A multicenter randomized controlled trial of home uterine monitoring: active versus sham device. The Collaborative Home Uterine Monitoring Study (CHUMS) Group

Predicting preterm births from electrohysterogram recordings via deep learning

About one in ten babies is born preterm, i.e., before completing 37 weeks of gestation, which can result in permanent neurologic deficit and is a leading cause of child mortality. Although imminent preterm labor can be detected, predicting preterm births more than one week in advance remains elusive. Here, we develop a deep learning method to predict preterm births directly from electrohysterogram (EHG) measurements of pregnant mothers recorded at around 31 weeks of gestation. We developed a prediction model, which includes a recurrent neural network, to predict preterm births using short-time Fourier transforms of EHG recordings and clinical information from two public datasets. We predicted preterm births with an area under the receiver-operating characteristic curve (AUC) of 0.78 (95% confidence interval: 0.76-0.80). Moreover, we found that the spectral patterns of the measurements were more predictive than the temporal patterns, suggesting that preterm births can be predicted from short EHG recordings in an automated process. We show that preterm births can be predicted for pregnant mothers around their 31st week of gestation, prompting beneficial treatments to reduce the incidence of preterm births and improve their outcomes.

Effectiveness of Telemonitoring in Obstetrics: Scoping Review

BACKGROUND

Despite reported positive results of telemonitoring effectiveness in various health care domains, this new technology is rarely used in prenatal care. A few isolated investigations were performed in the past years but with conflicting results.

OBJECTIVE

The aim of this review was to (1) assess whether telemonitoring adds any substantial benefit to this patient population and (2) identify research gaps in this area to suggest goals for future research.

METHODS

This review includes studies exploring the effectiveness of telemonitoring interventions for pregnant women reported in the English language. Due to the paucity of research in this area, all reports including uncontrolled nonrandomized and randomized controlled studies were selected.

RESULTS

Fourteen studies, which performed their data collection from 1988 to 2010, met the inclusion criteria and were published from 1995 to present; four of the 14 published papers were multicenter randomized controlled trials (RCTs), five papers were single-center RCTs, three papers were retrospective studies, one paper was an observational study, and one paper was a qualitative study. Of the 14 papers, nine were available for a risk of bias assessment: three papers were classified as low risk, one as medium risk, and five as high risk. Furthermore, of those 14 papers, 13 focused on telemonitoring for maternal outcomes, and nine of the 14 papers focused on telemonitoring for fetal or neonatal outcomes. The studies reviewed report that telemonitoring can contribute to significant reductions in health care costs, (unscheduled) face-to-face visits, low neonatal birth weight, and admissions to the neonatal intensive care unit (NICU), as well as prolonged gestational age and improved feelings of maternal satisfaction when compared with a control group. When only studies with low risk of bias were taken into account, the added value of telemonitoring became less pronounced: the only added value of telemonitoring is for pregnant women who transmitted their uterine activity by telecommunication. They had significant prolonged pregnancy survivals, and the newborns were less likely to be of low birth weight or to be admitted to the NICU. Following these results, telemonitoring can only be recommended by pregnant women at risk for preterm delivery. It is however important to consider that these studies were published in the mid-90s, which limits their direct applicability given the current technologies and practice.

CONCLUSIONS

This review shows that telemonitoring can be tentatively recommended for pregnant women at risk for preterm delivery. More recent RCTs with a blinded protocol are needed to strengthen the level of evidence around this topic and to have an insight in the added value of the technologies that are available nowadays. In addition, studies investigating patient satisfaction and economic effects in relation to telemonitoring are suggested for future research.

Remote Monitoring of Hypertension Diseases in Pregnancy: A Pilot Study

Background

Although remote monitoring (RM) has proven its added value in various health care domains, little is known about the remote follow-up of pregnant women diagnosed with a gestational hypertensive disorders (GHD).

Objective

The aim of this study was to evaluate the added value of a remote follow-up program for pregnant women diagnosed with GHD.

Methods

A 1-year retrospective study was performed in the outpatient clinic of a 2nd level prenatal center where pregnant women with GHD received RM or conventional care (CC). Primary study endpoints include number of prenatal visits and admissions to the prenatal observation ward. Secondary outcomes include gestational outcome, mode of delivery, neonatal outcome, and admission to neonatal intensive care (NIC). Differences in continuous and categorical variables in maternal demographics and characteristics were tested using Unpaired Student’s two sampled t test or Mann-Whitney U test and the chi-square test. Both a univariate and multivariate analysis were performed for analyzing prenatal follow-up and gestational outcomes. All statistical analyses were done at nominal level, Cronbach alpha=.05.

Results

Of the 166 patients diagnosed with GHD, 53 received RM and 113 CC. After excluding 5 patients in the RM group and 15 in the CC group because of the missing data, 48 patients in RM group and 98 in CC group were taken into final analysis. The RM group had more women diagnosed with gestational hypertension, but less with preeclampsia when compared with CC (81.25% vs 42.86% and 14.58% vs 43.87%). Compared with CC, univariate analysis in RM showed less induction, more spontaneous labors, and less maternal and neonatal hospitalizations (48.98% vs 25.00%; 31.63% vs 60.42%; 74.49% vs 56.25%; and 27.55% vs 10.42%). This was also true in multivariate analysis, except for hospitalizations.

Conclusions

An RM follow-up of women with GHD is a promising tool in the prenatal care. It opens the perspectives to reverse the current evolution of antenatal interventions leading to more interventions and as such to ever increasing medicalized antenatal care.

