Uterine artery embolization for symptomatic uterine fibroids

BACKGROUND

Uterine fibroids cause heavy prolonged bleeding, pain, pressure symptoms and subfertility. The traditional method of treatment has been surgery as medical therapies have not proven effective. Uterine artery embolization (UAE) has been reported to be an effective and safe alternative to treat fibroids in women not desiring future fertility. There is a significant body of evidence based on case controlled studies and case reports. This is an update of the review previously published in 2006.

OBJECTIVES

To review the benefits and risks of uterine artery embolization (UAE) versus other medical or surgical interventions for symptomatic uterine fibroids.

SEARCH METHODS

We searched the Cochrane Menstrual Disorders & Subfertility Group Trials register (searched November 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, 4th Quarter 2011), MEDLINE (1950 to November 2011) and EMBASE (January 1980 to November 2011). We also contacted authors of eligible RCTs for unpublished data.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of UAE versus any medical or surgical therapy for symptomatic uterine fibroids.

DATA COLLECTION AND ANALYSIS

Two of the authors (AS and JKG) assessed the trials and extracted the data independently.

MAIN RESULTS

Five RCTs were included in this review. Three trials compared UAE with abdominal hysterectomy in 291 women. A fourth trial included 157 women and compared UAE with surgery (43 hysterectomies and 8 myomectomies). The fifth trial included 121 women and compared UAE with myomectomy in women wishing to preserve fertility.There was moderately good evidence that there is no significant difference between UAE and surgery in patient satisfaction rates at two years (OR 0.69, 0.40 to 1.21, 516 women, 5 trials) nor at five years (OR 0.90, 95% CI 0.45 to 1.80, 295 women, 2 trials). There was very low level evidence suggesting that myomectomy may be associated with better fertility outcomes than UAE, but this analysis was restricted to the limited cohort of women (n=66) who tried to conceive in the single study of UAE versus myomectomy (live birth: OR 0.33, 95% CI 0.11 to 1.00; pregnancy: OR 0.29, 95% CI 0.10 to 0.85). There was no significant difference between the two interventions in the rate of major complications. Compared to surgery, UAE significantly reduced the length of the procedure, length of hospital stay and time to resumption of routine activities and also decreased the likelihood of needing a blood transfusion. However, UAE was associated with higher rates of minor short term and long term complications, more unscheduled readmissions after discharge and an increased surgical reintervention rate. This increase in the surgical reintervention rate may balance out the initial cost advantage of UAE (reinterventions within 2 years: OR 5.64, 95% CI 2.92 to 10.90, 486 women, 4 trials; within 5 years: OR 5.79, 95% CI 2.65 to 12.65. 289 women, 2 trials). There was no significant difference in ovarian failure rates at long term follow-up.

AUTHORS' CONCLUSIONS

UAE appears to have an overall patient satisfaction rate similar to hysterectomy and myomectomy and offers an advantage with regards to a shorter hospital stay and a quicker return to routine activities. However, UAE is associated with a higher rate of minor complications and an increased likelihood of requiring surgical intervention within two to five years of the initial procedure. There is very low level evidence suggesting that myomectomy may be associated with better fertility outcomes than UAE, but more research is needed.

Position in the second stage of labour for women without epidural anaesthesia

BACKGROUND

For centuries, there has been controversy around whether being upright (sitting, birthing stools, chairs, squatting, kneeling) or lying down have advantages for women delivering their babies.

OBJECTIVES

To assess the benefits and risks of the use of different positions during the second stage of labour (i.e. from full dilatation of the uterine cervix).

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group Trials Register (28 February 2012).

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials of any upright or lateral position assumed by pregnant women during the second stage of labour compared with supine or lithotomy positions. Secondary comparisons include comparison of different upright positions and the lateral position.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and assessed trial quality. At least two review authors extracted the data. Data were checked for accuracy.

