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Dysmenorrhea is one of the most usual causes of pelvic pain. It has
negative effects on woman’s quality of life and sometimes leads to daily
activity restriction. Primary dysmenorrhea is menstrual pain without pelvic
pathology. Abnormal bleeding, noncyclic pain, alteration in pain severity and
duration, and abnormal pelvic examination findings propose secondary
dysmenorrhea and need more assessment. Treatment options for primary
dysmenorrhea are consist of non-steroidal anti-inflammatory drugs and hormonal
contraceptives. Due to side effects related to such treatments, women seek
complementary and alternative medicines. The aim of this paper is to evaluate
the reasons for using chlorella to improve the side effects of primary
dysmenorrhea.
Keywords: Primary
dysmenorrhea, Chlorella, Systemic symptoms, Inflammation
INTRODUCTION
Cardiotocography (CTG) is used
worldwide to track fetal heart rate both before and during labor. A reactive,
or non-reactive tracing where the fetus shows accelerations after stimulation,
is considered normal and found in 95% of the cases. The remaining 5% need
individual interpretations [3]. Admission CTG was introduced by Ingemarsson in
1986 as a last assessment of fetal well-being prior to birthing [3]. Admission
CTG is a short fetal heart tracing (20 min) used routinely in Sweden and
Finland as an admission status of the fetal well-being when arriving to the
delivery unit. This is done to avoid unnecessary delay in action in cases with
pre-existing fetal distress [4].
The United Kingdom, Norway and
Denmark recommend only intermittent auscultation in low-risk-pregnancies as
they claim that the high number of non-reassuring admission CTGs (20-30%) lead
to unnecessary interventions and did not reduce delivery complications (usually
assessed 5-10 h later) [5-8]. Therefore, they do not recommend the use of
admission CTG.
Due
to the conflicting recommendations regarding the admission CTG, we decided to
do a retrospective validation study at Karolinska University Hospital, January
2011 to June 2015 (number of deliveries=40,061). All women who underwent
emergency caesarean section within one hour of admittance due to suspected
fetal distress were identified. An assessment was made regarding the existence
and interpretation of admission CTG, if the cesarean section was beneficial and
whether there were objective signs of fetal compromise. Objective signs
included pH<7.15, Apgar 5 min<7, neonatal intensive care, high scalp
lactate or obstetric catastrophe. Eighty-eight
pregnancies (0.2% out of 40,061) met the inclusion criteria and underwent
emergency cesarean section due to suspected fetal distress [9]. In 75% of both
low- and high-risk pregnancies was admission CTG deemed to have contributed in
the decision to perform emergency cesarean section. Over 90% of the 88 women
who underwent emergency cesarean section had objective signs that the
intervention was necessary. In 28% the CTG pathology was determined to be
difficult to identify by intermittent auscultation. 88 cases or 0.2% might seem
like a low number, but bear in mind that these women undergo emergency cesarean
delivery to avoid complications related to asphyxia such as hypoxic ischemic encephalopathy
(HIE) or stillbirth.
During the course
of this study it became evident that the definition of admission CTG differed
between prior publications and the routine clinical use. Prior studies have
performed CTG after anamnesis and examination to assess delivery outcome
(typically 5-10 h later), while in Sweden it is usually performed at arrival
before anamnesis and examination, aimed to identify pre-existing fetal
distress. Thus, it seems that prior studies were performed without knowledge
regarding how admission CTG is implemented. This explains the contradicting
results and conclusions drawn.
We believe it is
naïve to believe that a short CTG tracing at admission can predict fetal
outcome 5-10 h later and we agree with their conclusion that admission CTG is
not a method to predict fetal outcome. Thus, regarding this question we are all
in agreement – including Ingemarsson in 1986 – that admission CTG is not a
method that should be used to predict delivery outcome [4-8]. Thus, we believe
no further studies regarding prediction are needed.
However, we believe
that it is likely that recommendation against the use of admission CTG might
have caused several unnecessary asphyxic fetal complications [7-10]. Our study
identified an 18-fold increased risk of intrapartum stillbirth in the only unit
in Sweden not using routine admission CTG among a selected low-risk group as
compared to our standard care mixed risk population (0.9/1 000 vs. 0.05/1 000)
[1,11]. This unit was closed down after an assessment due too low safety and
high costs. The intention of admission CTG is to get an evaluation of the fetal
well-being at arrival, i.e., to identify those who are in need of emergent
delivery at admission without unnecessary delay and not a prediction method to identify
fetal distress 5-10 hours later.
We consider:
·
Admission CTG is effective in both low- and
high-risk cases in identifying the few 0.2% that need immediate action at
admission with a high risk of asphyxic sequel.
·
It identifies the 28% of pathological CTG
tracings not possible to auscultate.
·
Prior studies have misinterpreted the use of
admission CTG and had therefore resulted in misleading recommendations.
We recommend all
delivery units to use routine admission CTG.
1.
Lindqvist PG, Pettersson
K, Moren A, Kublickas M, Nordstrom L (2014) Routine ultrasound examination at
41 weeks of gestation and risk of post-term severe adverse fetal outcome: A
retrospective evaluation of two units, within the same hospital, with different
guidelines. BJOG 121: 1108-1115.
2.
Lindqvist PG, Molin J
(2005) Does antenatal identification of small-for-gestational age fetuses
significantly improve their outcome? Ultrasound Obstet Gynecol 25: 258-264.
3.
Ingemarsson I,
Ingemarsson E (2006) Fosterövervakning with CTG. Stockholm: Studentlitteratur
367.
4.
Ingemarsson I,
Arulkumaran S, Ingemarsson E, Tambyraja RL, Ratnam SS (1986) Admission test: A
screening test for fetal distress in labor. Obstet Gynecol 68: 800-806.
5.
Bix E, Reiner LM,
Klovning A, Oian P (2005) Prognostic value of the labour admission test and its
effectiveness compared with auscultation only: A systematic review. BJOG 112:
1595-604.
6.
Mires G, Williams F,
Howie P (2001) Randomised controlled trial of cardiotocography versus Doppler
auscultation of fetal heart at admission in labor in low risk obstetric
population. BMJ 322: 1457-1460.
7.
Devane D, Lalor JG, Daly
S, McGuire W, Cuthbert A, et al. (2017) Cardiotocography versus intermittent
auscultation of fetal heart on admission to labor ward for assessment of fetal
wellbeing. Cochrane Database Syst Rev CD005122.
8.
Impey L, Reynolds M,
MacQuillan K, Gates S, Murphy J, et al. (2003) Admission cardiotocography: A
randomised controlled trial. Lancet 361: 465-470.
9.
Parts L, Holzmann M,
Norman M, Lindqvist PG (2018) Admission cardiotocography: A hospital based
validation study. Eur J Obstet Gynecol Reprod Biol 229: 26-31.
10.
Delgado Nunes V,
Gholitabar M, Sims JM, Bewley S, Guideline Development G (2014) Intrapartum
care of healthy women and their babies: Summary of updated NICE guidance. BMJ
349: g6886.
11.
Gottvall K, Grunewald C,
Waldenstrom U (2004) Safety of birth centre care: Perinatal mortality over a 10
year period. BJOG 111: 71-78.
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