Home uterine monitoring for detecting preterm labour

BACKGROUND

To reduce the morbidity and mortality associated with preterm birth, home uterine activity monitoring aims for early detection of increased contraction frequency, and early intervention with tocolytic drugs to inhibit labour and prolong pregnancy. However, the effectiveness of such monitoring is disputed.

OBJECTIVES

To determine whether home uterine activity monitoring is effective in improving the outcomes for women and their infants considered to be at high risk of preterm birth, when compared with care that does not include home uterine activity monitoring.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2016), CENTRAL (Cochrane Library 2016, Issue 5), MEDLINE (1966 to 28 June 2016), Embase (1974 to 28 June 2016), CINAHL (1982 to 28 June 2016), and scanned reference lists of retrieved studies.

SELECTION CRITERIA

Randomised control trials of home uterine activity monitoring, with or without patient education programmes, for women at risk of preterm birth, compared with care that does not include home uterine activity monitoring.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risks of bias, extracted data and checked them for accuracy. We did not attempt to contact authors to resolve queries. We assessed the evidence using the GRADE approach.

MAIN RESULTS

There were 15 included studies (6008 enrolled participants); 13 studies contributed data. Women using home uterine monitoring were less likely to experience preterm birth at less than 34 weeks (risk ratio (RR) 0.78, 95% confidence interval (CI) 0.62 to 0.99; three studies, 1596 women; fixed-effect analysis) (GRADE high). This difference was not evident when we carried out a sensitivity analysis, restricting the analysis to studies at low risk of bias based on study quality (RR 0.75, 95% CI 0.57 to 1.00; one study, 1292 women). There was no difference in the rate of perinatal mortality (RR 1.22, 95% CI 0.86 to 1.72; two studies, 2589 babies) (GRADE low).There was no difference in the number of preterm births at less than 37 weeks (average RR 0.85, CI 0.72 to 1.01; eight studies, 4834 women; random-effects, Tau2 = 0.03, I2 = 68%) (GRADE very low). Infants born to women using home uterine monitoring were less likely to be admitted to neonatal intensive care unit (average RR 0.77, 95% CI 0.62 to 0.96; five studies, 2367 babies; random-effects, Tau2 = 0.02, I2 = 32%) (GRADE moderate). This difference was not maintained when we restricted the analysis to studies at low risk of bias (RR 0.86, 95% CI 0.74 to 1.01; one study, 1292 babies). Women using home uterine monitoring made more unscheduled antenatal visits (mean difference (MD) 0.48, 95% CI 0.31 to 0.64; two studies, 1994 women) (GRADE moderate). Women using home uterine monitoring were also more likely to have prophylactic tocolytic drug therapy (average RR 1.21, 95% CI 1.01 to 1.45; seven studies, 4316 women; random-effects, Tau2 = 0.03, I2 = 62%), but this difference was no longer evident when we restricted the analysis to studies at low risk of bias (average RR 1.22, 95% CI 0.90 to 1.65; three studies, 3749 women; random-effects, Tau2 = 0.05, I2 = 76%) (GRADE low). The number of antenatal hospital admissions did not differ between home groups (RR 0.91, 95% CI 0.74 to 1.11; three studies, 1494 women (GRADE low)). We found no data on maternal anxiety or acceptability.

AUTHORS' CONCLUSIONS

Home uterine monitoring may result in fewer admissions to a neonatal intensive care unit but in more unscheduled antenatal visits and tocolytic treatment; the level of evidence is generally low to moderate. Important group differences were not evident when we undertook sensitivity analysis using only trials at low risk of bias. There is no impact on maternal and perinatal outcomes such as perinatal mortality or incidence of preterm birth.

Home uterine monitoring for detecting preterm labour

BACKGROUND

To reduce the morbidity and mortality associated with preterm birth, home uterine activity monitoring aims for early detection of increased contraction frequency, and early intervention with tocolytic drugs to inhibit labour and prolong pregnancy. However, the effectiveness of such monitoring is disputed.

OBJECTIVES

To determine whether home uterine activity monitoring is effective in improving the outcomes for women and their infants considered to be at high risk of preterm birth, when compared with conventional or other care packages that do not include home uterine monitoring.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 October 2014), CENTRAL (The Cochrane Library 2014, Issue 8), MEDLINE (1966 to 31 August 2014), EMBASE (1974 to 31 August 2014), CINAHL (1982 to 31 August 2014) and scanned reference lists of retrieved studies.

SELECTION CRITERIA

Randomised control trials of home uterine activity monitoring, with or without patient education programmes, for women at risk for preterm birth, in comparison to the same care package without home uterine activity monitoring.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We did not attempt to contact authors to resolve queries.