MAIN RESULTS

Results should be interpreted with caution as the methodological quality of the 22 included trials (7280 women) was variable.In all women studied (primigravid and multigravid) there was a non-significant reduction in duration of second stage in the upright group (mean difference (MD) -3.71 minutes; 95% confidence interval (CI) -8.78 to 1.37 minutes; 10 trials, 3485 women; random-effects, I(2) = 94%), a significant reduction in assisted deliveries (risk ratio (RR) 0.78; 95% CI 0.68 to 0.90; 19 trials, 6024 women, I(2)= 27%), a reduction in episiotomies (average RR 0.79, 95% CI 0.70 to 0.90, 12 trials, 4541 women; random-effects, I(2) = 7%), an increase in second degree perineal tears (RR 1.35; 95% CI 1.20 to 1.51, 14 trials, 5367 women), increased estimated blood loss greater than 500 ml (RR 1.65; 95% CI 1.32 to 2.60; 13 trials, 5158 women, asymmetric funnel plot indicating publication bias), fewer abnormal fetal heart rate patterns (RR 0.46; 95% CI 0.22 to 0.93; two trials, 617 women). In primigravid women the use of any upright compared with supine positions was associated with: non-significant reduction in duration of second stage of labour (nine trials: mean 3.24 minutes, 95% CI 1.53 to 4.95 minutes) - this reduction was largely due to women allocated to the use of the birth cushion.

AUTHORS' CONCLUSIONS

The findings of this review suggest several possible benefits for upright posture in women without epidural, but with the possibility of increased risk of blood loss greater than 500 mL. Until such time as the benefits and risks of various delivery positions are estimated with greater certainty, when methodologically stringent data from trials are available, women should be allowed to make choices about the birth positions in which they might wish to assume for birth of their babies.

In vitro and in vivo antitumor activity of a methanol extract of Dregea volubilis leaves with its antioxidant effect

CONTEXT

In India, Dregea volubilis (L.f.) Benth. ex Hook.f. (Asclepediaceae), a large twining shrub with a woody vine, is used to treat tumors traditionally.

OBJECTIVE

This study evaluated the in vitro and in vivo antitumor activity of the methanol extract of Dregea volubilis leaves (MEDV) and elucidated its possible mechanism of action.

MATERIALS AND METHODS

In vitro antitumor activity of MEDV was evaluated against Ehrlich ascites carcinoma (EAC) cell-line. In vivo antitumor and antioxidant activity of MEDV at three dose levels (50, 100, and 200 mg/kg) were determined against EAC tumor-bearing mice. After 24 h of EAC inoculation, the extract was administered for 9 consecutive days. After the administration of the last dose on the 9th day followed by 18 h fasting, mice from all groups were sacrificed to determine antitumor activity and hematological profiles along with liver related biochemical parameters like lipid peroxidation, antioxidant enzymatic activity, etc.

RESULTS

For in vitro antitumor activity, IC(50) value of MEDV for EAC tumor cells was 85.51 ± 4.07 µg/ml. The MEDV showed a decrease in tumor volume, packed cell volume and viable cell count and an increase in the non-viable cell count of the EAC tumor-bearing mice (p < 0.001). Hematological profile reverted near to normal level in extract treated mice. MEDV decreased the hepatic lipid peroxidation level and enhanced superoxide dismutase and catalase level in tumor-bearing mice (p < 0.001).

DISCUSSION AND CONCLUSION

MEDV exhibited in vitro and in vivo antitumor activity in EAC tumor-bearing mice mediated through augmenting antioxidant defense system.

Inhalation of expiratory droplets in aircraft cabins

Airliner cabins have high occupant density and long exposure time, so the risk of airborne infection transmission could be high if one or more passengers are infected with an airborne infectious disease. The droplets exhaled by an infected passenger may contain infectious agents. This study developed a method to predict the amount of expiratory droplets inhaled by the passengers in an airliner cabin for any flight duration. The spatial and temporal distribution of expiratory droplets for the first 3 min after the exhalation from the index passenger was obtained using the computational fluid dynamics simulations. The perfectly mixed model was used for beyond 3 min after the exhalation. For multiple exhalations, the droplet concentration in a zone can be obtained by adding the droplet concentrations for all the exhalations until the current time with a time shift via the superposition method. These methods were used to determine the amount of droplets inhaled by the susceptible passengers over a 4-h flight under three common scenarios. The method, if coupled with information on the viability and the amount of infectious agent in the droplet, can aid in evaluating the infection risk.

