Placental heat shock proteins: no immunohistochemical evidence for a differential stress response in preterm labour

The aetiology of idiopathic preterm labour remains obscure. The hypothesis that a stress response induced by low-grade bacterial infection in utero-placental tissues was investigated. Distribution of cognate and inducible isoforms of heat shock proteins (HSP) 70 kD, HSP 60 kD and HSP 90 kD were investigated in an immunohistochemical study of placental and decidual tissues before and after labour at varying gestations. Subjects were pregnant women undergoing singleton delivery after idiopathic preterm labour at less than 34 weeks' gestation (n = 23); spontaneous term labour at 37-42 weeks' gestation (n =24); preterm caesarean sections at less than 34 weeks' gestation for preeclampsia or intrauterine growth retardation (n=14); elective caesarean section at 37-42 weeks' gestation for cephalopelvic disproportion (n = 6). HSP expression was constant throughout the third trimester of pregnancy and did not change following the onset of labour, regardless of gestational age. A stress response in decidual tissues as determined by immunohistochemical analysis is apparently not associated with preterm labour.

Health services research--what it is, how to do it, and why it matters

The term 'Health Services Research' (HSR) has achieved only recent currency in the UK. The purpose of this short article is to explain what it is, to say how it differs from clinical research even when using similar methods, and to argue that it is likely to become of rapidly increasing importance to health policy-makers and managers.

Management of apparently isolated fetal ventriculomegaly

Early ultrasound examination can provide accurate antenatal diagnosis of many fetal congenital abnormalities but it is often difficult to translate this into prognosis because of the variable functional effects of similar anatomical changes. In the case of isolated fetal ventriculomegaly it is the prognosis that parents require in order to choose between continuing with the pregnancy or termination. The outcome for antenatally diagnosed ventriculomegaly seems to be worse than that reported in the neurosurgical literature for children treated with congenital hydrocephalus. Follow-up is available for 276 cases with apparently isolated ventriculomegaly who did not undergo termination of pregnancy. One hundred ninety-four (70 per cent) survived and of these 114 (59 per cent) had normal developmental quotient to follow-up. Intrapartum cephalocentesis to aid vaginal delivery is almost invariably associated with fetal/neonatal death. A favorable outcome of normal mental development is present in cases with borderline, stable (nonprogressive) isolated ventriculomegaly or cases in which ventriculomegaly has resolved in utero. Fetal surgery would seem to offer no benefit. The outcome is much worse when other associated congenital anomalies are present.

Active management of labour: current knowledge and research issues

OBJECTIVES

To review the evidence that the package of labour interventions collectively called "active management"--namely, strict diagnostic criteria for labour, early amniotomy, early use of oxytocin, and continuous professional support--reduce rates of caesarean sections and operative vaginal delivery in first labours.

DESIGN

Review of observational data, supplemented by evidence from four separate overviews of relevant randomised trials previously published as part of the Cochrane Collaboration pregnancy and childbirth database.

RESULTS

Observational data do not permit a clear conclusion. There have been no randomised trials of the total package of active management or of the use of strict diagnostic criteria alone, but trials of early amniotomy, early oxytocin, and these interventions combined do not suggest that these interventions are effective in reducing rates of caesarean sections or operative vaginal deliveries. In contrast, the provision of continuous professional support in labour seems to reduce both types of operative delivery, although the effect on caesarean sections is confined to those settings where non-professional companions are not normally present in labour.

CONCLUSIONS

Delivery units should endeavour to provide continuous professional support in labour, but routine use of amniotomy and early oxytocin is not recommended.

Fetal pulse oximetry: a new method of monitoring the fetus

Experimental pulse oximetry devices, similar to the existing systems used in adult and neonatal monitoring, can be used on the fetus to provide safe, and rapid information about oxygenation. They have been calibrated using fetal lambs and validated in human cross-sectional studies. Experiments have shown that fetal oxygen saturation decreases during normal labour, and drops after a uterine contraction especially with oxytocin-induced tachysystole. When the mother is given oxygen the fetal oxygen saturation increases. Readings are effected by caput and movement, and trends seem to be more meaningful than absolute values. Pulse oximetry can predict fetal outcome and a normal oxygen saturation result is specific for a good outcome perhaps even if the CTG is abnormal. However the technique is still experimental and there is insufficient data to support its use as a replacement for fetal blood sampling or a discriminator for an abnormal fetal heart trace.

Specificity of antenatal ultrasound in the Yorkshire Region: a prospective study of 2261 ultrasound detected anomalies

OBJECTIVE

To evaluate the specificity of the ultrasound diagnosis of fetal anomalies. Pregnancies which proceeded to termination and ultrasound-diagnosed fetal anomalies which were not offered termination were considered.

DESIGN

Prospective, region-wide study over three and a half years.

SETTING

Cases were identified through 25 ultrasound departments representing the 15 districts in the Yorkshire Region.