MAIN RESULTS

There were 15 included studies (total number of enrolled participants 6008); 13 studies contributed data. Women using home uterine monitoring were less likely to experience preterm birth at less than 34 weeks (risk ratio (RR) 0.78; 95% confidence interval (CI) 0.62 to 0.99; three studies, n = 1596; fixed-effect analysis) (GRADE high). The significant difference was not evident when we carried out a sensitivity analysis, restricting the analysis to studies at low risk of bias based on study quality (RR 0.75; 95% CI 0.57 to 1.00, one study, 1292 women). There was no significant difference in the rate of perinatal mortality (RR 1.22; 95% CI 0.86 to 1.72; two studies, n = 2589) (GRADE low)There was no significant difference in the number of preterm births at less than 37 weeks (average RR 0.85; CI 0.72 to 1.01; eight studies, n = 4834; random-effects, T² = 0.03, I² = 68%) (GRADE very low). Infants born to women using home uterine monitoring were less likely to be admitted to neonatal intensive care unit (average RR 0.77; 95% CI 0.62 to 0.96; five studies, n = 2367; random-effects, T² = 0.02, I² = 32%) (GRADE moderate). The difference was not statistically significant when only high quality studies were included (RR 0.86; 95% CI 0.74 to 1.01; one study, n = 1292). Women using home uterine monitoring made more unscheduled antenatal visits (mean difference (MD) 0.49; 95% CI 0.39 to 0.62; two studies, n = 3707) (GRADE moderate). Women using home uterine monitoring were also more likely to have prophylactic tocolytic drug therapy (average RR 1.21; 95% CI 1.01 to 1.45; seven studies, n = 4316; random-effects. T² = 0.03, I² = 62%) but this difference was no longer significant when the analysis was restricted to higher quality studies (average RR 1.22; 95% CI 0.90 to 1.65, three studies, n = 3749,random-effects, T² = 0.05, I² = 76%) (GRADE low). One small study reported that the home uterine monitoring group spent fewer days in hospital antenatally. No data on maternal anxiety or acceptability were found.

AUTHORS' CONCLUSIONS

Home uterine monitoring may result in fewer admissions to a neonatal intensive care unit but more unscheduled antenatal visits and tocolytic treatment, but the level of evidence is generally low to moderate. Important group differences were not evident when sensitivity analysis was undertaken using only high quality trials. There is no impact on maternal and perinatal outcomes such as perinatal mortality or incidence of preterm birth.

Home uterine monitoring for detecting preterm labour

BACKGROUND

To reduce the morbidity and mortality associated with preterm birth, home uterine activity monitoring aims for early detection of increased contraction frequency, and early intervention with tocolytic drugs to inhibit labour and prolong pregnancy. However, the effectiveness of such monitoring is disputed.

OBJECTIVES

To determine whether home uterine activity monitoring is effective in improving the outcomes for women and their infants considered to be at high risk of preterm birth, when compared with conventional or other care packages that do not include home uterine monitoring.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 November 2011), CENTRAL (The Cochrane Library 2011, Issue 4 of 4), MEDLINE (1966 to 30 November 2011), EMBASE (1974 to 30 November 2011), CINAHL (1982 to 30 November 2011) and scanned reference lists of retrieved studies.

SELECTION CRITERIA

Randomised control trials of home uterine activity monitoring, with or without patient education programmes, for women at risk for preterm birth, in comparison to the same care package without home uterine activity monitoring.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion, extracted data and assessed risk of bias. Data were checked for accuracy. We did not attempt to contact authors to resolve queries.

MAIN RESULTS

There were 15 included studies (total number of enrolled participants 6008); 13 studies contributed data. Women using home uterine monitoring were less likely to experience preterm birth at less than 34 weeks (risk ratio (RR) 0.78; 95% confidence interval (CI) 0.62 to 0.99; three studies, n = 1596; fixed-effect analysis). However, this significant difference was not evident when we carried out a sensitivity analysis, restricting the analysis to studies at low risk of bias based on study quality (RR 0.75; 95% CI 0.57 to 1.00, one study, 1292 women). There was no significant difference in the rate of perinatal mortality (RR 1.22; 95% CI 0.86 to 1.72; two studies, n = 2589).There was no significant difference in the number of preterm births at less than 37 weeks (average RR 0.85; CI 0.72 to 1.01; eight studies, n = 4834; random effects, T(2) = 0.03, I(2) = 68%). Infants born to women using home uterine monitoring were less likely to be admitted to neonatal intensive care unit (average RR 0.77; 95% CI 0.62 to 0.96; five studies, n = 2367; random-effects, T(2) = 0.02, I(2) = 32%). Although this difference was not statistically significant when only high quality studies were included (RR 0.86; 95% CI 0.74 to 1.01; one study, n = 1292). Women using home uterine monitoring made more unscheduled antenatal visits (mean difference (MD) 0.49; 95% CI 0.39 to 0.62; two studies, n = 2807). Women using home uterine monitoring were also more likely to have prophylactic tocolytic drug therapy (average RR 1.21; 95% CI 1.01 to 1.45; seven studies, n = 4316; random-effects. T(2) = 0.03, I(2) = 62%) but this difference was no longer significant when the analysis was restricted to high quality studies (average RR 1.22; 95% CI 0.90 to 1.65, three studies, n = 3749,random effects, T(2) = 0.05, I(2) = 76%). One small study reported that the home uterine monitoring group spent fewer days in hospital antenatally. No data on maternal anxiety or acceptability were found.

AUTHORS' CONCLUSIONS

Home uterine monitoring may result in fewer admissions to a neonatal intensive care unit but more unscheduled antenatal visits and tocolytic treatment. There is no impact on maternal and perinatal outcomes such as perinatal mortality or incidence of preterm birth.

The pregnant uterus as a psycho-endocrine organ

The pathogenesis of preterm birth (PTB) is largely unknown and the endocrine stress pathway is likely to participate in the mechanisms allowing onset of labor. However, the vast majority of the studies evaluating psychosocial distress denied an association with PTB. Uterine contractility rather than PTB seems associated with distress in pregnancy.

Home uterine monitoring: a case of telemedicine failure?