PRACTICAL IMPLICATIONS

The distribution of the infectious agents contained in the expiratory droplets of an infected occupant in an indoor environment is transient and non-uniform. The risk of infection can thus vary with time and space. The investigations developed methods to predict the spatial and temporal distribution of expiratory droplets, and the inhalation of these droplets in an aircraft cabin. The methods can be used in other indoor environments to assess the relative risk of infection in different zones, and suitable measures to control the spread of infection can be adopted. Appropriate treatment can be implemented for the zone identified as high-risk zones.

Antidiabetic Activity of the Ethanol Extract of Capparis sepiaria L Leaves

Capparis sepiaria L, a profusely branched hedge plant, is used in Indian traditional medicine. Capparis sepiaria leaves were extracted with ethanol and concentrated to dryness. The LD₅₀ value was determined as 894.43 mg/kg body weight by acute toxicity study. The ethanol extract was investigated for possible hypoglycemic effect produced by single oral administration at various dose levels 100, 200 and 300 mg/kg in the streptozotocin induced diabetic rats and compared against normal saline control and the standard glibenclamide. A maximum fall of plasma glucose level 9.40%; 13.57%; 15.25% and 18.80% was observed after 12 h of treatment when administered with ethanol extract of Capparis sepiaria at 100, 200 and 300 mg/kg, and glibenclamide 10 mg/kg dose, respectively. The findings from the study suggest that the Capparis sepiaria leaves may be prescribed as an adjunct to traditional formulation and drug treatment for controlling diabetes mellitus.

Oral progestogens vs levonorgestrel-releasing intrauterine system for endometrial hyperplasia: a systematic review and metaanalysis

OBJECTIVE

To conduct a systematic review and metaanalysis of studies evaluating the regression rate of endometrial hyperplasia with oral progestogens and levonorgestrel-releasing intrauterine system.

STUDY DESIGN

Searches were conducted on Medline, Embase, Cochrane Library, and Web of Science, and reference lists of relevant articles were examined. The methodologic index for nonrandomized studies was used for quality assessment. Metaanalysis was performed with random effects model.

RESULTS

There were 24 observational studies (1001 women), of low methodologic quality, evaluating the outcome of regression of endometrial hyperplasia with oral progestogens or levonorgestrel-releasing intrauterine system. Metaanalysis showed that oral progestogens achieved a lower pooled regression rate compared with levonorgestrel-releasing intrauterine system for complex (pooled rate, 66% vs 92%; P < .01) and atypical hyperplasia (pooled rate, 69% vs 90%; P = .03). There was no statistical difference in simple hyperplasia (pooled rate, 89% vs 96%; P = .41).

CONCLUSION

Oral progestogens appear to induce a lower disease regression rate than Levonorgestrel-releasing intrauterine system in the treatment of endometrial hyperplasia.

Outpatient Thermachoice endometrial balloon ablation: long-term, prognostic and quality-of-life measures

STUDY OBJECTIVE

To evaluate short- and long-term treatment outcomes of outpatient local anaesthetic thermal balloon endometrial ablation (LA-TBEA) and identify any prognostic factors.

STUDY DESIGN

Prospective observational study in a UK teaching hospital involving 102 menorrhagic women undergoing LA-TBEA between 2001 and 2005. Women underwent either Gynecare® Thermachoice I (n = 51) or Thermachoice III (n = 51) TBEA performed in the outpatient setting under local anaesthesia without conscious sedation. The main outcome measures were: treatment completion, pain and analgesia, duration of stay (from admission to discharge), duration of follow-up, primary treatment success and nature of any secondary treatment, menstrual symptoms and amenorrhoea, patient satisfaction, and quality of life.

