Do maternal haemodynamics have a causal influence on treatment for gestational diabetes?

BACKGROUND

Arterial stiffening is believed to contribute to the worsening of insulin resistance, and factors which are associated with needing pharmacological treatment of gestational diabetes (GDM), such as maternal obesity or advanced age, are associated with impaired cardiovascular adaptation to pregnancy. In this observational study, we aimed to investigate causal relationships between maternal haemodynamics and treatment requirement amongst women with GDM.

METHODS

We assessed maternal haemodynamics in women with GDM, comparing those who remained on dietary treatment with those who required pharmacological management. Maternal haemodynamics were assessed using the Arteriograph® (TensioMed Ltd, Budapest, Hungary) and the NICOM® non-invasive bio-reactance method (Cheetah Medical, Portland, Oregon, USA). A graphical causal inference technique was used for statistical analysis.

RESULTS

120 women with GDM were included in the analysis. Maternal booking BMI was identified as having a causative influence on treatment requirement, with each unit increase in BMI increasing the odds of needing metformin and/or insulin therapy by 12% [OR 1.12 (1.02 - 1.22)]. The raw values of maternal heart rate (87.6 ± 11.7 vs. 92.9 ± 11.90 bpm, p = 0.014) and PWV (7.8 ± 1.04 vs. 8.4 ± 1.61 m/s, p = 0.029) were both significantly higher amongst the women requiring pharmacological management, though these relationships did not remain significant in causal logistic regression.

CONCLUSIONS

Maternal BMI at booking has a causal, rather than simply associational, relationship on the need for pharmacological treatment of GDM. No significant causal relationships were found between maternal haemodynamics and the need for pharmacological treatment.

Does treatment modality affect measures of arterial stiffness in women with gestational diabetes?

OBJECTIVE

To investigate whether arterial stiffness (AS) differs between healthy women and women with gestational diabetes mellitus (GDM) managed by different treatment modalities.

METHODS

This was a prospective longitudinal cohort study comparing AS in pregnancies complicated by GDM and low-risk controls. AS was assessed by recording aortic pulse-wave velocity (AoPWV), brachial augmentation index (BrAIx) and aortic augmentation index (AoAIx) using the Arteriograph® at four gestational-age windows: 24 + 0 to 27 + 6 weeks (W1); 28 + 0 to 31 + 6 weeks (W2); 32 + 0 to 35 + 6 weeks (W3) and ≥ 36 + 0 weeks (W4). Women with GDM were considered both as a single group and as subgroups stratified by treatment modality. Data were analyzed using a linear mixed model on each AS variable (log-transformed) with group, gestational-age window, maternal age, ethnicity, parity, body mass index, mean arterial pressure and heart rate as fixed effects and individual as a random effect. We compared the group means including relevant contrasts and adjusted the P-values using Bonferroni correction.

RESULTS

The study population comprised 155 low-risk controls and 127 women with GDM, of whom 59 were treated with dietary intervention, 47 were treated with metformin only and 21 were treated with metformin + insulin. The two-way interaction term of study group and gestational age was significant for BrAIx and AoAIx (P < 0.001), but there was no evidence that mean AoPWV was different between the study groups (P = 0.729). Women in the control group demonstrated significantly lower BrAIx and AoAIx compared with the combined GDM group at W1-W3, but not at W4. The mean difference in log-transformed BrAIx was -0.37 (95% CI, -0.52 to -0.22), -0.23 (95% CI, -0.35 to -0.12) and -0.29 (95% CI, -0.40 to -0.18) at W1, W2 and W3, respectively. The mean difference in log-transformed AoAIx was -0.49 (95% CI, -0.69 to -0.30), -0.32 (95% CI, -0.47 to -0.18) and -0.38 (95% CI -0.52 to -0.24) at W1, W2 and W3, respectively. Similarly, women in the control group also demonstrated significantly lower BrAIx and AoAIx compared with each of the GDM treatment subgroups (diet, metformin only and metformin + insulin) at W1-W3. The increase in mean BrAIx and AoAIx seen between W2 and W3 in women with GDM treated with dietary management was attenuated in the metformin-only and metformin + insulin groups. However, the mean differences in BrAIx and AoAIx between these treatment groups were not statistically significant at any gestational-age window.

CONCLUSIONS

Pregnancies complicated by GDM demonstrate significantly higher AS compared with low-risk pregnancies regardless of treatment modality. Our data provide the basis for further investigation into the association of metformin therapy with changes in AS and risk of placenta-mediated diseases. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Congenital CMV infection following a CMV PCR negative amniotic fluid result

Cytomegalovirus DNA PCR testing on amniotic fluid is a routine method to determine if a foetus is CMV-infected (congenital CMV infection, cCMV) following a diagnosis of maternal primary CMV infection. However, a negative CMV PCR result on an amniotic fluid sample taken at one time-point does not always preclude foetal CMV infection later in pregnancy, in the context of ongoing maternal CMV viremia. Here we describe a case of confirmed congenital CMV (cCMV) infection, diagnosed at birth in a baby, following a negative CMV PCR result on an amniotic fluid taken at 25 + 1/40 gestation. This article is protected by copyright. All rights reserved.

