Specialised antenatal clinics for women with a pregnancy at high risk of preterm birth (excluding multiple pregnancy) to improve maternal and infant outcomes

Perinatal and neonatal outcomes of high-risk asymptomatic women from a specialist preterm birth surveillance clinic

OBJECTIVES

To report the perinatal outcomes of high-risk asymptomatic women who attended a specialist preterm surveillance clinic (PSC) to undergo screening for spontaneous preterm birth (PTB) in Ireland.

METHODS

Single center, retrospective cohort study of asymptomatic high risk women who attended the PSC between January 2019 and December 2022. A comprehensive database of all patients who attended the clinic during the study period was constructed and analyzed. Overall outcomes were reported, and stratified per the occurrence of preterm or term birth. Iatrogenic PTBs were included in the outcome data.

RESULTS

Following exclusions for loss-to-follow-up, 762 cases were analyzed, constituting 2262 PSC visits. Of those, 183 women were prescribed progesterone (24.0 %), and 100 women underwent cervical cerclage (13.1 %) to prevent spontaneous PTB. Overall, 2.4 %, 6.2 % and 18.6 % of participants gave birth prior to 30 weeks, 34 weeks, and 37 weeks, respectively. The median gestational age at birth for the entire cohort was 38.6 weeks (inter-quartile range (IQR) 37.2-39.6 weeks). Women who delivered < 37 weeks were significantly more likely to be smokers (p = 0.030), have a previous spontaneous PTB (p = 0.016), have multiple pregnancies (p < 0.001), type 1 or 2 diabetes (p = 0.044), or have a previous full dilatation caesarean section birth (p = 0.024). Infants born prior to 37 weeks were more likely to have a lower median birthweight (2270 vs 3300 g, p < 0.001), be admitted to a neonatal intensive care unit (53.8 % vs 2.3 %, p < 0.001) or experience short-term morbidity, including respiratory support (38.0 % vs 1.6 %, p < 0.001).

CONCLUSIONS

Over 80% of women deemed to be at high risk of PTB gave birth at term gestations following attendance at a PSC during pregnancy. Most women can be successfully managed without interventions, instead employing a policy of serial cervical surveillance, to identify those at greatest risk of PTB.

Sonographic evaluation of maternal uterine artery from 11 - 30 weeks 6 days of gestational age in a Nigerian population: A predictive index for pre-eclampsia and intrauterine growth restriction

INTRODUCTION

Uterine artery (UtA) Doppler sonography is a potential screening tool for pregnancy complications in placental insufficiency. Evaluation of the maternal and fetal vessels in pregnancy ensures accurate identification and prediction of pregnancy complications, such as preeclampsia (PE) and intrauterine growth restrictions (IUGR). The study aims to establish local reference values for UtA in a Nigerian population.

METHODS

This prospective longitudinal study was conducted among 230 pregnant women. All participants had their left (Lt) and right (RT) UtAs evaluated with a Doppler ultrasound from 11 to 30 weeks 6 days of gestational age. Peak systolic velocity (PSV), End diastolic Velocity (EDV), Systolic/Diastolic ratio (S/D), Pulsatility Index (PI), and Resistivity Index (RI) were measured and documented.

RESULTS

The mean values of UtA at 11-30 weeks 6 days of GA ranged as follows: 0.79-0.53 (RI), 1.83-0.79 (PI), 5.16-2.23 (S/D), 96.37-98.00 (PSV) & 26.07-44.14 (EDV). While the mean values of the Rt. & Lt. UtA 's ranged as follows: 0.79-0.50 (RI. Rt), 0.78-0.56 (RI. Lt), 2.05-0.80 (PI. Rt), 1.61-0.78 (PI. Lt), 6.03-2.13 (S/D. Rt), 4.29-2.33 (S/D. Lt), 89.79-99.23 (PSV. Rt), 102.76-96.71 (PSV. Lt) & 23.31-45.25 (EDV. Rt), 28.83-43.02 (EDV. Lt) respectively.

CONCLUSION

UtA Doppler reference range was established in the study population. These reference ranges will be of clinical value in daily obstetric practice.

IMPLICATION FOR PRACTICE

Obstetricians and sonographers will apply these values for early prediction of pregnancies at risk of complications in the locality.