RESULTS

TBEA was completed in 97% of women. Mean duration of stay was 8.0 h (95% CI 6.6-9.3). Mean follow-up was 30 months (95% CI 26-32). Secondary treatment with the levonorgestrel intrauterine system, repeat TBEA or hysterectomy occurred in 19/102 (19%). Overall, 50% of surgical re-interventions occurred by 19 months. There were high rates of amenorrhoea (29%) and treatment satisfaction (76%). Higher mean intrauterine ablation pressure was associated with increased treatment satisfaction.

CONCLUSION

TBEA can be successfully performed in the outpatient setting. Higher endometrial ablation pressure may improve long-term treatment outcome.

Flow dynamics and characterization of a cough

Airborne disease transmission has always been a topic of wide interests in various fields for decades. Cough is found to be one of the prime sources of airborne diseases as it has high velocity and large quantity of droplets. To understand and characterize the flow dynamics of a cough can help to control the airborne disease transmission. This study has measured flow dynamics of coughs with human subjects. The flow rate variation of a cough with time can be represented as a combination of gamma-probability-distribution functions. The variables needed to define the gamma-probability-distribution functions can be represented by some medical parameters. A robust multiple linear regression analysis indicated that these medical parameters can be obtained from the physiological details of a person. However, the jet direction and mouth opening area during a cough seemed not related to the physiological parameters of the human subjects. Combining the flow characteristics reported in this study with appropriate virus and droplet distribution information, the infectious source strength by coughing can be evaluated.

PRACTICAL IMPLICATIONS

There is a clear need for the scientific community to accurately predict and control the transmission of airborne diseases. Transportation of airborne viruses is often predicted using Computational Fluid Dynamics (CFD) simulations. CFD simulations are inexpensive but need accurate source boundary conditions for the precise prediction of disease transmission. Cough is found to be the prime source for generating infectious viruses. The present study was designed to develop an accurate source model to define thermo-fluid boundary conditions for a cough. The model can aid in accurately predicting the disease transmission in various indoor environments, such as aircraft cabins, office spaces and hospitals.

Evidence for preventing infection in abortion care

There is controversy of whether prophylaxis treatment or a ''screen and treat'' policy should be adopted for preventing infective complications when women undergo abortion. There is currently compelling evidence that indicates that a universal policy of prophylaxis treatment to all women undergoing abortion should receive antibiotics. It is also a cost-effective policy.

Quality of life instruments in studies of chronic pelvic pain: a systematic review

The use of quality of life (QoL) instruments in chronic pelvic pain (CPP) will allow a more objective assessment of patient-centred clinical outcomes. However, there is concern that not enough emphasis is placed on clinical face validity (i.e. issues which are of importance to patients and reflect their experiences and concerns). To explore this issue, we performed a systematic review of published research. Relevant papers were identified through electronic scanning of six electronic databases and by manual searching of bibliographies of known primary and review articles. Studies were selected if they assessed women with CPP for life quality, either developing QoL instruments or applying them as an outcome measure. Selected studies were assessed for the quality of their QoL instruments using a 17-item checklist, including 10 items for clinical face validity and seven items for measurement (psychometric) properties. A total of 19 articles were eligible for inclusion in the review. The generic Short Form 36 Health Survey Questionnaire (SF-36) was used most frequently, being employed in 10/19 (53%) of the studies. Three studies developed disease-specific QoL instruments for CPP complying with 59 - 77% of the quality criteria. Overall, quality assessment showed that only 4/18 (22.2%) studies complied with more than half the criteria for face validity, whereas 12/18 (66.6%) studies complied with more than half of the criteria for measurement properties (P = 0.0001). Among existing QoL instruments, compliance with the quality criteria for measurement properties is higher than for clinical face validity. There is a need to develop disease specific QoL instruments for CPP with face validity in addition to sound measurement properties.