Noninvasive prenatal screening in twin pregnancies with cell-free DNA using the IONA test: a prospective multicenter study

BACKGROUND

In singleton pregnancies, studies investigating cell-free DNA in maternal blood have consistently reported high detection rate and low false-positive rate for the 3 common fetal trisomies (trisomies 21, 18, and 13). The potential advantages of noninvasive prenatal testing in twin pregnancies are even greater than in singletons, in particular lower need for invasive testing and consequent fetal loss rate. However, several organizations do not recommend cell-free DNA in twin pregnancies and call for larger prospective studies.

OBJECTIVE

In response to this, we undertook a large prospective multicenter study to establish the screening performance of cell-free DNA for the 3 common trisomies in twin pregnancies. Moreover, we combined our data with that reported in published studies to obtain the best estimate of screening performance.

STUDY DESIGN

This was a prospective multicenter blinded study evaluating the screening performance of cell-free DNA in maternal plasma for the detection of fetal trisomies in twin pregnancies. The study took place in 6 fetal medicine centers in England, United Kingdom. The primary outcome was the screening performance and test failure rate of cell-free DNA using next generation sequencing (the IONA test). Maternal blood was taken at the time of (or after) a conventional screening test. Data were collected at enrolment, at any relevant invasive testing throughout pregnancy, and after delivery until the time of hospital discharge. Prospective detailed outcome ascertainment was undertaken on all newborns. The study was undertaken and reported according to the Standards for Reporting of Diagnostic Accuracy Studies. A pooled analysis was also undertaken using our data and those in the studies identified by a literature search (MEDLINE, Embase, CENTRAL, Cochrane Library, and ClinicalTrials.gov) on June 6, 2020.

RESULTS

A total of 1003 women with twin pregnancies were recruited, and complete data with follow-up and reference data were available for 961 (95.8%); 276 were monochorionic and 685 were dichorionic. The failure rate was 0.31%. The mean fetal fraction was 12.2% (range, 3%-36%); all 9 samples with a 3% fetal fraction provided a valid result. There were no false-positive or false-negative results for trisomy 21 or trisomy 13, whereas there was 1 false-negative and 1 false-positive result for trisomy 18. The IONA test had a detection rate of 100% for trisomy 21 (n=13; 95% confidence interval, 75-100), 0% for trisomy 18 (n=1; 95% confidence interval, 0-98), and 100% for trisomy 13 (n=1; 95% confidence interval, 3-100). The corresponding false-positive rates were 0% (95% confidence interval, 0-0.39), 0.10% (95% confidence interval, 0-0.58), and 0% (95% confidence interval, 0-0.39), respectively. By combining data from our study with the 11 studies identified by literature search, the detection rate for trisomy 21 was 95% (n=74; 95% confidence interval, 90-99) and the false-positive rate was 0.09% (n=5598; 95% confidence interval, 0.03-0.19). The corresponding values for trisomy 18 were 82% (n=22; 95% confidence interval, 66-93) and 0.08% (n=4869; 95% confidence interval, 0.02-0.18), respectively. There were 5 cases of trisomy 13 and 3881 non-trisomy 13 pregnancies, resulting in a computed average detection rate of 80% and a false-positive rate of 0.13%.

CONCLUSION

This large multicenter study confirms that cell-free DNA testing is the most accurate screening test for trisomy 21 in twin pregnancies, with screening performance similar to that in singletons and very low failure rates (0.31%). The predictive accuracy for trisomies 18 and 13 may be less. However, given the low false-positive rate, offering first-line screening with cell-free DNA to women with twin pregnancy is appropriate in our view and should be considered a primary screening test for trisomy 21 in twins.

Effect of metformin on biomarkers of placental- mediated disease: A systematic review and meta-analysis

Metformin reduces the incidence of placental-mediated disease (PMD) in pregnancies with and without diabetes, but the mechanism through which it exerts these effects is not yet fully understood. We performed a systematic review and meta-analysis to examine the effect of metformin on biomarkers implicated in the pathogenesis of PMD. We searched Medline, Embase and the Cochrane Library for studies of metformin and biomarkers of PMD in pregnancy. Meta-analysis was undertaken where comparable data were obtained from two or more studies. 12 studies were included in the final review. Meta-analysis of 2 studies including 323 pregnant women showed significantly reduced CRP levels following treatment with metformin compared to placebo [mean difference = -1.72, 95% CI (-2.97; -0.48); p = 0.007]. Metformin exposure was also associated with decreased levels of the inflammatory cytokines TNFα, IL-1a, IL-1b and IL-6 in serum, placenta and omental tissue taken from pregnant women. Metformin significantly decreased the release of anti-angiogenic factors sFlt-1 and sEng from ex-vivo placental and umbilical vein tissue, and increased maternal serum levels of non-phosphorylated IGFBP-1. Overall, our findings show that metformin mediates several molecular pathways implicated in the pathogenesis of pre-eclampsia and intrauterine growth retardation. Metformin therefore has exciting potential as a therapeutic, as well as preventative, agent in the treatment of PMD, which warrants further investigation.

Mechanical and surgical interventions for treating primary postpartum haemorrhage

BACKGROUND

Primary postpartum haemorrhage (PPH) is commonly defined as bleeding from the genital tract of 500 mL or more within 24 hours of birth. It is one of the most common causes of maternal mortality worldwide and causes significant physical and psychological morbidity. An earlier Cochrane Review considering any treatments for the management of primary PPH, has been split into separate reviews. This review considers treatment with mechanical and surgical interventions.