The contemporary value of dedicated preterm birth clinics for high-risk singleton pregnancies: 15-year outcomes from a leading maternal centre

OBJECTIVES

Preterm birth clinics provide dedicated obstetric care to women at high risk of spontaneous preterm birth (SPTB). There remains a lack of conclusive evidence to support the overall utility of such clinics, attributable to a paucity and heterogeneity of primary data. This study audits Australia's largest and oldest dedicated preterm birth clinic with the aim to add primary data to the area and offer opportunities for similar clinics to align practice.

METHODS

A retrospective audit of referrals to the Preterm Labour Clinic at the Royal Women's Hospital, Melbourne, Australia, between 2004 and 2018 was conducted. 1,405 singleton pregnancies met inclusion criteria. The clinic's key outcomes, demographics, predictive tests and interventions were analysed. The primary outcomes were SPTB before 37, 34 and 30 weeks' gestation.

RESULTS

The overall incidence of SPTB in the clinic was 21.2% (n=294). Linear regression showed reductions in the adjusted rates of overall SPTB and pre-viable SPTB (delivery <24 weeks) from 2004 (108%; 8%) to 2018 (65%; 2% respectively). Neonatal morbidity and post-delivery intensive care admission concurrently declined (p=0.02; 0.006 respectively). Rates of short cervix (cervical length <25 mm) increased over time (2018: 30.9%) with greater uptake of vaginal progesterone for treatment. Fetal fibronectin, mid-trimester short cervix, and serum alkaline phosphatase were associated with SPTB on logistic regression.

CONCLUSIONS

Dedicated preterm birth clinics can reduce rates of SPTB, particularly deliveries before 24 weeks' gestation, and improve short-term neonatal outcomes in pregnant women at risk of preterm birth.

The use of specialised preterm birth clinics for women at high risk of spontaneous preterm birth: a systematic review

Background

Specialised preterm birth clinics care for women at high risk of spontaneous preterm birth. This systematic review assesses current practice within preterm birth clinics globally.

Methods

A comprehensive search strategy was used to identify all studies on preterm birth clinics on the MEDLINE, Embase, PsycINFO, CENTRAL and CINAHL databases. There were no restrictions to study design. Studies were limited to the English language and publications from 1998 onwards. Two reviewers assessed studies for inclusion, performed data extraction and reviewed methodological quality. Primary outcomes were referral criteria, investigations and interventions offered in preterm birth clinics. Secondary outcomes were the timing of planned first and last appointments and frequency of review.

Results

Thirty-two records fulfilled eligibility criteria and 20 studies were included in the main analysis following grouping of records describing the same study or clinic. Studies were of mixed study design and methodological quality. A total of 39 clinics were described; outcome data was not available for all clinics. Referral criteria included previous spontaneous preterm birth (38/38, 100%), previous mid-trimester loss (34/38, 89%) and previous cervical surgery (33/38, 87%). All clinics offered transvaginal cervical length scans. Additional investigations varied, including urogenital swabs (16/28, 57%) and fetal fibronectin (8/28, 29%). The primary treatment of choice for a sonographic short cervix was cervical cerclage in 10/33 (30%) clinics and vaginal progesterone in 6/33 (18%), with 10/33 (30%) using multiple first-line options and 6/33 (18%) using a combination of treatments. The majority of clinics planned timing of first review for 12–16 weeks (30/35, 86%) and the frequency of review was usually determined by clinical findings (18/24, 75%). There was a wide variation in gestational age at clinic discharge between 24 and 37 weeks.

Conclusions

There is variation in the referral criteria, investigations and interventions offered in preterm birth clinics and in the timing and frequency of review. Consistency in practice may improve with the introduction of consensus guidelines and national preterm birth prevention programmes.

Trial registration

Systematic review registration number: CRD42019131470.

Reducing the Risk of Preterm Birth by Ambulatory Risk Factor Management

BACKGROUND

The preterm birth rate in Germany has remained unchanged at 8-9% since 2009. Preterm birth is the most common cause of neonatal morbidity and mortality. In the absence of a causal treatment, it is important to lower the risk of preterm birth by preventive measures in prenatal outpatient care.