Variation in practice of laparoscopic uterosacral nerve ablation: a European survey

To examine the variation in current indications and surgical techniques for performing laparoscopic uterosacral nerve ablation (LUNA) in Europe, all consultants on the databases of the UK Royal College of Obstetricians and Gynaecologists (1569) and the European Society of Gynaecological Endoscopy (301) were surveyed. The questionnaire was returned by 719 (38% of 1870) of the gynaecologists contacted and 173 (24%) performed LUNA. Indications for LUNA, which included chronic pelvic pain (68%), dysmenorrhoea (66%), dyspareunia (39%) and endometriosis (60%), were similar across the United Kingdom and the rest of Europe. The European group were more likely to perform LUNA (62% versus 21%), completely transect the uterosacral ligaments (56% versus 36%) and at a distance of more than 2 cm from its cervical insertion (50% versus 21%) than the UK group. There is variation in the surgical techniques of performing LUNA in Europe and the techniques vary according to operator experience.

Hysteroscopic myomectomy for menorrhagia using Versascope bipolar system: efficacy and prognostic factors at a minimum of one year follow up

OBJECTIVE

To evaluate the effectiveness of hysteroscopic submucous myomectomy for women with heavy menstrual bleeding (HMB) over a minimum 1-year period and assess prognostic factors associated with treatment success.

STUDY DESIGN

Prospective observational study set in a university teaching hospital in UK involving 92 women symptomatic of HMB with submucous myomas consecutively recruited between June 2003 and November 2006. Hysteroscopic myomectomy was performed under outpatient local anaesthetic (n=35, 38%) or daycase general anaesthesia (n=57, 62%) using Gynecare Versascope bipolar system. The main outcome measures were: the need for secondary surgical or medical re-intervention, menstrual improvement and patient satisfaction. Other outcome measures include: successful completion of primary resection, type of secondary treatment.

RESULT

Mean follow up was 2.6 years (95% CI 2.3-2.9). Complete fibroid excision was achieved in 66%. Secondary surgical re-intervention was required in 27 (29%) of which 11 (12%) were repeat hysteroscopic myomectomy and 10 (11%) were hysterectomy procedures. Multiple uterine fibroids and adenomyosis were identified in 80% of hysterectomies. At follow up, improved menstrual symptoms and patient satisfaction were reported by 91% and 86%, respectively. Irregular cycle HMB and incomplete fibroid excision were associated with secondary retreatment. Size of the submucous fibroid resected, presence of intramural and subserosal fibroids, or LA vs. GA setting were unrelated to treatment success.

CONCLUSION

HMB with submucous myomas may be successfully treated by completely removing the intracavity myoma component, irrespective of co-existent intramural or subserosal fibroids or size of fibroid resected. This effect remains sustained over at least a 1-2 year period.

Methods of prediction and prevention of pre-eclampsia: systematic reviews of accuracy and effectiveness literature with economic modelling

OBJECTIVES

To investigate the accuracy of predictive tests for pre-eclampsia and the effectiveness of preventative interventions for pre-eclampsia. Also to assess the cost-effectiveness of strategies (test-intervention combinations) to predict and prevent pre-eclampsia.

DATA SOURCES

Major electronic databases were searched to January 2005 at least.

REVIEW METHODS

Systematic reviews were carried out for test accuracy and effectiveness. Quality assessment was carried out using standard tools. For test accuracy, meta-analyses used a bivariate approach. Effectiveness reviews were conducted under the auspices of the Cochrane Pregnancy and Childbirth Group and used standard Cochrane review methods. The economic evaluation was from an NHS perspective and used a decision tree model.