OBJECTIVES

To determine the effectiveness and safety of mechanical and surgical interventions used for the treatment of primary PPH.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (26 July 2019) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of mechanical/surgical methods for the treatment of primary PPH compared with standard care or another mechanical/surgical method. Interventions could include uterine packing, intrauterine balloon insertion, artery ligation/embolism, or uterine compression (either with sutures or manually). We included studies reported in abstract form if there was sufficient information to permit risk of bias assessment. Trials using a cluster-RCT design were eligible for inclusion, but quasi-RCTs or cross-over studies were not.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion and risk of bias, independently extracted data and checked data for accuracy. We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

We included nine small trials (944 women) conducted in Pakistan, Turkey, Thailand, Egypt (four trials), Saudi Arabia, Benin and Mali. Overall, included trials were at an unclear risk of bias. Due to substantial differences between the studies, it was not possible to combine any trials in meta-analysis. Many of this review's important outcomes were not reported. GRADE assessments ranged from very low to low, with the majority of outcome results rated as very low certainty. Downgrading decisions were mainly based on study design limitations and imprecision; one study was also downgraded for indirectness. External uterine compression versus normal care (1 trial, 64 women) Very low-certainty evidence means that we are unclear about the effect on blood transfusion (risk ratio (RR) 2.33, 95% confidence interval (CI) 0.66 to 8.23). Uterine arterial embolisation versus surgical devascularisation plus B-Lynch (1 trial, 23 women) The available evidence for hysterectomy to control bleeding (RR 0.73, 95% CI 0.15 to 3.57) is unclear due to very low-certainty evidence. The available evidence for intervention side effects is also unclear because the evidence was very low certainty (RR 1.09; 95% CI 0.08 to 15.41). Intrauterine Tamponade Studies included various methods of intrauterine tamponade: the commercial Bakri balloon, a fluid-filled condom-loaded latex catheter ('condom catheter'), an air-filled latex balloon-loaded catheter ('latex balloon catheter'), or traditional packing with gauze. Balloon tamponade versus normal care (2 trials, 356 women) One study(116 women) used the condom catheter. This study found that it may increase blood loss of 1000 mL or more (RR 1.52, 95% CI 1.15 to 2.00; 113 women), very low-certainty evidence. For other outcomes the results are unclear and graded as very low-certainty evidence: mortality due to bleeding (RR 6.21, 95% CI 0.77 to 49.98); hysterectomy to control bleeding (RR 4.14, 95% CI 0.48 to 35.93); total blood transfusion (RR 1.49, 95% CI 0.88 to 2.51); and side effects. A second study of 240 women used the latex balloon catheter together with cervical cerclage. Very low-certainty evidence means we are unclear about the effect on hysterectomy (RR 0.14, 95% CI 0.01 to 2.74) and additional surgical interventions to control bleeding (RR 0.20, 95% CI 0.01 to 4.12). Bakri balloon tamponade versus haemostatic square suturing of the uterus (1 trial, 13 women) In this small trial there was no mortality due to bleeding, serious maternal morbidity or side effects of the intervention, and the results are unclear for blood transfusion (RR 0.57, 95% CI 0.14 to 2.36; very low certainty). Bakri balloon tamponade may reduce mean 'intraoperative' blood loss (mean difference (MD) -426 mL, 95% CI -631.28 to -220.72), very low-certainty evidence. Comparison of intrauterine tamponade methods (3 trials, 328 women) One study (66 women) compared the Bakri balloon and the condom catheter, but it was uncertain whether the Bakri balloon reduces the risk of hysterectomy to control bleeding due to very low-certainty evidence (RR 0.50, 95% CI 0.05 to 5.25). Very low-certainty evidence also means we are unclear about the results for the risk of blood transfusion (RR 0.97, 95% CI 0.88 to 1.06). A second study (50 women) compared Bakri balloon, with and without a traction stitch. Very low-certainty evidence means we are unclear about the results for hysterectomy to control bleeding (RR 0.20, 95% CI 0.01 to 3.97). A third study (212 women) compared the condom catheter to gauze packing and found that it may reduce fever (RR 0.47, 95% CI 0.38 to 0.59), but again the evidence was very low certainty. Modified B-Lynch compression suture versus standard B-Lynch compression suture (1 trial, 160 women) Low-certainty evidence suggests that a modified B-Lynch compression suture may reduce the risk of hysterectomy to control bleeding (RR 0.33, 95% CI 0.11 to 0.99) and postoperative blood loss (MD -244.00 mL, 95% CI -295.25 to -192.75).

AUTHORS' CONCLUSIONS

There is currently insufficient evidence from RCTs to determine the relative effectiveness and safety of mechanical and surgical interventions for treating primary PPH. High-quality randomised trials are urgently needed, and new emergency consent pathways should facilitate recruitment. The finding that intrauterine tamponade may increase total blood loss > 1000 mL suggests that introducing condom-balloon tamponade into low-resource settings on its own without multi-system quality improvement does not reduce PPH deaths or morbidity. The suggestion that modified B-Lynch suture may be superior to the original requires further research before the revised technique is adopted. In high-resource settings, uterine artery embolisation has become popular as the equipment and skills become more widely available. However, there is little randomised trial evidence regarding efficacy and this requires further research. We urge new trial authors to adopt PPH core outcomes to facilitate consistency between primary studies and subsequent meta-analysis.

