE use, surveillance should include initial continuous FHR and uterine activity monitoring and recumbent position for the pregnant patient.
* Limited data show that outpatient use of intravaginal PGE2 gel for 5 days, controlled-release PGE2, and a Foley catheter appear to be effective and safe.
* Oxytocin for labor induction can be given as low dose (initial 0.5 - 2 mU/minute with incremental increases of 1 - 2 mU/minute) or high dose (initial 6 mU/minute with increases of 3 - 6 mU/minute).
* The maximal oxytocin dose is unknown.
* The main adverse effects of oxytocin are dose-related uterine tachysystole and category II or category III FHR tracings.
* The risks for amniotomy are umbilical cord prolapse, chorioamnionitis, umbilical cord compression, vasa previa rupture, and the risk for vertical transmission of HIV.
* Amniotic membrane stripping risks include bleeding from placenta previa or low-lying placenta and amniotomy.
* Breast stimulation is linked with uterine tachysystole with FHR decelerations and increased trend in perinatal death.
* In women with premature rupture of membranes at term, labor can be induced with oxytocin or PGE, but there are insufficient data on mechanical dilator use.
* Management of intrauterine fetal demise depends on gestational age, uterine scar, and maternal preference.
* For intrauterine fetal demise in the second trimester, dilation and evacuation is an option.
* For intrauterine demise before 28 weeks' gestational age, misoprostol is the most efficient method; high-dose oxytocin is also an option.

Clinical Implications

* In pregnant women who require cervical ripening and labor induction, PGE analogues are effective, and the Foley catheter is an effective alternative. Labor can be induced with low-dose or high-dose oxytoxin regimens.
* For intrauterine fetal demise before 28 weeks of gestation, the most efficient method of labor induction is vaginal misoprostol. Misoprostol use should be avoided in the third trimester in women with previous cesarean delivery or major uterine surgery because of a link with an increased risk for uterine rupture.

No Benefit in Lowering BP Below "Standard" 140/90 mm Hg

July 23, 2009 — A new review has found that lowering blood pressure below the "standard" target of 140/90 mm Hg is not beneficial in terms of reducing mortality or morbidity [1]. Dr Jose Agustin Arguedas (Universidad de Costa Rica, San Pedro de Montes de Oca) and colleagues report their findings online July 8, 2009 in the Cochrane Database of Systematic Reviews.

They explain that over the past five years, a trend toward lower targets has been recommended by hypertension experts who set treatment guidelines, "based on the assumption that the use of drugs to bring the BP lower than 140/90 mm Hg will reduce heart attack and stroke." But this approach "is not proven," they point out.

Arguedas told heartwire that they reviewed seven trials with more than 22 000 subjects comparing lower or standard diastolic BP targets, but they were unable to identify any studies comparing different systolic BP targets. "We found there is no evidence that reaching a target of below 90 mm Hg diastolic BP will provide additional clinical benefit, but we can't say whether lowering systolic BP below 140 mm Hg will be beneficial or not; there are no data."

Dr Franz Messerli (St Luke Roosevelt Hospital, New York, NY), who was not involved with this review, told heartwire that there is no question that the 140/90-mm-Hg BP limit is "absolutely arbitrary, and the benefits of antihypertensive medications are most obvious in patients with the highest BP. The closer we get to 'normotension,' the more difficult it becomes to show benefits of BP lowering.

"The Lewington meta-analysis of one million patients has convincingly shown that people fare better—ie, have fewer strokes and heart attacks—when their 'usual' BP is 115/70 mm Hg compared with those with a 'usual' BP of 130/80," Messerli adds. "However there are no data and probably never will be that lowering BP from 130/80 mm Hg to 115/70 mm Hg confers any benefits," he says.

Further Review Required in at-Risk Patients

Attempting to achieve lower BP targets has several consequences, the researchers note; "the most obvious is the need for large doses and increased number of antihypertensive drugs. This has inconvenience and economic costs to patients. More drugs and higher doses will also increase adverse drug effects, which if serious could negate any potential benefit associated with lower BP." There is also the potential that lowering BP too much may cause adverse cardiovascular (CV) events, the so-called "J-curve" phenomenon, they observe.

In their review, they included: the Modification of Diet in Renal Disease (MDRD) trial; the Hypertension Optimal Treatment (HOT) study; the BP Control in Diabetes (ABCD) trials H and N; the African American Study of Kidney Disease and Hypertension (AASK), and the Renoprotection in Patients With Nondiabetic Chronic Renal Disease (REIN-2) study.

They found that, despite a 4/3-mm-Hg-greater achieved reduction in systolic/diastolic BP (p < 0.001), attempting to achieve "lower targets" instead of "standard targets" did not change: * Total mortality (relative risk 0.92). * Myocardial infarction (MI; RR 0.90). * Stroke (RR 0.99). * Congestive heart failure (RR 0.88). * Major cardiovascular events (RR 0.94). * End-stage renal disease (RR 1.01)."This strategy did not prolong survival or reduce stroke, heart attack, heart failure, or kidney failure," they note. "More trials are needed, but at present there is no evidence to support aiming for a blood-pressure target lower than 140/90 mm Hg in any hypertensive patient."The researchers say they were unable to fully assess the net health effect of lower targets due to lack of information regarding all total serious adverse events and withdrawals due to adverse effects in six of seven trials.
Trials Needed to Compare Lower With Standard Systolic Targets

Arguedas and his colleagues note that a lower BP target of 130/80 mm Hg is currently recommended for at-risk patients, and they did perform a sensitivity analysis in diabetic and kidney-disease patients, which did not show significant benefits for treating to targets of lower than 135/85 mm Hg. "However, in these two populations, the evidence for a lack of benefit is less robust," they note.

Arguedas told heartwire that properly conducted randomized controlled trials are needed comparing lower systolic BP targets with standard ones in the general population and also in specific subgroups of at-risk patients.

One such study is the ongoing Action to Control Cardiovascular Disease in Diabetes (ACCORD) blood-pressure trial—an unmasked, open-label, randomized trial with participants randomized to one of two groups with different treatment goals: systolic blood pressure < 120 mm Hg for the more intensive goal, and systolic blood pressure < 140 mm Hg for the less intensive goal [2].The primary outcome measure is the first occurrence of a major CVD event, specifically nonfatal MI or stroke, or cardiovascular death during a follow-up period ranging from four to eight years. The results should provide some of the first definitive clinical-trial data on the possible benefit of treating to a more aggressive systolic blood-pressure goal.In the meantime, says Arguedas, "We are doing another separate systematic review specifically in patients with diabetes and chronic kidney disease to see whether targets lower than 130/80 mm Hg change morbidity or mortality as compared with standard targets."References

1. Arguedas JA, Perez MI, Wright JM. Treatment blood pressure targets for hypertension. Cochrane Database Syst Rev 2009; 3:CD004349.
2. Cushman WC, Grimm RH Jr, Cutler JA, et al. Rationale and design for the blood pressure intervention of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial. Am J Cardiol 2007; 99(12A):44i-55i.

Clinical Context

There is a continuous adverse relationship between BP and CV events, but despite practice guidelines recommending control of BP with a threshold of 140/90 mm Hg, it is unclear if lower thresholds are associated with improved outcomes. In recent practice guidelines, lower thresholds have been recommended for patients with comorbidities such as diabetes or renal disease, but data for patients without these comorbidities are scarce.

This is a systematic review to examine if lower targeted BP is achieved in trials with lower vs higher targets and if lower targets are associated with improved clinical outcomes.