METHODS

This review is based on pertinent publications from the years 2000-2019 that were retrieved by a selective search in PubMed.

RESULTS

The clinical risk factors for preterm birth-known mainly from retrospective cohort studies-include previous preterm birth (adjusted odds ratio [aOR]: 3.6), multiple pregnancy (relative risk [RR]: 7.7), nicotine consumption (aOR: 1.7), and a short uterine cervix, i.e., <25 mm in the second trimester (aOR: 6.9). In women with a short cervix, vaginally administered progesterone significantly lowers the preterm birth rate (22.5% vs. 14.1% for birth before 33 weeks of gestation, RR: 0.62; 95% confidence interval [0.47; 0.81]). Nicotine abstinence is associated with a lower pre- term birth rate as well (aOR: 0.91; [0.88; 0,.94]), while working more than 40 hours per week (aOR: 1.25; [1,.01; 1,.54]) and heavy lifting during pregnancy (hazard ratio [HR]: 1.43; [1.13; 1.80]) are associated with a higher preterm birth rate. Avoidance of physical exertion, or bed rest, in the face of impending preterm birth does not lower the preterm birth rate, but it does increase the risk of complications, such as thromboembolism.

CONCLUSION

The meticulous assessment and elimination of treatable risk factors at the outset of ambulatory prenatal care can help lower the preterm birth rate. Further velopment of causally directed treat- ments (e.g., changes of relevant environmental and epigenetic factors).

Support during pregnancy for women at increased risk of low birthweight babies

BACKGROUND

Studies consistently show a relationship between social disadvantage and low birthweight. Many countries have programmes offering special assistance to women thought to be at risk for giving birth to a low birthweight infant. These programmes, collectively referred to in this review as additional social support, may include emotional support, which gives a person a feeling of being loved and cared for, tangible/instrumental support, in the form of direct assistance/home visits, and informational support, through the provision of advice, guidance and counselling. The programmes may be delivered by multidisciplinary teams of health professionals, specially trained lay workers, or a combination of lay and professional workers. This is an update of a review first published in 2003 and updated in 2010.

OBJECTIVES

The primary objective was to assess the effects of programmes offering additional social support (emotional, instrumental/tangible and informational) compared with routine care, for pregnant women believed to be at high risk for giving birth to babies that are either preterm (less than 37 weeks' gestation) or weigh less than 2500 g, or both, at birth. Secondary objectives were to determine whether the effectiveness of support was mediated by timing of onset (early versus later in pregnancy) or type of provider (healthcare professional or lay person).

SEARCH METHODS

For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) on 5 February 2018, and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised trials of additional social support during at-risk pregnancy by either a professional (social worker, midwife, or nurse) or specially trained lay person, compared to routine care. We defined additional social support as some form of emotional support (e.g. caring, empathy, trust), tangible/instrumental support (e.g. transportation to clinic appointments, home visits complemented with phone calls, help with household responsibilities) or informational support (advice and counselling about nutrition, rest, stress management, use of alcohol/recreational drugs).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion and risk of bias, extracted data and checked them for accuracy. We assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