An integrated in utero MR method for assessing structural brain abnormalities and measuring intracranial volumes in fetuses with congenital heart disease: results of a prospective case-control feasibility study

Purpose

To refine methods that assess structural brain abnormalities and calculate intracranial volumes in fetuses with congenital heart diseases (CHD) using in utero MR (iuMR) imaging. Our secondary objective was to assess the prevalence of brain abnormalities in this high-risk cohort and compare the brain volumes with normative values.

Methods

We performed iuMR on 16 pregnant women carrying a fetus with CHD and gestational age ≥ 28-week gestation and no brain abnormality on ultrasonography. All cases had fetal echocardiography by a pediatric cardiologist. Structural brain abnormalities on iuMR were recorded. Intracranial volumes were made from 3D FIESTA acquisitions following manual segmentation and the use of 3D Slicer software and were compared with normal fetuses. Z scores were calculated, and regression analyses were performed to look for differences between the normal and CHD fetuses.

Results

Successful 2D and 3D volume imaging was obtained in all 16 cases within a 30-min scan. Despite normal ultrasonography, 5/16 fetuses (31%) had structural brain abnormalities detected by iuMR (3 with ventriculomegaly, 2 with vermian hypoplasia). Brain volume, extra-axial volume, and total intracranial volume were statistically significantly reduced, while ventricular volumes were increased in the CHD cohort.

Conclusion

We have shown that it is possible to perform detailed 2D and 3D studies using iuMR that allow thorough investigation of all intracranial compartments in fetuses with CHD in a clinically appropriate scan time. Those fetuses have a high risk of structural brain abnormalities and smaller brain volumes even when brain ultrasonography is normal.

Haemodynamic differences amongst women who were screened for gestational diabetes in comparison to healthy controls

AIM

To assess the changes in haemodynamics amongst pregnant women who were screened for gestational diabetes mellitus (GDM) in comparison to low-risk healthy pregnant controls.

METHODOLOGY

A total of 120 pregnant women of mean (standard deviation) age 31.03 (5.41) years who attended their oral glucose tolerance test as part of the national screening for GDM (study), and 60 low-risk healthy pregnant women (control) of mean age 29.71 (5.33) years, were invited to participate in this study. All women included in the study booked at the University Hospitals of Leicester NHS Trust and fulfilled the relevant inclusion criteria. Non-invasive assessment of arterial stiffness and cardiac output were undertaken on participants between 26 and 28 weeks of pregnancy. The mean difference between GDM and low-risk group for each of the arterial stiffness and cardiac output measurements was assessed by a two-sample unpaired t-test.

RESULTS

Significant differences were found between the study and control groups for brachial (-64.5 vs. -69.5, p < 0.04) and aortic augmentation indices (5.2 vs. 2.7, p = 0.04), though there was no significant difference for PWV (8.3 vs. 8.1, p = 0.49). Cardiac output (7.6 vs. 7.0, p = 0.011), stroke volume (84.4 vs. 76.9, p = 0.013) and central mean arterial pressure (71 vs. 58, <0.001) were also significantly different between groups. However, no significant differences were reported for heart rate, systolic and diastolic blood pressure, or total peripheral resistance.

CONCLUSION

Pregnant women at risk of GDM between gestational weeks 26 and 28 had significantly increased measures of arterial stiffness, as assessed by brachial and aortic augmentation indices, compared with low-risk healthy controls. Whether these women are at greater long-term cardiovascular disease risk warrants further investigation.

The effects of metformin on maternal haemodynamics in gestational diabetes mellitus: A pilot study

BACKGROUND

Gestational diabetes mellitus (GDM) is a major clinical challenge and is likely to remain so as the incidence of GDM continues to increase.

AIM

To assess longitudinal changes in maternal haemodynamics amongst women diagnosed with GDM requiring either metformin or dietary intervention in comparison to low-risk healthy controls.

METHODOLOGY

Fifty-six pregnant women attending their first appointment at the GDM clinic and 60 low-risk healthy pregnant controls attending their routine antenatal clinics were recruited and assigned to three groups: GDM Metformin (GDM-M), GDM Diet (GDM-D) and Control. Non-invasive assessment of maternal haemodynamics, using recognised measures of arterial stiffness and central blood pressure (Arteriograph®), were undertaken under controlled conditions within four gestational windows: antenatal; AN1 (26-28 weeks), AN2 (32-34 weeks) and AN3 (37-40 weeks), and postnatal (PN) (6-8 weeks after delivery). Data were analysed using a linear mixed model incorporating gestational age and other relevant predictors, including age, blood pressure (BP), baseline bodyweight and pulse as fixed effects, and patient as a random effect.

RESULTS

Fitted linear mixed models showed evidence of a two-way interaction effect between groups (GDM-D, GDM-M and Control) and stages of gestation (AN1, AN2, AN3 and PN) for maternal haemodynamic parameters: brachial artery augmentation index (AIx) (p = 0.004), aortic AIx (p = 0.008), and central systolic BP (p = 0.001). However, differences in respect of aortic pulse wave velocity (p = 0.001) and heart rate (p < 0.001) were only significant for gestational stage. At AN2, we did not observe any evidence that the mean brachial Aix in the GDM-M was different from the control group (p = 0.158).