RESULTS

For the 27 tests reviewed, the quality of included studies was generally poor. Some tests appeared to have high specificity, but at the expense of compromised sensitivity. Tests that reached specificities above 90% were body mass index greater than 34, alpha-foetoprotein and uterine artery Doppler (bilateral notching). The only Doppler test with a sensitivity of over 60% was resistance index and combinations of indices. A few tests not commonly found in routine practice, such as kallikreinuria and SDS-PAGE proteinuria, seemed to offer the promise of high sensitivity, without compromising specificity, but these would require further investigation. For the 16 effectiveness reviews, the quality of included studies was variable. The largest review was of antiplatelet agents, primarily low-dose aspirin, and included 51 trials (36,500 women). This was the only review where the intervention was shown to prevent both pre-eclampsia and its consequences for the baby. Calcium supplementation also reduced the risk of pre-eclampsia, but with some uncertainty about the impact on outcomes for the baby. The only other intervention associated with a reduction in RR of pre-eclampsia was rest at home, with or without a nutritional supplement, for women with normal blood pressure. However, this review included just two small trials and its results should be interpreted with caution. The cost of most of the tests was modest, ranging from 5 pounds for blood tests such as serum uric acid to approximately 20 pounds for Doppler tests. Similarly, the cost of most interventions was also modest. In contrast, the best estimate of additional average cost associated with an average case of pre-eclampsia was high at approximately 9000 pounds. The results of the modelling revealed that prior testing with the test accuracy sensitivities and specificities identified appeared to offer little as a way of improving cost-effectiveness. Based on the evidence reviewed, none of the tests appeared sufficiently accurate to be clinically useful and the results of the model favoured no-test/treat-all strategies. Rest at home without any initial testing appeared to be the most cost-effective 'test-treatment' combination. Calcium supplementation to all women, without any initial testing, appeared to be the second most cost-effective. The economic model provided little support that any form of Doppler test has sufficiently high sensitivity and specificity to be cost-effective for the early identification of pre-eclampsia. It also suggested that the pattern of cost-effectiveness was no different in high-risk mothers than the low-risk mothers considered in the base case.

CONCLUSIONS

The tests evaluated are not sufficiently accurate, in our opinion, to suggest their routine use in clinical practice. Calcium and antiplatelet agents, primarily low-dose aspirin, were the interventions shown to prevent pre-eclampsia. The most cost-effective approach to reducing pre-eclampsia is likely to be the provision of an effective, affordable and safe intervention applied to all mothers without prior testing to assess levels of risk. It is probably premature to suggest the implementation of a treat-all intervention strategy at present, however the feasibility and acceptability of this to women could be explored. Rigorous evaluation is needed of tests with modest cost whose initial assessments suggest that they may have high levels of both sensitivity and specificity. Similarly, there is a need for high-quality, adequately powered randomised controlled trials to investigate whether interventions such as advice to rest are indeed effective in reducing pre-eclampsia. In future, an economic model should be developed that considers not just pre-eclampsia, but other related outcomes, particularly those relevant to the infant such as perinatal death, preterm birth and small for gestational age. Such a modelling project should make provision for primary data collection on the safety of interventions and their associated costs.

Predicting negligence in female sterilization failure using time interval to sterilization failure: analysis of 131 cases

BACKGROUND

Sterilization failure due to 'tubal non-occlusion' or 'wrong structure sterilization' is considered negligent, whereas 'spontaneous tubal recanalization' or 'fistula formation' is considered non-negligent. We examined whether interval to pregnancy failure was predictive of a negligent rather non-negligent failure mechanism. We aim to test this hypothesis in a selected population series of known mechanisms of sterilization failure and their time interval to failure.

METHODS

Analyses of 131 failed sterilizations pooled from UK (NHS Litigation Authority, Medical Protection Society and our hospital), Australia and a qualitative systematic review.

RESULTS

We identified 88 negligent and 43 non-negligent sterilization failures. Filshie and ring methods failed earlier than diathermy and Pomeroy methods. Sterilization failure occurred significantly earlier in negligent than non-negligent failure mechanisms [median failure intervals 7.0 versus 12.0 months; Hazard ratio (2.35 95% CI 1.31-4.21)]. Knowing that sterilization failure occurred early, increased the probability that the failure mechanism was likely to be negligent rather than non-negligent.

CONCLUSIONS

A short interval to failure is suggestive of a negligent failure mechanism. There is less certainty in the predictive value of longer time intervals on the mechanism of failure due to a paucity of cases. A national register of failed sterilizations that have been systematically investigated is needed to improve our understanding of negligent and non-negligent failure mechanisms.