This updated review includes a total of 25 studies, with outcome data for 11,246 mothers and babies enrolled in 21 studies. We assessed the overall risk of bias of included studies to be low or unclear, mainly because of limited reporting or uncertainty in how randomisation was generated or concealed (which led us to downgrade the quality of most outcomes to moderate), and the impracticability of blinding participants.When compared with routine care, programmes offering additional social support for at-risk pregnant women may slightly reduce the number of babies born with a birthweight less than 2500 g from 127 per 1000 to 120 per 1000 (risk ratio (RR) 0.94, 95% confidence interval (CI) 0.86 to 1.04; 16 studies, n = 11,770; moderate-quality evidence), and the number of babies born with a gestational age less than 37 weeks at birth from 128 per 1000 to 117 per 1000 (RR 0.92, 95% CI 0.84 to 1.01, 14 studies, n = 12,282; moderate-quality evidence), though the confidence intervals for the pooled effect for both of these outcomes just crossed the line of no effect, suggesting any effect is not large. There may be little or no difference between interventions for stillbirth/neonatal death (RR 1.11, 95% CI 0.88 to 1.41; 15 studies, n = 12,091; low-quality evidence). Secondary outcomes of moderate quality suggested that there is probably a reduction in caesarean section (from 215 per 1000 to 194 per 1000; RR 0.90, 95% CI 0.83 to 0.97; 15 studies, n = 9550), a reduction in the number of antenatal hospital admissions per participant (RR 0.78, 95% CI 0.68 to 0.91; 4 studies; n = 787), and a reduction in the mean number of hospitalisation episodes (mean difference -0.05, 95% CI -0.06 to -0.04; 1 study, n = 1525) in the social support group, compared to the controls.Postnatal depression and women's satisfaction were reported in different ways in the studies that considered these outcomes and so we could not include data in a meta-analysis. In one study postnatal depression appeared to be slightly lower in the support group in women who screened positively on the Edinbugh Postnatal Depression Scale at eight to 12 weeks postnatally (RR 0.74, 95% CI 0.55 to 1.01; 1 study, n = 1008; moderate-quality evidence). In another study, again postnatal depression appeared to be slightly lower in the support group and this was a self-report measure assessed at six weeks postnatally (RR 0.85, 95% CI 0.69 to 1.05; 1 study, n = 458; low-quality evidence). A higher proportion of women in one study reported that their prenatal care was very helpful in the supported group (RR 1.17, 95% CI 1.05 to 1.30; 1 study, n = 223; moderate-quality evidence), although in another study results were similar. Another study assessed satisfaction with prenatal care as being "not good" in 51 of 945 in the additional support group, compared with 45 of 942 in the usual care group.No studies considered long-term morbidity for the infant. No single outcome was reported in all studies. Subgroup analysis demonstrated consistency of effect when the support was provided by a healthcare professional or a trained lay worker.The descriptions of the additional social support were generally consistent across all studies and included emotional support, tangible support such as home visits, and informational support.

AUTHORS' CONCLUSIONS

Pregnant women need the support of caring family members, friends, and health professionals. While programmes that offer additional social support during pregnancy are unlikely to have a large impact on the proportion of low birthweight babies or birth before 37 weeks' gestation and no impact on stillbirth or neonatal death, they may be helpful in reducing the likelihood of caesarean birth and antenatal hospital admission.

Recent advances in the prevention of preterm birth

Preterm birth (PTB) remains a major obstetric healthcare problem and a significant contributor to perinatal morbidity, mortality, and long-term disability. Over the past few decades, the perinatal outcomes of preterm neonates have improved markedly through research and advances in neonatal care, whereas rates of spontaneous PTB have essentially remained static. However, research into causal pathways and new diagnostic and treatment modalities is now bearing fruit and translational initiatives are beginning to impact upon PTB rates. Successful PTB prevention requires a multifaceted approach, combining public health and educational programs, lifestyle modification, access to/optimisation of obstetric healthcare, effective prediction and diagnostic modalities, and the application of effective, targeted interventions. Progress has been made in some of these areas, although there remain areas of controversy and uncertainty. Attention is now being directed to areas where greater gains can be achieved. In this mini-review, we will briefly and selectively review a range of PTB prevention strategies and initiatives where progress has been made and where exciting opportunities await exploitation, evaluation, and implementation.

Does attendance at a specialist antenatal clinic improve clinical outcomes in women with class III obesity compared with standard care? A retrospective case-note analysis

OBJECTIVES

To determine whether attendance at a specialised multidisciplinary antenatal clinic for women with class III obesity (BMI >40 kg/m²) is associated with improved clinical outcomes compared with standard antenatal care.

DESIGN

Retrospective cohort study using routinely collected data from electronic patient record.

SETTING

Community and hospital based antenatal care.

PARTICIPANTS

Women with a singleton pregnancy with class III obesity booked for antenatal care and delivered in one of two hospitals in NHS Lothian, Scotland, UK between 2008 and 2014. Maternal and offspring outcomes were compared in women who attended a specialised obesity clinic (n=511) compared with standard antenatal care (n=502).

MAIN OUTCOME MEASURES

Included stillbirth, low birth weight, gestational diabetes, induction of labour and caesarean section.