CONCLUSION

AIx and central systolic BP measures of arterial stiffness are adversely affected by GDM in comparison to controls during pregnancy. The possible beneficial effects of metformin therapy seen at 32 to 34 weeks of gestation require further exploration.

Antifibrinolytic drugs for treating primary postpartum haemorrhage

BACKGROUND

Postpartum haemorrhage (PPH) - heaving bleeding within the first 24 hours after giving birth - is one of the main causes of death of women after childbirth. Antifibrinolytics, primarily tranexamic acid (TXA), have been shown to reduce bleeding in surgery and safely reduces mortality in trauma patients with bleeding without increasing the risk of adverse events.An earlier Cochrane review on treatments for primary PPH covered all the various available treatments - that review has now been split by types of treatment. This new review concentrates only on the use of antifibrinolytic drugs for treating primary PPH.

OBJECTIVES

To determine the effectiveness and safety of antifibrinolytic drugs for treating primary PPH.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (28 May 2017) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs), including cluster-randomised trials of antifibrinolytic drugs (aprotinin, TXA, epsilon-aminocaproic acid (EACA) and aminomethylbenzoic acid, administered by whatever route) for primary PPH in women.Participants in the trials were women after birth following a pregnancy of at least 24 weeks' gestation with a diagnosis of PPH, regardless of mode of birth (vaginal or caesarean section) or other aspects of third stage management.We have not included quasi-randomised trials, or cross-over studies. Studies reported as abstracts have not been included if there was insufficient information to allow assessment of risk of bias.In this review we only identified studies looking at TXA.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data from each study using an agreed form. We entered data into Review Manager software and checked for accuracy.For key review outcomes, we rated the quality of the evidence as 'high', 'moderate', 'low' or 'very low' according to the GRADE approach.

MAIN RESULTS

Three trials (20,412 women) met our inclusion criteria. Two trials (20,212 women) compared intravenous (IV) TXA with placebo or standard care and were conducted in acute hospital settings (labour ward, emergency department) (in high-, middle- and low-income countries).One other trial (involving 200 women) was conducted in Iran and compared IV TXA with rectal misoprostol, but did not report on any of this review's primary or GRADE outcomes. There were no trials that assessed EACA, aprotinin or aminomethylbenzoic acid.Standard care plus IV TXA for the treatment of primary PPH compared with placebo or standard care aloneTwo trials (20,212 women) assessed the effect of TXA for the treatment of primary PPH compared with placebo or standard care alone. The larger of these (The WOMAN trial) contributed over 99% of the data and was assessed as being at low risk of bias. The quality of the evidence varied for different outcomes, Overall, evidence was mainly graded as moderate to high quality.The data show that IV TXA reduces the risk of maternal death due to bleeding (risk ratio (RR) 0.81, 95% confidence interval (CI) 0.65 to 1.00; two trials, 20,172 women; quality of evidence: moderate). The quality of evidence was rated as moderate due to imprecision of effect estimate. The effect was more evident in women given treatment between one and three hours after giving birth with no apparent reduction when given after three hours (< one hour = RR 0.80, 95% CI 0.55 to 1.16; one to three hours = RR 0.60, 95% CI 0.41 to 0.88; > three hours = RR 1.07, 95% 0.76 to 1.51; test for subgroup differences: Chi² = 4.90, df = 2 (P = 0.09), I² = 59.2%). There was no heterogeneity in the effect by mode of birth (test for subgroup differences: Chi² = 0.01, df = 1 (P = 0.91), I² = 0%). There were fewer deaths from all causes in women receiving TXA, although the 95% CI for the effect estimate crosses the line of no effect (RR 0.88, 95% CI 0.74 to 1.05; two trials, 20,172 women, quality of evidence: moderate). Results from one trial with 151 women suggest that blood loss of ≥ 500 mL after randomisation may be reduced (RR 0.50, 95% CI 0.27 to 0.93; one trial, 151 women; quality of evidence: low). TXA did not reduce the risk of serious maternal morbidity (RR 0.99, 95% CI 0.83 to 1.19; one trial, 20,015 women; quality of evidence: high), hysterectomy to control bleeding (RR 0.95, 95% CI 0.81 to 1.12; one trial, 20,017 women; quality of evidence: high) receipt of blood transfusion (any) (RR 1.00, 95% CI 0.97 to 1.03; two trials, 20,167 women; quality of evidence: moderate) or maternal vascular occlusive events (any), although results were imprecise for this latter outcome (RR 0.88, 95% CI 0.54 to 1.43; one trial, 20,018 women; quality of evidence: moderate). There was an increase in the use of brace sutures in the TXA group (RR 1.19, 95% CI 1.01, 1.41) and a reduction in the need for laparotomy for bleeding (RR 0.64, 95% CI 0.49, 0.85).

AUTHORS' CONCLUSIONS

TXA when administered intravenously reduces mortality due to bleeding in women with primary PPH, irrespective of mode of birth, and without increasing the risk of thromboembolic events. Taken together with the reliable evidence of the effect of TXA in trauma patients, the evidence suggests that TXA is effective if given as early as possible.Facilities for IV administration may not be available in non-hospital settings therefore, alternative routes to IV administration need to be investigated.