The feasibility, success and patient satisfaction associated with outpatient hysteroscopic sterilisation

OBJECTIVE

To determine the feasibility and patient satisfaction of female sterilisation using the Essure system in an outpatient hysteroscopy clinic without conscious sedation or general anaesthesia.

DESIGN

Prospective cohort study.

SETTING

Outpatient hysteroscopy clinic in a large teaching hospital.

POPULATION

Women undergoing outpatient hysteroscopic sterilisation using the Essure system for permanent fertility control.

METHODS

Demographic and procedural data were prospectively collected from 112 consecutive women undergoing outpatient hysteroscopic sterilisation without sedation or general anaesthesia. A hysterosalpingogram (HSG) was performed routinely in all women 3 months after the procedure to confirm bilateral tubal occlusion. Postal questionnaires were sent at this time enquiring about patient satisfaction and experience with the outpatient procedure. Multivariable logistic regression was used to identify factors independently predictive of successful completion of the procedure.

MAIN OUTCOME MEASURES

Technical feasibility, predictive factors for technical success (operator, body mass index, uterine size, axis, menstrual phase and cervical stenosis), complications, tubal occlusion on HSG, patient satisfaction and procedure-related experience.

RESULTS

Successful bilateral tubal placement of the Essure microinserts was achieved in 103/112 (92%, 95% CI 85-96%) women. Nonsecretory phase of the menstrual cycle (P = 0.04) and a clinically normal-sized uterus (P = 0.003) were independently predictive for successful completion of the outpatient procedure on multivariable modelling. There were no major procedure-related complications recorded, but transient vasovagal reactions occurred in 5/112 (5%) women. Of the original cohort of 112 women with successful procedures, 84 women were 3 months postprocedure and had undergone a HSG. Bilateral tubal occlusion was confirmed in 83/84 (99%, 95% CI 94-100%) women at 3 months and in 100% at 6 months. Seventy-six of 84 (91%) had returned the questionnaires, and 70/73 (96%, 95% CI 88-99%) were satisfied with their overall experience of the procedure including radiological follow up, with most reporting being 'very satisfied' (64/73, 88%, 95% CI 78-94%).

CONCLUSIONS

Outpatient hysteroscopic sterilisation using the Essure system without sedation or general anaesthesia is a successful and safe procedure associated with high rates of patient satisfaction. If practical, women should be scheduled to have their procedures in the proliferative phase of the menstrual cycle to optimise successful placement of Essure devices, especially if the uterus is clinically enlarged.

Do screening-preventative interventions in asymptomatic pregnancies reduce the risk of preterm delivery—A critical appraisal of the literature

Recent research has suggested that women who experience preterm delivery (PTD) may be identified earlier in pregnancy and before onset of symptoms. Interventions commenced at this earlier asymptomatic stage may offer an opportunity to prevent PTD or lengthen gestation sufficiently to reduce adverse perinatal outcome. Our objective was to examine the evidence that supports or refutes this approach to preventing PTD. We therefore conducted a systematic search and critical appraisal of the identified literature. We found evidence that introducing screening-preventative strategies for asymptomatic pregnancies may reduce the rate of PTD. Evidence for screening and selective treatment exists for: asymptomatic bacteriuria; bacterial vaginosis in low-risk population groups; elective cervical cerclage in high-risk pregnancies; indicated cervical cerclage in women with short cervical length on ultrasound; prophylactic progesterone supplementation in high-risk pregnancies, and smoking cessation. However, for most other strategies, such as increased antenatal attendance, or routine administration of prophylactic micronutrients, the evidence is inconsistent and conflicting. Information on neonatal outcomes apart from PTD (such as serious neonatal morbidity and mortality) was found to be lacking in most studies. It was therefore not possible to establish whether preventing PTD or prolonging gestation would correlate to improved perinatal outcome, and this lessened the potential clinical usefulness of any proposed preventative strategy. No studies were found that evaluated the effectiveness of combining screening-preventative strategies. The review concludes with a suggested an antenatal management plan designed to prevent PTD based on current practice and the evidence presented in this article.