RESULTS

Compared with standard care, women receiving specialist care were less likely to have a stillbirth (OR 0.12, 95% CI 0.06 to 0.97) and a low birthweight baby (OR 0.57, 95% CI 0.33 to 0.99) and more likely to be screened for (100% vs 73.6%; p<0.001) and diagnosed with (26.0% vs 12.5%; p<0.001) gestational diabetes, to require induction of labour (38.4% vs 29.9%; p=0.009), an elective (20.3% vs 17.7%; p<0.001) and emergency (23.9% vs 20.3%; p<0.001) caesarean section and attend antenatal triage one or more times during pregnancy (77.7% vs 53.1%; p<0.001). Women attending the specialist clinic had a higher BMI (44.5 kg/m² (4.3) vs 43.2 kg/m² (3.1); p<0.001) and were more likely to be nulliparous (46.0% vs 24.9%; p<0.001). There were no other differences in maternal demographic or maternal and offspring outcomes between groups.

CONCLUSIONS

Attendance at a specialised antenatal clinic for obesity is associated with reduced rates of stillbirth and low birth weight and improved detection of gestational diabetes. The improvement in clinical outcomes is associated with an increase in healthcare attendance to obstetric triage and clinical interventions including induction of labour and caesarean section.

Specialist antenatal clinics for women at high risk of preterm birth: a systematic review of qualitative and quantitative research

Background

Preterm birth (PTB) is the leading cause of perinatal morbidity and mortality. Women with previous prenatal loss are at higher risk of preterm birth. A specialist antenatal clinic is considered as one approach to improve maternity and pregnancy outcomes.

Methods

A systematic review of quantitative, qualitative and mixed method studies conducted on women at high risk of preterm birth (PTB). The review primary outcomes were to report on the specialist antenatal clinics effect in preventing or reducing preterm birth, perinatal mortality and morbidity and women’s perceptions and experiences of a specialist clinic whether compared or not compared with standard antenatal care. Other secondary maternal, infant and economic outcomes were also determined. A comprehensive search strategy was carried out in English within electronic databases as far back as 1980. The reviewers selected studies, assessed the quality, and extracted data independently. Results were summarized and tabulated.

Results

Eleven studies fully met the review inclusion criteria, ten were quantitative design studies and only one was a qualitative design study. No mixed method design study was included in the review. All were published after 1989, seven were conducted in the USA and four in the UK. Results from five good to low quality randomised controlled trials (RCTs), all conducted before 1990, did not illustrate the efficacy of the clinic in reducing preterm birth. Whereas results from more recent low quality cohort studies showed some positive neonatal outcomes. Themes from one good quality qualitative study reflected on the emotional and psychological need to reduce anxiety and stress of women referred to such a clinic. Women expressed their negative emotional responses at being labelled as high risk and positive responses to being assessed and treated in the clinic. Women also reported that their partners were struggling to cope emotionally.

Conclusions

Findings from this review were mixed. Evidence from cohort studies indicated a specialist clinic may be a means of predicting or preventing preterm birth. Testing this in a randomised controlled trial is desirable, though may be hard to achieve due to the growing focus of such clinics on managing women at high risk of preterm birth. Ongoing research has to recognize women’s experiences and perceptions of such a clinic. Further clarification of the optimal referral route and a clear and standardized management and cost economic evaluation plan are also required. Fathers support and experience of PTB clinics should also be included in further research.

Models of antenatal care to reduce and prevent preterm birth: a systematic review and meta-analysis

OBJECTIVE

To assess the effectiveness of models of antenatal care designed to prevent and reduce preterm birth (PTB) in pregnant women.

METHODS

We conducted a search of seven electronic databases and reference lists of retrieved studies to identify trials from inception up to July 2014 where pregnant women, regardless of risk factors for pregnancy complications, were randomly allocated to receive an alternative model of antenatal care or routine care. We pooled risks of PTB to determine the effect of alternative care models in all pregnant women. We also assessed secondary maternal and infant outcomes, women's satisfaction and economic outcomes.