Thrombin activatable fibrinolysis inhibitor and its fibrinolytic effect in normal pregnancy

We investigated changes in both thrombin activatable fibrinolysis inhibitor (TAFI) antigen levels and its functional effect on in vitro fibrinolysis in normal pregnancy. 152 pregnant women and 31 women in the immediate postpartum period were studied, with pregnancy divided into 6 windows at 4 weekly intervals. As TAFI influences and is in turn influenced by components of the protein C (PC) pathway, its measurements were correlated with levels of soluble thrombomodulin, PC, protein S (PS) and the overall phenotype of activated PC resistance (APCR). Compared with mean TAFI levels at booking gestation (6.6 +1.2 μg/ml), levels peaked at 35-39 weeks gestation (9.6 +2 μg/ml, p = 0.001), followed by a significant drop within 24 hours of delivery (7.2 + 1.1 μg/ml). In functional terms, the mean clot lysis time (CLT) (101 + 13 min at booking) also peaked at 35-39 weeks gestation (141 + 42 min, p = 0.007) and dropped after delivery (99 + 33 min), and was significantly correlated with gestational age (r = 0.410, p = 0.001) and could be abrogated in the presence of an inhibitor to TAFI activation. A significant negative correlation was found between TAFI levels and APCR (r = −0.478, p <0.001), APCRV (r = −0.598; p <0.001), PS (r = −0.490, P <0.001) and PC (r = −0.198, p = 0.02). In summary, there is a significant increase in TAFI levels, which translates into increased CLT during pregnancy. Furthermore, changes in TAFI contribute to the increasing APCR of pregnancy.

Longitudinal study to assess changes in arterial stiffness and cardiac output parameters among low-risk pregnant women

AIM

A single-centre, prospective longitudinal study to assess changes in maternal arterial stiffness and cardiac output parameters among low-risk healthy pregnant women.

METHODOLOGY

Thirty low-risk, healthy, pregnant women attending their routine antenatal dating ultrasound scan were recruited. Non-invasive assessment of arterial stiffness and cardiac output was undertaken at five gestational windows from 11 to 40 weeks of pregnancy. Data were analysed using a linear mixed model incorporating time and other relevant predictors as fixed effects, and patient as a random effect.

RESULTS

Gestational age had a significant effect on all arterial stiffness parameters, including brachial augmentation index (AIx) (p = .001), aortic AIx (p = .002) and aortic pulse wave velocity (p = .002). The aortic AIx (%) reduced during pregnancy: the lowest mean (standard error, SE) was 4.07 (1.01) at 28 weeks before it increased to 7.04 (SE 1.64) at 40 weeks. Similarly, non-invasive assessments of cardiac output (p < .001), stroke volume (p = .014), heart rate (p < .001) and total peripheral resistance (p < .001) demonstrated significant changes with gestational age. Mean cardiac output (l/m) increased during pregnancy reaching a peak at 28 weeks gestation 6.66 (SE 0.28), but dropped thereafter to reach 5.71 (SE 0.25) around term.

CONCLUSION

The current study provides pregnancy normograms for gestational changes in arterial stiffness and cardiac output parameters among low-risk, healthy pregnant women. Further work will be required to assess the risk of placental mediated diseases and pregnancy outcome among pregnant women with parameters outside the normal range.

Renal anomalies and lymphedema distichiasis syndrome. A rare association?

Lymphedema distichiasis syndrome (LDS) is a rare, autosomal dominant genetic condition, characterized by lower limb lymphedema and distichiasis. Other associated features that have been reported include varicose veins, cleft palate, congenital heart defects, and ptosis. We update a previously reported family with a pathogenic variant in FOXC2 (c.412-413insT) where five affected individuals from the youngest generation had congenital renal anomalies detected on prenatal ultrasound scan. These included four fetuses with hydronephrosis and one with bilateral renal agenesis. A further child with LDS had prominence of the left renal pelvis on postnatal renal ultrasound. We also describe a second family in whom the proband and his affected son had congenital renal anomalies; left ectopic kidney, right duplex kidney, and bilateral duplex collecting systems with partial duplex kidney with mild degree of malrotation, respectively. Foxc2 is expressed in the developing kidney and therefore congenital renal anomalies may well be associated, potentially as a low penetrance feature. We propose that all individuals diagnosed with LDS should have a baseline renal ultrasound scan at diagnosis. It would also be important to consider the possibility of renal anomalies during prenatal ultrasound of at risk pregnancies, and that the presence of hydronephrosis may be an indication that the baby is affected with LDS.

Planned home versus hospital care for preterm prelabour rupture of the membranes (PPROM) prior to 37 weeks' gestation

BACKGROUND

Preterm prelabour rupture of membranes (PPROM) is associated with increased risk of maternal and neonatal morbidity and mortality. Women with PPROM have been predominantly managed in hospital. It is possible that selected women could be managed at home after a period of observation. The safety, cost and women's views about home management have not been established.

OBJECTIVES

To assess the safety, cost and women's views about planned home versus hospital care for women with PPROM.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 July 2013) and the reference lists of all the identified articles.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing planned home versus hospital management for women with PPROM before 37 weeks' gestation.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed clinical trials for eligibility for inclusion, risk of bias, and carried out data extraction.