The aim of the article is to explore and explain some of the controversies around home uterine monitoring, using a socio-technical interaction networks (STIN) approach. A Cochrane systematic review identified 15 included studies. A critique of these studies, using the eight components of the STIN framework, illustrated very clearly the different assumptions made about the purpose of home uterine monitoring, and helped to explain the different outcomes. The final mapping stage suggested that systems architecture choices included that of the role of monitoring support, to complement patient education or to enhance education for provider and patient. A similar choice concerned the type and extent of patient-care-provider contacts to be used. Using the STIN framework provided a useful perspective on the telemedicine aspects of home uterine monitoring, providing value beyond the systematic review conclusions alone.

Goals and strategies for prevention of preterm birth: an obstetric perspective

Complications of prematurity surpass congenital malformations as the leading cause of infant mortality in the United States. Since 1990, there has been a steady rise in preterm birth, alarming health professionals from all disciplines. This review from a prenatal perspective confirms those concerns and describes the risks and opportunities that may attend efforts to improve the health of fetuses, newborns, and infants. Fetal and live-born outcomes are included.

Prevention of Preterm Birth

The preterm birth rate in the USA is nearing 13%. The recent rise has been attributed to increased indicated preterm births and multiple births following artificial conceptions. There are few obstetrical interventions that successfully delay or prevent spontaneous preterm birth or reduce the risk factors leading to indicated preterm birth. On the other hand, there are many strategies that have improved outcomes for those infants who are born preterm. These include the use of corticosteroids for fetal maturation and regionalization of perinatal care for high-risk mothers and their infants. Several interventions, including progesterone use and cerclage, demonstrate promise in reducing spontaneous preterm births. The most pressing need is to better define the populations of pregnant women for whom these and other interventions will effectively reduce preterm birth.

Primary, secondary, and tertiary interventions to reduce the morbidity and mortality of preterm birth

Interventions to reduce the morbidity and mortality of preterm birth can be primary (directed to all women), secondary (aimed at eliminating or reducing existing risk), or tertiary (intended to improve outcomes for preterm infants). Most efforts so far have been tertiary interventions, such as regionalised care, and treatment with antenatal corticosteroids, tocolytic agents, and antibiotics. These measures have reduced perinatal morbidity and mortality, but the incidence of preterm birth is increasing. Advances in primary and secondary care, following strategies used for other complex health problems, such as cervical cancer, will be needed to prevent prematurity-related illness in infants and children.

Predictors of preterm birth

OBJECTIVE

This is a systematic review to assess published scientific evidence on preterm birth predictors.

METHODS

An Internet search for predictors of preterm birth was performed and the evidence level of each method was evaluated.

RESULTS

There is strong evidence that preterm birth can be predicted using vaginal sonography to evaluate cervical characteristics, fetal fibronectin in cervicovaginal secretions and interleukin-6 in amniotic fluid. There is consistent evidence that digital cervical examination is a weak predictor, and controversy regarding home uterine activity monitoring. There is scanty evidence about the predictive ability of maternal history and perceptions of symptoms since the study design fails to provide high evidence level.

CONCLUSION

Cervical evaluation by vaginal sonography, fetal fibronectin and interleukin-6 are the best methods for predicting preterm birth.

Uterine contraction assessment

Few approaches to preterm birth prevention have been as thoroughly studied yet as enigmatic as uterine contraction assessment. Despite multiple randomized clinical trials (level 1 evidence), the effectiveness of home uterine contraction assessment as an adjunct to the clinical management of women at risk for preterm birth remains controversial. This article reviews these trials with particular attention to study design and patient inclusion criteria. The data are absolutely clear that home uterine contraction monitoring with or without frequent perinatal nursing contact can reduce the risk of preterm birth and improve perinatal outcomes and that both are independently superior to standard preterm birth prevention education and care.

Towards improved neonatal outcome: future strategies

The role of the obstetrician is to help predict and prevent maternal/fetal infection/inflammation related to neonatal mortality and morbidity. Predictive studies have mainly focused on the high-risk phenotype. Currently, there is a scientific drive to analyse the genetic susceptibility of preterm birth (PTB). Studies of the combination of environmental and lifestyle risk factors with the known genotype may result in a better understanding of the causation of PTB. Predictive technical markers such as fibronectin, cervical length measurement and home uterine activity remain largely unproven. Current antenatal care has not achieved primary prevention of PTB. Tocolytics and antibiotics constitute the two key elements of secondary prevention. Tocolytics have a minimal benefit but should not be used to prolong an infected preterm pregnancy. The use of antibiotics in preterm premature rupture of membranes can prolong the pregnancy with a decrease in neonatal morbidity. Anti-inflammatory cytokines, cytokine inhibitors and soluble cytokine receptors are promising treatment options that could modulate the intra-amniotic inflammatory process.

Obstetric complications of twin pregnancies

Advances in assisted reproductive technology and increases in the proportion of maternities in older women have both contributed to the steep increase in the incidence of twin pregnancies since the 1980s. Maternal and perinatal complications are higher in twins than in singleton pregnancies. A significant proportion of perinatal mortality and morbidity among twins is due to the high incidence of preterm delivery and the added complication of twin-to-twin transfusion syndrome (TTTS) in monochorionic twins. Monochorionic twins also have a much higher rate of perinatal mortality than dichorionic twins, the greatest risk being before fetal viability (<24 weeks gestation). Early diagnosis of twins and their chorionicity, close fetal surveillance, particularly of monochorionic twins, and prompt therapeutic intervention in TTS are necessary to reduce perinatal mortality. Intrapartum management in the hospital setting with anaesthetic and neonatal facilities, as well as critical assessment of mode of delivery, have led to better outcomes. Ultrasonography is a valuable tool in the management of twin pregnancy. This chapter briefly summarises these topics, with a particular focus on recent literature.