RESULTS

15 trials involving 22,437 women were included. Pregnant women in alternative care models were less likely to experience PTB (risk ratio 0.84, 95% CI 0.74 to 0.96). The subgroup of women randomised to midwife-led continuity models of antenatal care were less likely to experience PTB (0.78, 0.66 to 0.91) but there was no significant difference between this group and women allocated to specialised care (0.92, 0.76 to 1.12) (interaction test for subgroup differences p=0.20). Overall low-risk women in alternative care models were less likely to have PTB (0.74, 0.59 to 0.93), but this effect was not significantly different from that in mixed-risk populations (0.91, 0.79 to 1.05) (subgroup p=0.13).

CONCLUSIONS

Alternative models of antenatal care for all pregnant women are effective in reducing PTB compared with routine care, but no firm conclusions could be drawn regarding the relative benefits of the two models. Future research should evaluate the impact of antenatal care models which include more recent interventions and predictive tests, and which also offer continuity of care by midwives throughout pregnancy.

PROSPERO REGISTRATION NUMBER

CRD42014007116.

Specialised antenatal clinics for women with a multiple pregnancy for improving maternal and infant outcomes

BACKGROUND

Regular antenatal care for women with a multiple pregnancy is accepted practice, and while most women have an increase in the number of antenatal visits, there is no consensus as to what constitutes optimal care. 'Specialised' antenatal clinics have been advocated as a way of improving outcomes for women and their infants.

OBJECTIVES

To assess, using the best available evidence, the benefits and harms of 'specialised' antenatal clinics compared with 'standard' antenatal care for women with a multiple pregnancy.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2015) and reference lists of retrieved studies.

SELECTION CRITERIA

All published, unpublished, and ongoing randomised controlled trials with reported data that compared outcomes in mothers and babies with a multiple pregnancy who received antenatal care specifically designed for women with a multiple pregnancy (as defined by the trial authors) with outcomes in controls who received 'standard' antenatal care (as defined by the trial authors).

DATA COLLECTION AND ANALYSIS

Two of the review authors independently assessed trials for inclusion and trial quality. Both review authors extracted data. Data were checked for accuracy. We graded the quality of the evidence using GRADEpro software.

MAIN RESULTS

Findings were based on the results of a single study with some design limitations.Data were available from one study involving 162 women with a multiple pregnancy. For the only reported primary outcome, perinatal mortality, we are uncertain whether specialised antenatal clinics makes any difference compared to standard care (risk ratio (RR) 1.02; 95% confidence interval (CI) 0.26 to 4.03; 324 infants, very low quality evidence). Women receiving specialised antenatal care were significantly more likely to birth by caesarean section (RR 1.38; 95% CI 1.06 to 1.81; 162 women, moderate quality evidence). Data were not reported in the study on the following primary outcomes: small-for-gestational age, very preterm birth or maternal death. There were no differences identified between specialised antenatal care and standard care for other secondary outcomes examined: postnatal depression (RR 0.48; 95% CI 0.19 to 1.20; 133 women, very low quality evidence), breastfeeding (RR 0.63; 95% CI 0.24 to 1.68; 123 women, very low quality evidence), stillbirth (RR 0.68; 0.12 to 4.04) or neonatal death (RR 2.05; 95% CI 0.19 to 22.39) (324 infants).

AUTHORS' CONCLUSIONS

There is currently limited information available from randomised controlled trials to assess the role of 'specialised' antenatal clinics for women with a multiple pregnancy compared with 'standard' antenatal care in improving maternal and infant health outcomes. The value of 'specialised' multiple pregnancy clinics in improving health outcomes for women and their infants requires evaluation in appropriately powered and designed randomised controlled trials.

Prevention of preterm birth in modern obstetrics

Spontaneous preterm labor is a complex process characterized by the interplay of multiple different pathways. Prevention of preterm labor and delivery is also complicated. The most effective interventions for prevention of preterm birth (PTB) are progestin prophylaxis and lifestyle modifications, with cerclage placement also playing a role in selected populations. Interventions such as activity modification, home tocometry, and routine antibiotic use have fallen out of favor because of lack of effectiveness and possibility of harm. The solution to the problem of PTB remains elusive, and researchers and clinicians must collaborate to find a cure for preterm labor.