MAIN RESULTS

We included two trials (116 women) comparing planned home versus hospital management for PPROM. Overall, the number of included women in each trial was too small to allow adequate assessment of pre-specified outcomes. Investigators used strict inclusion criteria and in both studies relatively few of the women presenting with PPROM were eligible for inclusion. Women were monitored for 48 to 72 hours before randomisation. Perinatal mortality was reported in one trial and there was insufficient evidence to determine whether it differed between the two groups (risk ratio (RR) 1.93, 95% confidence interval (CI) 0.19 to 20.05).  There was no evidence of differences between groups for serious neonatal morbidity, chorioamnionitis, gestational age at delivery, birthweight and admission to neonatal intensive care.There was no information on serious maternal morbidity or mortality. There was some evidence that women managed in hospital were more likely to be delivered by caesarean section (RR (random-effects) 0.28, 95% CI 0.07 to 1.15). However, results should be interpreted cautiously as there is moderate heterogeneity for this outcome (I² = 35%). Mothers randomised to care at home spent approximately 10 fewer days as inpatients (mean difference -9.60, 95% CI -14.59 to -4.61) and were more satisfied with their care. Furthermore, home care was associated with reduced costs.

AUTHORS' CONCLUSIONS

The review included two relatively small studies that did not have sufficient statistical power to detect meaningful differences between groups. Future large and adequately powered randomised controlled trials are required to measure differences between groups for relevant pre-specified outcomes. Special attention should be given to the assessment of maternal satisfaction with care and cost analysis as they will have social and economic implications in both developed and developing countries.

Treatment for primary postpartum haemorrhage

BACKGROUND

Primary postpartum haemorrhage (PPH) is one of the top five causes of maternal mortality in both developed and developing countries.

OBJECTIVES

To assess the effectiveness and safety of any intervention used for the treatment of primary PPH.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 August 2013).

SELECTION CRITERIA

Randomised controlled trials comparing any interventions for the treatment of primary PPH.

DATA COLLECTION AND ANALYSIS

We assessed studies for eligibility and quality and extracted data independently. We contacted authors of the included studies to request more information.

MAIN RESULTS

Ten randomised clinical trials (RCTs) with a total of 4052 participants fulfilled our inclusion criteria and were included in this review.Four RCTs (1881 participants) compared misoprostol with placebo given in addition to conventional uterotonics. Adjunctive use of misoprostol (in the dose of 600 to 1000 mcg) with simultaneous administration of additional uterotonics did not provide additional benefit for our primary outcomes including maternal mortality (risk ratio (RR) 6.16, 95% confidence interval (CI) 0.75 to 50.85), serious maternal morbidity (RR 0.34, 95% CI 0.01 to 8.31), admission to intensive care (RR 0.79, 95% CI 0.30 to 2.11) or hysterectomy (RR 0.93, 95% CI 0.16 to 5.41).  Two RCTs (1787 participants) compared 800 mcg sublingual misoprostol versus oxytocin infusion as primary PPH treatment; one trial included women who had received prophylactic uterotonics, and the other did not. Primary outcomes did not differ between the two groups, although women given sublingual misoprostol were more likely to have additional blood loss of at least 1000 mL (RR 2.65, 95% CI 1.04 to 6.75). Misoprostol was associated with a significant increase in vomiting and shivering.Two trials attempted to test the effectiveness of estrogen and tranexamic acid, respectively, but were too small for any meaningful comparisons of pre-specified outcomes.One study compared lower segment compression but was too small to assess impact on primary outcomes.We did not identify any trials evaluating surgical techniques or radiological interventions for women with primary PPH unresponsive to uterotonics and/or haemostatics.

AUTHORS' CONCLUSIONS

Clinical trials included in the current review were not adequately powered to assess impact on the primary outcome measures. Compared with misoprostol, oxytocin infusion is more effective and causes fewer side effects when used as first-line therapy for the treatment of primary PPH. When used after prophylactic uterotonics, misoprostol and oxytocin infusion worked similarly. The review suggests that among women who received oxytocin for the treatment of primary PPH, adjunctive use of misoprostol confers no added benefit.The role of tranexamic acid and compression methods requires further evaluation. Furthermore, future studies should focus on the best way to treat women who fail to respond to uterotonic therapy.

Would gestational age and presence of brain anomalies affect interobserver reliability of fetal head biometry? Using off-line analysis of 3-D dataset

The objective was to assess interobserver reliability of fetal head biometry using archived three-dimensional (3-D) volumes and the impact of gestational age and presence of brain anomalies on examiners' performance. Seventy nine 3-D volume datasets of fetal head were examined: 27 were normal and 52 had brain abnormalities. Off-line analysis was done by three fetal medicine experts (E1, E2 and E2), all were blinded to history and patient details. Measurements of the biparietal diameter (BPD), head circumference (HC), lateral ventricle (Vp) and transcerebellar diameter (TCD) were compared between examiners and to two-dimensional (2-D) measurements. Comparisons were made at two gestational age groups (≤22 and >22 weeks) and in presence and absence of brain anomalies. The intraclass coefficient showed a significantly high level of measurement agreement between 3-D examiners and 2-D, with values >0.9 throughout (p < 0.001). Bias was evident between 3-D examiners. E2 produced smaller measurements. The mean percentage difference between this examiner and the other two in BPD, HC, Vp and TCD measurements was significant, of 1.6%, 1%, 4.9% and 1.8%, respectively. E1 measured statistically larger for HC and TCD. E3 measured significantly larger for only BPD. The presence of anomalies was of no influence on the 3-D examiners' performance except for E3 who showed bias in BPD measurements only in cases with brain anomalies. Unlike other examiners, bias of E2 was only seen at gestational age group ≤22 weeks. Limits of agreement in measurements between observers were narrow for all parameters but were widest for the Vp measurements, being ±23% of the mean difference. Despite the above bias, the actual mean difference between examiners was small and unlikely to be of any clinical significance. Off-line measurement of fetal head biometry using 3-D volumes is reliable. In our study, presence of brain anomalies was unlikely to influence the reproducibility of measurements. Gestational age seemed to be of an impact on examiners' bias. Among experts this bias may be of no clinical significance.