Current status of home uterine activity monitoring

A comprehensive evidence-based review of the clinical data leads to the conclusion that if patients at high risk for preterm birth (eg, prior preterm birth because of preterm labor, twins and higher-order multiple gestation, women who have preterm labor during the current pregnancy tocolyzed effectively) use the comprehensive system of HUAM correctly (ie, daily nursing care and twice-daily monitoring) with appropriate alarm rates and sensitive monitors, the incidence of early diagnosis of preterm labor, effective prolongation of pregnancy with fewer preterm births, and a reduction in neonatal morbidity is always demonstrated when the study group is compared with a control group consisting of women receiving standard care available to obstetricians in the United States. The authors expect that there will always be arguments regarding whether the monitor or the nurse contributes most to preterm birth reduction. Even when the alerts of detected contractions or patient-reported symptoms are sounded, the issue of prompt and effective medical intervention will always be hotly debated. The appropriate research design that tests HUAM while allowing various diagnostic and treatment modalities that physicians employ around the United States must be individualized. Physicians must make the decision, based on the evidence, regarding whether or not this system would benefit their patients. While investigators argue about research designs and statistical analyses, physicians simply want the best outcomes for their patients, which is what women and the whole of society also want. Based on the available evidence, it is clear that when the comprehensive system of HUAM is used appropriately in the right patients, everyone benefits.

Our unrequited love for simple explanation

In the complex and often perplexing field of perinatology, it is often tempting to extrapolate the results of the latest published study to our daily clinical practice, especially when the study appears to provide simple answers to difficult questions. This tendency is further encouraged by sensational media coverage and commentaries that, by necessity, further simplify the issues and hype the speculation. Without a critical appraisal of the study population, methodology, analysis and conclusions stated, globalizing a single study's results to anyone's clinical practice can be well-intentioned but misguided. As an example, approximately 1 year ago the results of an NICHD study involving home uterine activity monitoring (HUAM) were released. The study concluded that, while the likelihood of preterm delivery increased with an increased baseline frequency of uterine contractions, measurement of this contractility was not a clinically efficient predictor of preterm delivery. Through the media and editorials that followed, the study results became translated so as to indicate that HUAM was not effective in preventing preterm delivery or improving perinatal outcomes. In our desire for a simple and definitive conclusion on HUAM, key facts about this study were forgotten. In the NICHD study, uterine contraction data were blinded to both physician and patient, and only intermittent preterm monitoring was used with no provision for emergency monitoring; a study design that guaranteed patient management and outcomes would not be affected by HUAM. Using the NICHD HUAM study as an example to be learned from, we should be more critical and independent in our appraisal of published trials. Evidence-based medicine is only useful when we pay as much attention to the methodology as we do to the results.

What have we learned about uterine contractions and preterm birth? The HUAM Prediction Study

Measurement of uterine contraction frequency has been employed as a screening test to identify women with increased risk of preterm birth, and as an aid in the early diagnosis of preterm labor. The National Institute of Child Health and Human Development Maternal-Fetal Medicine Units (NICHD MFMU) Network performed a prospective, blinded observational study of uterine contraction frequency to detect and predict preterm labor and birth, respectively. The goal of the study was to assess the sensitivity, specificity, and positive and negative predictive value of various measures of uterine contraction frequency. Data collected from 306 women revealed that contraction frequency was significantly greater in women who would ultimately deliver before rather than after 35 weeks' gestation. However, both sensitivity and positive predictive value of any measure of contraction frequency to predict preterm birth were poor. Contraction frequency did not increase significantly within 1 or 2 weeks of an episode of preterm labor. These results serve to explain the absence of an association between contraction-based surveillance and preterm birth in randomized trials conducted in women at risk of preterm birth.

The diagnosis and management of preterm labor

Accurate diagnosis of preterm labor remains a problematic issue. New techniques such as transvaginal cervical sonography and fetal fibronectin are increasingly important in diagnosis and intervention planning. Neither test can, at present, be recommended for screening of the general population since there is no effective intervention for a positive test. Future directions in research include development of new tocolytic agents such as COX-2 inhibitors and clarification of the best use of adjunctive therapies such as betamethasone for lung maturity.

Alternative approaches to preterm labor

Alternative approaches to the management of preterm labor have included home uterine activity monitoring, long-term tocolysis, bed rest, and intravenous hydration. Current evidence in the literature does not support improved pregnancy outcomes with these various therapies.

A preterm birth prevention project in Nova Scotia, Canada

OBJECTIVE

The Halifax County Preterm Birth Prevention Project was designed to evaluate the effectiveness of a population-based preterm birth (PTB) prevention program in Nova Scotia from January 1995 through June 1997 (n = 10,326).

METHODS

Preterm birth rates, adjusted for risk status and maternal age, were evaluated over time in Halifax County and compared to non-Halifax County parturients in Nova Scotia. Physician participation was evaluated by means of a mailed survey.

RESULTS

There was no appreciable change in the overall (<37 weeks) or early (<34 weeks) PTB rates within or outside Halifax County during the intervention period compared to the preintervention period. Although not significant, the very (<30 weeks) PTB rate in Halifax County decreased by 40% from 0.53 to 0.32%, while outside Halifax County it remained stable (0.43-0.42%). There was a statistically significant decrease in early and very PTB associated with spontaneous labour, as well as an apparent shift in the timing of delivery from very preterm to preterm (> or =30 weeks). Participation among responding physicians was greater for high-risk than low-risk women, but full compliance with project recommendations was low.