Strategies to prevent preterm birth

After several decades of research, we now have evidence that at least six interventions are suitable for immediate use in contemporary clinical practice within high-resource settings and can be expected to safely reduce the rate of preterm birth. These interventions involve strategies to prevent non-medically indicated late preterm birth; use of maternal progesterone supplementation; surgical closure of the cervix with cerclage; prevention of exposure of pregnant women to cigarette smoke; judicious use of fertility treatments; and dedicated preterm birth prevention clinics. Quantification of the extent of success is difficult to predict and will be dependent on other clinical, cultural, societal, and economic factors operating in each environment. Further success can be anticipated in the coming years as other research discoveries are translated into clinical practice, including new approaches to treating intra-uterine infection, improvements in maternal nutrition, and lifestyle modifications to ameliorate maternal stress. The widespread use of human papillomavirus vaccination in girls and young women will decrease the need for surgical interventions on the cervix and can be expected to further reduce the risk of early birth. Together, this array of clinical interventions, each based on a substantial body of evidence, is likely to reduce rates of preterm birth and prevent death and disability in large numbers of children. The process begins with an acceptance that early birth is not an inevitable and natural feature of human reproduction. Preventative strategies are now available and need to be applied. The best outcomes may come from developing integrated strategies designed specifically for each health-care environment.

Prevalence and perinatal mortality associated with preterm births in a tertiary medical center in South East Nigeria

BACKGROUND

Preterm birth is a high risk condition associated with significant mortality and morbidity in the perinatal, neonatal, and childhood periods, and even in adulthood. Knowledge of the epidemiology of preterm births is necessary for planning appropriate maternal and fetal care.

OBJECTIVE

The objective of this study was to determine the prevalence, pattern, and perinatal mortality associated with preterm births at the University of Nigeria Teaching Hospital, Enugu, South East Nigeria.

METHODS

This was a review of prospectively collected routine delivery data involving preterm deliveries that occurred between 1 January 2009 and 31 December 2013. Data analysis involved descriptive and inferential statistics at 95% level of confidence using SPSS version 17.0 for Windows.

RESULTS

There were 3,760 live births over the 5-year study period out of which 636 were preterm births, giving a prevalence rate of 16.9%. Spontaneous preterm births occurred in approximately 57% of preterm births while provider-initiated births occurred in 43%. The mean gestational age at preterm deliveries was 32.6±3.2 weeks while the mean birth weight was 2.0±0.8 kilograms. Approximately 89% of preterm births involved singleton pregnancies. Sixty-eight percent of preterm births were moderate to late preterm. The male:female ratio of preterm babies born during the period was 1.2:1. The adjusted perinatal mortality rate for preterm babies in the study center was 46.1% (236/512). The stillbirth rate for preterm babies was 22.0% (149/678) and the adjusted early neonatal death rate was 24.0% (87/363).

CONCLUSION

The prevalence of preterm births and associated perinatal mortality were high which may be a reflection of suboptimal prenatal and newborn care. An urgent improvement in prenatal and newborn care is therefore needed in the study center in order to improve the capacity to prevent or abate preterm labor, and preterm premature rupture of membranes; and to reduce avoidable stillbirths. Further upgrading of personnel and facilities in the newborn special care unit is also required to minimize early neonatal deaths.

Antenatal interventions to reduce preterm birth: an overview of Cochrane Systematic Reviews

BACKGROUND

Several factors are associated with an increased risk of preterm birth (PTB); therefore, various interventions might have the potential to influence it. Due to the large number of interventions that address PTB, the objective of this overview is to summarise evidence from Cochrane reviews regarding the effects and safety of these different interventions.

METHODS

We conducted a systematic literature search in the Cochrane Database of Systematic Reviews. Included reviews should be based on randomised controlled trials comparing antenatal non-pharmacological and pharmacological interventions that directly or indirectly address PTB with placebo/no treatment or routine care in pregnant women at less than 37 completed weeks of gestation without signs of threatened preterm labour. We considered PTB at less than 37 completed weeks of gestation as the primary outcome.

RESULTS

We included 56 Cochrane systematic reviews. Three interventions increased PTB risk significantly. Twelve interventions led to a statistically significant lower incidence of PTBs. However, this reduction was mostly observed in defined at-risk subgroups of pregnant women. The remaining antenatal interventions failed to prove a significant effect on PTB < 37 weeks, but some of them at least showed a positive effect in secondary outcomes (e.g., reduction in early PTBs). As an unintended result of this review, we identified 28 additional Cochrane reviews which intended to report on PTB < 37 weeks, but were not able to find any RCTs reporting appropriate data.