SUBJECTS

Pregnant women with an ultrasound-diagnosed fetal anomaly.

MAIN OUTCOME MEASURES

Information obtained from the ultrasound report was compared with the outcomes determined by cytogenetics, postmortem or paediatric examination.

RESULTS

Of 2261 pregnancies with an ultrasound-diagnosed fetal anomaly 369, (16%) were terminated and 357 (97%) were followed by postmortem examination. Ultrasound findings exactly matched those of the postmortem or were accompanied by additional anomalies in 325 cases (91%). In 32 cases ultrasound findings were not confirmed by postmortem, but in 30 of these the decision to offer termination remained justified because the correct diagnosis was judged equally or more serious. Two (0.5%) were terminated for an anomaly which subsequently proved less severe than predicted on ultrasound. Ultrasound significantly over- or under-diagnosed a major fetal anomaly in 27 of the 1139 (2.4%) cases in which an anomaly was detected, but the pregnancy was not terminated.

CONCLUSION

Termination of pregnancy was based on the correct prognosis in over 99.5% of cases. This does not obviate the need for pathological examination of the fetus which changed or refined the diagnosis in 35% of cases.

A randomised trial of routine versus selective counselling in perinatal bereavement from congenital disease

OBJECTIVE

To find out whether routine counselling improves psychological wellbeing after bereavement for fetal abnormality.

DESIGN

A randomised trial among bereaved couples who did not demonstrate any unexpected strain or psychopathology after bereavement.

SETTING

St. James's University Hospital, Leeds.

SUBJECTS

Fifty-seven couples.

INTERVENTIONS

Independent counselling by an experienced psychotherapist.

MAIN OUTCOME MEASURES

Self-administered questionnaires measuring grief, anxiety and depression and a structured psychological interview 16 to 20 months after the loss. Anniversaries of a death or expected birth date were avoided.

RESULTS

There were no differences in outcome between women randomised to the study group or randomised to the control group with respect to grief, anxiety, depression or the results of the structured overview. Among those in the randomised study group, women who attended for counselling had a much better outcome than women who defaulted from counselling. Overall, women who underwent termination of pregnancy did slightly worse than those who had experienced stillbirth or neonatal death. On an informal basis, the clinician concerned believes that he was better able to help bereaved couples as a result of feedback and criticism from the independent counsellor.

CONCLUSIONS

(1) The hypothesis that all couples should have independent counselling after prenatal loss for congenital abnormality is unproven, but it is likely that clinicians can benefit from feedback from a counsellor; (2) it is possible that termination of pregnancy is more psychopathogenic than other forms of fetal loss; (3) people who attend for their counselling sessions are probably inherently better able to adjust to bereavement; (4) trials of psychological intervention are feasible, but follow up is either difficult to achieve or expensive.

Infertility treatment: from cookery to science. The epidemiology of randomised controlled trials

OBJECTIVES

To review the epidemiology of published randomised controlled trials in infertility treatment over the last 25 years, with special emphasis on the number and quality of trials.

DESIGN

Computer literature review by MEDLINE backed up by a manual search of 41 journals. Each trial was classified according to the methodology described and quality criteria. The results were recorded in a computer database. Odds ratios (OR) and confidence intervals (CI) were calculated where the data were sufficient.

SUBJECTS

Couples suffering from primary or secondary infertility. The trials studied 33,761 patients overall.

SETTING

Institute of Epidemiology and Health Services Research, Leeds.

RESULTS

Five hundred and one randomised trials in male and female infertility treatment were identified between 1966 and 1990. Pregnancy was an outcome in 291 (58%) and these were the subject of detailed analysis. Two hundred and twenty-four (77%) and 67 (23%) 'pregnancy trials' were concerned, respectively, with female and male infertility. Four per cent of the trials were preceded by a sample size calculation, and the average sample size was 96 patients (range 5-933); 700 patients per group would be required to demonstrate plausible success rates for most treatments. The method of randomisation was unstated or pseudo-randomised in 206 (71%) of trials where pregnancy was an outcome. Only 29 (5.8%) of studies were multicentre. The method of confirmation of pregnancy was omitted for 70% of papers. Cross-over design was used in 103 (21%) of cases. Meta-analysis is possible for selected topics such as the use of anti-oestrogens in idiopathic oligospermia and unexplained female infertility. Eight cases of double reporting were identified.

CONCLUSIONS

Trials using randomised methodology were relatively few in comparison with other branches of medicine, although their use is important in the evaluation of treatment for infertility as treatment-independent pregnancy is common. It was encouraging to note that an exponential increase in the use of this methodology occurred during the last three years, especially in association with assisted conception techniques, and meta-analysis has become possible for selected topics. However, many trials suffer from an unrealistically small sample size, inappropriate use of cross-over design or pseudo-randomisation. The trend towards properly controlled studies should be encouraged but these studies should be of improved quality and organised on a multicentre or even international basis.