CONCLUSION

The overall ineffectiveness of the Halifax County Preterm Birth Prevention Project may reflect the reluctance of practitioners to fully incorporate the recommended prevention strategies into their practice. However, such interventions may reduce the risk of spontaneous early preterm birth.

Uterine electrical activity as predictor of preterm birth in women with preterm contractions

OBJECTIVE

To estimate the risk of preterm birth in women admitted to the tertiary maternity hospital for preterm contractions by measuring electrical uterine activity.

STUDY DESIGN

The study included 47 patients with contractions between the 25th and 35th week of gestation and additional risk factors for preterm delivery. Uterine electrical activity was recorded using bipolar electrodes placed on the abdominal surface. A logistic model with the electromyographic and obstetric data was built, preterm delivery before 37th week of gestation being the outcome measure.

RESULTS

Seventeen patients (36%) delivered before term. Logistic regression model suggested only the intensity of electrical uterine activity and woman's body weight to be significant predictors of preterm delivery, with high values related to preterm birth. They predict preterm delivery with the sensitivity of 47% and specificity of 90%.

CONCLUSION

We propose uterine EMG as a simple, non-invasive means to estimate the risk of preterm birth in a high-risk population with multiple risk factors present.

Current concepts on the pathogenesis and markers of preterm births

Preterm births remain a major cause of neonatal morbidity and mortality despite our efforts over the past several decades. Our improved understanding of the complex mechanisms surrounding preterm labor, however, has resulted in the development of numerous biologic and clinical predictors of spontaneous preterm births. These developments offer the exciting prospect for the creation of specific interventions that are directed toward the various pathways involved with preterm births.

Prevention of premature birth: do pediatricians have a role?

The rate of prematurity in the United States has increased over the past 15 years despite a reduction in overall infant mortality and birth weight-specific mortality. The major factors contributing to premature birth exist before pregnancy and therefore will require intervention strategies in the pediatric patient. The high-risk factors include young age at conception (16 years), use of illicit drugs and smoking, poor nutritional status, and certain vaginal infections. Pediatric intervention strategies should include sociologic as well as health education stressing heightened self-esteem and communication skills, avoidance of pregnancy and unprotected sexual activity, avoidance of smoking and drug use, and promotion of a good nutritional status.

Telemedicine versus face to face patient care: effects on professional practice and health care outcomes

BACKGROUND

Telemedicine is the use of telecommunications technology for medical diagnosis and patient care. From its beginnings telemedicine has been used in a variety of health care fields, although widespread interest among healthcare providers has only now become apparent with the development of more sophisticated technology.

OBJECTIVES

To assess the effects of telemedicine as an alternative to face-to-face patient care.

SEARCH STRATEGY

We searched the Effective Practice and Organisation of Care Group's specialised register, The Cochrane Library, MEDLINE (1966-August 1999), EMBASE (to 1996), Cinahl (to August 1999), Inspec (to August 1996), Healthstar (1983-1996), OCLC, Sigle (to 1999), Assia, SCI (1981-1997), SSCI (1981-1997), DHSS-Data. We hand searched the Journal of Telemedicine and Telecare (1995-1999), Telemedicine Journal (1995-1999) and reference lists of articles. We also hand searched conference proceedings and contacted experts in countries identified as having an interest in telemedicine.

SELECTION CRITERIA

Randomised trials, controlled before and after studies and interrupted time series comparing telemedicine with face-to-face patient care. The participants were qualified health professionals and patients receiving care through telemedicine.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data.

MAIN RESULTS

Seven trials involving more than 800 people were included. One trial was concerned with telemedicine in the emergency department, one with video-consultations between primary health care and the hospital outpatients department, and the remainder were concerned with the provision of home care or patient self-monitoring of chronic disease. The studies appeared to be well conducted, although patient numbers were small in all but one. Although none of the studies showed any detrimental effects from the interventions, neither did they show unequivocal benefits and the findings did not constitute evidence of the safety of telemedicine. None of the studies included formal economic analysis. All the technological aspects of the interventions appear to have been reliable, and to have been well accepted by patients.

REVIEWER'S CONCLUSIONS

Establishing systems for patient care using telecommunications technologies is feasible, but there is little evidence of clinical benefits. The studies provided variable and inconclusive results for other outcomes such as psychological measures, and no analysable data about the cost effectiveness of telemedicine systems. The review demonstrates the need for further research and the fact that it is feasible to carry out randomised trials of telemedicine applications. Policy makers should be cautious about recommending increased use and investment in unevaluated technologies.

Use of the electrohysterogram signal for characterization of contractions during pregnancy

This article proposes a method to evaluate the ability of the electrohysterogram signal to characterize the contractions during pregnancy, in a population with high risk of preterm deliveries. This study constitutes a first stage of a project intended to develop a monitoring system for the early diagnosis of preterm deliveries. After a proper signal denoising, we calculate some parameters characteristic of the extracted contractions. These contractions are then divided into classes of different physiological terms. Classical techniques of data analysis, such as principal component analysis and discriminant analysis, permit us to show an evolution of the contractions during pregnancy, which is different between the groups of preterm deliveries and that of deliveries at term. We show that, in an early term of pregnancy, we can separate the two populations: women delivering at term from women delivering preterm. We then show that these two kinds of pregnancy are of different evolutions. These results are encouraging, because they would permit, in a follow-up medical study, to diagnose a possible preterm delivery, as well as the proximity of the delivery.