CONCLUSIONS

The possible effects of a diverse range of interventions on PTB have been evaluated in Cochrane systematic reviews. Few interventions have been demonstrated to be effective and a small number have been found to be harmful. For around half of the interventions evaluated, the Cochrane review concluded that there was insufficient evidence to provide sound recommendations for clinical practice. No RCT evidence is available for a number of potentially relevant interventions.

Uterine artery Doppler study in second trimester of pregnancy

INTRODUCTION

The uterine artery Doppler has potentials for screening for complications of impaired placentation. This study examines the indices of uterine artery impedance at 22-23 weeks gestation and their relationship with maternal age and parity.

METHODS

Uterine artery colour imaging and pulsed wave Doppler ultrasound was conducted between 22nd and 23rd weeks in 430 pregnancies. The pregnancies were classified into 2 groups: normal and abnormal outcomes. The indices of impedance recorded were pulsatility index, resistance index and the systolic/diastolic ratio. Relevant obstetric information was retrieved from the antenatal records. The student t- test and Pearson's product moment were used for statistical analysis.

RESULTS

Fifty eight (13.5%) out of 430 pregnancies had complications of impaired placentation, mainly intrauterine growth restriction and preterm birth (24 or 41.4% each). The indices in normal pregnancies were similar to presently used values. There was no statistically significant difference in the 2 pregnancies groups. The Pulsatility Index (PI) in the right uterine artery was statistically different from the left (t-test 32.8, p < 0.05). Maternal age and parity demonstrate statistically significant positive correlation with PI (r =0.9, p < 0.05; r =0.8, p < 0.05).

CONCLUSION

The indices in normal pregnancies were similar to values from previous studies. The values are however not significantly different in pregnancies with abnormal outcome.

Specialised antenatal clinics for women with a multiple pregnancy for improving maternal and infant outcomes

BACKGROUND

Regular antenatal care for women with a multiple pregnancy is accepted practice, and while most women have an increase in the number of antenatal visits, there is no consensus as to what constitutes optimal care. 'Specialised' antenatal clinics have been advocated as a way of improving outcomes for women and their infants.

OBJECTIVES

To assess, using the best available evidence, the benefits and harms of 'specialised' antenatal clinics compared with 'standard' antenatal care for women with a multiple pregnancy.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (11 April 2012).

SELECTION CRITERIA

All published, unpublished, and ongoing randomised controlled trials with reported data that compared outcomes in mothers and babies with a multiple pregnancy who received antenatal care specifically designed for women with a multiple pregnancy (as defined by the trial authors) with outcomes in controls who received 'standard' antenatal care (as defined by the trial authors).

DATA COLLECTION AND ANALYSIS

Both review authors independently assessed trials for inclusion and trial quality. Both review authors extracted data. Data were checked for accuracy.

MAIN RESULTS

There were data available from one study included in the review involving 162 women with a multiple pregnancy. For the only reported primary outcome, perinatal mortality, there were no statistically significant differences identified between specialised antenatal care and standard care (risk ratio (RR) 1.02; 95% confidence interval (CI) 0.26 to 4.03). Women receiving specialised antenatal care were significantly more likely to birth by caesarean section (RR 1.38; 95% CI 1.06 to 1.81). Data was not reported in the study on the following primary outcomes: small-for-gestational age, very preterm birth or maternal death. There were no statistically significant differences identified between specialised antenatal care and standard care for other secondary outcomes examined: postnatal depression (RR 0.48; 95% CI 0.19 to 1.20), breastfeeding (RR 0.63; 95% CI 0.24 to 1.68), still birth (RR 0.68; 0.12 to 4.04) or neonatal death (RR 2.05; 95% CI 0.19 to 22.39).

AUTHORS' CONCLUSIONS

There is currently limited information available from randomised controlled trials to assess the role of 'specialised' antenatal clinics for women with a multiple pregnancy compared with 'standard' antenatal care in improving maternal and infant health outcomes. The value of 'specialised' multiple pregnancy clinics in improving health outcomes for women and their infants requires evaluation in appropriately powered and designed randomised controlled trials.