Treatment of male infertility: is it effective? Review and meta-analyses of published randomized controlled trials

There are few widely accepted treatments for male subfertility. Controlled trials are necessary to evaluate different subfertility treatments because pregnancies and spontaneous improvements in semen parameters occur without treatment. Properly randomized trials can find out whether pregnancy rates are higher or lower than expected after treatment. Quantitative meta-analysis improves precision where individual trials are not powerful enough to demonstrate moderate treatment effects. Only 174 published randomized treatment trials for male subfertility were found after extensive literature review, both by computerized search and hand searches of 41 journals. In 72 of the studies, pregnancy was an outcome measure and these are analysed and discussed. The quality of most trials is poor. Meta-analysis was possible on seven themes, but the results of this exercise appear to be unduly influenced by trials of poor quality. Few conventional treatments (i.e. those not involving assisted conception techniques) result in improved fertility rates.

Decision analysis for best management of mildly dyskaryotic smear

Should a woman with a mildly dyskaryotic cervical smear be referred for colposcopy or should the smear be repeated? One way to answer this question is to use decision analysis and compare the expected mortality and cost of each policy. Data for each component of the question were obtained from published work worldwide and were supplemented with an audit of mildly dyskaryotic smears in West Yorkshire, UK. 2 out of 1000 women with an initial mildly dyskaryotic smear will develop cancer if a conservative repeat smear policy is adopted in association with five-yearly cervical screening. This number can be reduced to 1.6 per 1000 if cervical screening is offered every three years. A policy of immediate referral for colposcopy is also associated with a subsequent cancer rate of 1.6 per 1000. Therefore, repeating the smear is almost as effective as an immediate referral to a colposcopy unit. Even if a five-yearly cervical screening programme is adopted, 2500 women with a mildly dyskaryotic smear will need to be referred for immediate colposcopy to save 1 additional cancer. A conservative policy is not financially cheaper: an average of six additional smears is required to save each colposcopy referral. Sensitivity analysis shows that the excess cost of the conservative policy increases exponentially as the risk of a subsequent cytological abnormality exceeds 60%. Local cytopathology laboratories should audit their recurrent dyskaryosis rate associated with borderline, mild, and moderate dyskaryosis before accepting the U-turn in the national recommendations.

Randomised comparison of routine versus highly selective use of Doppler ultrasound in low risk pregnancies

OBJECTIVE

To help answer the question: should Doppler ultrasound of the umbilical circulation be made available to all pregnant women as part of their routine antenatal care?

DESIGN

A randomised trial.

SETTING

St James's University Hospital, Leeds.

SUBJECTS

2025 low risk primigravid women.

MAIN OUTCOME MEASURES

Obstetric intervention rates and short term neonatal morbidity.

RESULTS

The incidence of abnormal Doppler was low (1.7%) with complete absence of end diastolic flow in only 0.3% of cases. No significant differences could be demonstrated between control and study women in any of the outcomes measured.

CONCLUSION

This study did not demonstrate any benefit or harm from Doppler ultrasound as a routine screening test for all low risk women, whereas our previous studies have suggested that it is useful in high risk pregnancies. Any marginal returns on extending access to Doppler ultrasound from high risk to all women must be small. Since this test has excellent performance characteristics (sensitivity and specificity) for the prediction of fetal hypoxia and acidosis our results call into question the cost to benefit ratio of all tests designed to predict these outcomes in low risk women.

Effect of using protocols on medical care: randomised trial of three methods of taking an antenatal history

OBJECTIVE

To compare the effectiveness of three methods of taking an antenatal history on the quality of obstetric care.

DESIGN

Randomised controlled trial.

SETTING

Antenatal clinic of St James's University Hospital, Leeds.

SUBJECTS

2424 women attending the hospital for the first (booking) visit.

INTERVENTIONS

Histories were taken by midwives using an unstructured paper questionnaire, a structured paper questionnaire (incorporating a checklist), or an interactive computerised questionnaire (incorporating 101 clinical reminders).

MAIN OUTCOME MEASURES

The number of clinical responses to factors arising from the antenatal booking history according to method of taking the history. Actions were categorised as medical and surgical, obstetric, personal, current symptoms and treatment, related to maternal age, and related to two common actions (cervical smear testing and dental hygiene) and were weighted for clinical importance by 10 obstetricians.

RESULTS

Overall the unstructured questionnaire generated 1063 actions, the structured questionnaire 1146, and the computerised questionnaire 1122. The clinical importance of these actions was lowest for the unstructured questionnaire (overall total value score 1987 v 2182 and 2110 for the structured and computerised questionnaires respectively). The structured questionnaire was better than the computerised questionnaire in the medical and surgical (total value score 191 v 184), obstetric (275 v 241), and personal (430 v 360) categories but inferior in the current symptoms category (179 v 191).

CONCLUSION

Structured questionnaires (computerised or paper) provide more and better information, and their use improves clinical response to risk factors. Computerised systems offer no further advantage in antenatal clinics.