A randomized comparison of home uterine activity monitoring in the outpatient management of women treated for preterm labor

OBJECTIVE

The aim of the study was to evaluate home uterine activity monitoring as an intervention in reducing the rate of preterm birth among women treated for preterm labor.

STUDY DESIGN

A total of 186 women were treated in the hospital with magnesium sulfate for preterm labor and were prospectively randomly assigned to study groups; among these, 162 were ultimately eligible for comparison. Eighty-two of these women were assigned to the monitored group and 80 were assigned to an unmonitored control group. Other than monitoring, all women received identical prenatal follow-up, including daily perinatal telephone contact and oral terbutaline therapy. Outcome comparisons were primarily directed toward evaluation of preterm birth at <35 weeks' gestation. Readmissions for recurrent preterm labor and observations lasting <24 hours were evaluated in monitored and unmonitored groups. Compliance with monitoring was also evaluated in the monitored group.

RESULTS

The monitored and control groups were demographically similar. According to a multivariate logistic regression model, women with cervical dilatation of >/=2 cm were 4 times more likely to be delivered at <35 weeks' gestation (P <.05). Gestational ages at delivery were similar in the monitored and control groups. There was no significant difference in the overall rate of preterm delivery at <35 weeks' gestation between the monitored group (10.9%) and the control group (15.0%). The overall rates of delivery at <37 weeks' gestation were high (48.8% and 60.0% for monitored and control groups, respectively), and the difference was not significant. The numbers of women with >/=1 instance of readmission and treatment for recurrent preterm labor were equal in the monitored and control groups. The numbers of women with >/=1 hospital observation lasting <24 hours were not different between the groups. Compliance with monitoring did not significantly differ for women who were delivered at <35 weeks' gestation, women with >/=2 cm cervical dilatation at enrollment, or for African American women.

CONCLUSION

A reduction in the likelihood of preterm delivery at <35 weeks' gestation was not further enhanced by the addition of home uterine monitoring to the outpatient management regimens of women treated for preterm labor.

Ambulatory management of multiple gestation

Ambulatory management of multiple gestation requires careful and continuing care by the obstetrician. The initial evaluation should include a comprehensive history, including use of fertility enhancing drugs and ART, family history, social history; a general physical examination, including a pelvic examination; laboratory evaluation, including complete blood cell count, dipstick urinalysis for protein and glucose, urine culture, blood type, Rh factor and irregular blood antibody determination, serology for rubella, syphilis, hepatitis B surface antigen and varicella (if there is no history). A Papanicolaou smear should be done at the time of the pelvic examination, as should evaluation for bacterial vaginosis. Ultrasound assessment of placentation should be done at 14 weeks' gestation, but vaginal or perineal ultrasound of cervical length should be done at the initial visit. Other testing procedures should include repeat ultrasound evaluation for fetal growth every 4 weeks in a dichorionic placentation and every 3 weeks if monochorionic placentation is present. Triple screen MSAFP at 16-18 weeks' gestation and blood sugar screening at 22-26 weeks should be performed. After the first trimester, the patient should schedule physician visits every 2 weeks or less. Routine medications should include one prenatal vitamin per day, additional folic acid supplementation of 1.0 mg per fetus, supplemental iron preparation, and additional calcium to equal 1500 mg/day. The use of low-dose aspirin to prevent preeclampsia in twin gestations has not been adequately studied. Continuing vigilance by the knowledgeable obstetrician should occur. Multiple gestations should not be cared for by non-physician providers or by family physicians. Referral to a maternal-fetal medicine unit is recommended.

The U.S. Preventive Services Task Force: putting evidence-based medicine to work

The U.S. Preventive Services Task Force is a prominent example of evidence-based medicine put to work. The Guide to Clinical Preventive Services and its Canadian counterpart distill thousands of articles into easily understood guidelines for the busy clinician. Rather than dictating practice, it provides the scientific base for prevention services. The second fundamental part of evidence-based medicine is the filtering of that evidence through the clinical skill of the clinician. Only the clinician can judge the applicability of the evidence and the preferences of the woman and her family. Some common preventive practices in women's health lack a scientific basis. Others clearly work. To maximize benefit, clinicians should emphasize and encourage prevention strategies that are effective. These include cervical cytology screening, blood pressure screening, urine cultures in early pregnancy, testing for phenylketonuria, and discouraging smoking. No health program can be reviewed in a vacuum. This is especially true in the managed care era. Clinicians must ask what benefit would have accrued had the same amount of time and money been spent on alternative programs. If practices with only a class C recommendation draw money and resources from other programs of proven worth (e.g., class A recommendations), then the former have a net negative impact on women's health. The Task Force report helps women, clinicians, payers, and policymakers make these important decisions.

Preterm labour: recent advances in understanding of pathophysiology, diagnosis and management

Recent advances in the importance of sociodemographic factors, including maternal stress, as well as potential predictors of preterm birth are reviewed. The recommended role of adjunctive antibiotic therapy, in women with preterm premature rupture of the membranes but not in women with intact membranes, is discussed. The possibility of causes other than those related to infection in preterm rupture of the membranes is raised, and new information regarding the use of glucocorticoids and tocolytics is presented. Despite steady improvements in neonatal survival and morbidity rates over the past decade primarily as a result of improved neonatal care, there has been no corresponding decrease in the incidence of preterm birth. An improved understanding of the pathophysiology and diagnosis of preterm birth remains one of the greatest challenges in obstetric care in this decade.

Has the use of home monitors, fetal fibronectin, and measurement of cervical length helped predict labor and/or prevent preterm delivery in twins?

Home monitoring accurately detects contractions, and thus is useful in predicting preterm labor. Appropriate physician action is necessary to significantly prolong pregnancy even in the presence of evidence of excessive contractions. Despite conflicting studies, the majority of evidence heavily favors the use of monitoring as part of a comprehensive preterm birth prevention program. Indeed, monitoring has greater clinical utility in twin gestations because of the recognized propensity for preterm labor. Fetal fibronectin is one of the most sensitive and specific markers for preterm labor and subsequent early delivery presently available. It appears to be equally effective in multifetal gestations compared with singleton gestations, but intervention trials are needed to substantiate its clinical effectiveness. Cervical status monitoring by ultrasound correlates inversely with preterm labor, but studies in twin gestation are currently lacking. Other markers, such as salivary estriol for preterm labor, have yet to be assessed as predictors of preterm labor among multifetal gestations.

Monitoring women at risk for preterm labor

BACKGROUND

Preterm birth is a major cause of perinatal morbidity and mortality. Whether the rate of preterm birth can be reduced by frequent contact between nurses and pregnant women or home monitoring of uterine activity is not known.

METHODS

We randomly assigned 2422 pregnant women with known risk factors for preterm labor (including 844 women who were pregnant with twins) to receive education and to have one of the following: weekly contact with a nurse, daily contact with a nurse, or daily contact with a nurse and home monitoring of uterine activity. The nurses elicited the women's own assessments of their symptoms and signs of preterm labor. The primary end point was the incidence of birth at less than 35 weeks' gestation. Secondary end points included cervical status at the time preterm labor was diagnosed and birth weight.

RESULTS

There were no significant differences among the groups in the incidence of birth at less than 35 weeks (14 percent in the weekly-contact group, 13 percent in the daily-contact group, and 14 percent in the home-monitoring group), in the mean amount of cervical dilatation at the time preterm labor was diagnosed (1.8 cm, 1.5 cm, and 1.4 cm, respectively), or in such neonatal outcomes as birth weights of less than 1500 g or less than 2500 g. However, daily contact with a nurse increased the mean number of unscheduled visits to obstetricians (1.2 in the weekly-contact group, 1.8 in the daily-contact group, and 2.3 in the home-monitoring group) and the proportion of women who received prophylactic tocolytic drugs (12 percent, 14 percent, and 19 percent, respectively).

CONCLUSIONS

Women who have daily contact with a nurse, with or without home monitoring of uterine activity, have no better pregnancy outcomes than women who have weekly contact with a nurse.

Toward lower cesarean birth rates and effective care: five years' outcomes of joint private obstetric practice

BACKGROUND

Many ways to improve perinatal outcomes, deliver cost-effective care, and increase client and caregiver satisfaction have been suggested. This article adds to the body of such literature by describing a joint practice in California and reporting five years of its outcomes.

METHOD

Frequency data were recorded prospectively for all pregnant women seen between January 1, 1991, and December 31, 1995. Overall statistics and variable-specific frequencies were then analyzed for the 1303 consecutive singleton births that occurred during this period.

RESULTS

The primary cesarean birth rate for the sample was 6.5 percent, the total rate was 9.1 percent, and the rate for women having their first full-term pregnancy was 11.3 percent. Of all women with a previous cesarean birth, 72.2 percent delivered vaginally. The success rate of attempted vaginal births after cesarean was 83.5 percent. Instrument deliveries were performed for 2.0 percent of births, and the frequency of third- or fourth-degree lacerations was 3.0 percent of all vaginal births. Transfers to a tertiary neonatal intensive care unit were 1.3 percent, and the perinatal mortality rate was 5.4 per 1000 births (corrected for serious anomalies: 3/1000). The preterm birth rate (including maternal transfers) was 2.0 percent.

CONCLUSION

An obstetric practice in a private community hospital setting that effectively used obstetricians, nurse-midwives, and nurse practitioners reported low rates of cesarean birth, preterm birth, severe lacerations, instrument deliveries, and legal incidents, and excellent cost-effective maternal and neonatal outcomes.

Further defining the risks confronting twins

OBJECTIVE

We report the absolute and relative risks for neonatal and infant death, low and very low birth weight, and delivery at < 33 and < 35 weeks' gestation in twin pregnancy stratified by maternal race and age, as well as gender pair combinations of the twins.

STUDY DESIGN

Data on 324,141 twin infants were obtained from the 1985 to 1988 U.S. Linked Birth/ Infant, Death Data Sets. In this observational cohort study, we analyzed the outcomes of 138,779 twin pregnancies of white and black women that ended with the delivery of two live-born infants.

RESULTS

Rates for the aforementioned outcomes are increased for black infants, for male-male pairs compared with male-female pairs (with female-female pairs being intermediate), and for young mothers. For male-male twins born to young (< or = 22 years old) black women, relative risks range from 2.1 for both pair members being low birth weight (< 2500 gm) to 5.0 for both pair members dying in infancy, when male-female pairs born to older (> or = 28 years) white women served as the reference group.

CONCLUSIONS

Although all twin pregnancies are at higher risk than singletons, risk is influenced by maternal race and age, as well as gender pair combination. These analyses provide useful information for counseling women pregnant with twins. Furthermore, they suggest that failure to consider variations in baseline risk may have seriously flawed studies evaluating prophylactic interventions in twin pregnancy.