Evaluating the intra- and interobserver reliability of three-dimensional ultrasound and power Doppler angiography (3D-PDA) for assessment of placental volume and vascularity in the second trimester of pregnancy

Three-dimensional (3-D) power Doppler angiography (3-D-PDA) allows visualisation of Doppler signals within the placenta and their quantification is possible by the generation of vascular indices by the 4-D View software programme. This study aimed to investigate intra- and interobserver reproducibility of 3-D-PDA analysis of stored datasets at varying gestations with the ultimate goal being to develop a tool for predicting placental dysfunction. Women with an uncomplicated, viable singleton pregnancy were scanned at 12, 16 or 20 weeks gestational age groups. 3-D-PDA datasets acquired of the whole placenta were analysed using the VOCAL software processing tool. Each volume was analysed by three observers twice in the A plane. Intra- and interobserver reliability was assessed by intraclass correlation coefficients (ICCs) and Bland Altman plots. At each gestational age group, 20 low risk women were scanned resulting in 60 datasets in total. The ICC demonstrated a high level of measurement reliability at each gestation with intraobserver values >0.90 and interobserver values of >0.6 for the vascular indices. Bland Altman plots also showed high levels of agreement. Systematic bias was seen at 20 weeks in the vascular indices obtained by different observers. This study demonstrates that 3-D-PDA data can be measured reliably by different observers from stored datasets up to 18 weeks gestation. Measurements become less reliable as gestation advances with bias between observers evident at 20 weeks.

Planned home versus hospital care for preterm prelabour rupture of the membranes (PPROM) prior to 37 weeks' gestation

BACKGROUND

Preterm prelabour rupture of membranes (PPROM) is associated with increased risk of maternal and neonatal morbidity and mortality. Women with PPROM have been predominantly managed in hospital. It is possible that selected women could be managed at home after a period of observation. The safety, cost and women's views about home management have not been established.

OBJECTIVES

To assess the safety, cost and women's views about planned home versus hospital care for women with PPROM.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (January 2010) and the reference lists of all the identified articles.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing planned home versus hospital management for women with PPROM before 37 weeks' gestation.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed clinical trials for eligibility for inclusion, risk of bias, and carried out data extraction.

MAIN RESULTS

We included two trials (116 women) comparing planned home versus hospital management for PPROM. Overall, the number of included women in each trial was too small to allow adequate assessment of pre-specified outcomes. Investigators used strict inclusion criteria and in both studies relatively few of the women presenting with PPROM were eligible for inclusion. Women were monitored for 48 to 72 hours before randomisation. Perinatal mortality was reported in one trial and there was insufficient evidence to determine whether it differed between the two groups (risk ratio (RR) 1.93, 95% confidence interval (CI) 0.19 to 20.05). There was no evidence of differences between groups for serious neonatal morbidity, chorioamnionitis, gestational age at delivery, birthweight and admission to neonatal intensive care.There was no information on serious maternal morbidity or mortality. There was some evidence that women managed in hospital were more likely to be delivered by caesarean section (RR (random-effects) 0.28, 95% CI 0.07 to 1.15). However, results should be interpreted cautiously as there is a moderate heterogeneity for this outcome (I(2) = 35%). Mothers randomised to care at home spent approximately 10 fewer days as inpatients (mean difference -9.60, 95% CI -14.59 to -4.61) and were more satisfied with their care. Furthermore, home care was associated with reduced costs.

AUTHORS' CONCLUSIONS

The review included two relatively small studies that did not have sufficient statistical power to detect meaningful differences between groups. Future large and adequately powered randomised controlled trials are required to measure differences between groups for relevant pre-specified outcomes. Special attention should be given to the assessment of maternal satisfaction with care and cost analysis as they will have social and economic implications in both developed and developing countries.

Peripartum hysterectomy for primary postpartum haemorrhage: Incidence and maternal morbidity

This was a retrospective analysis of postpartum emergency hysterectomy performed between 1988-2003, to study incidence indicators, risk factors and complications. We included any women who required emergency hysterectomy to control major postpartum haemorrhage (PPH) after delivery, following a pregnancy of at least 24 weeks' gestation, regardless of the mode of delivery. We excluded cases that required a hysterectomy for gynaecological reasons. There were 18 cases of emergency hysterectomy (14 caesarean hysterectomy and four postpartum hysterectomy, after vaginal delivery), giving a rate of 0.36/1,000 deliveries. Overall, the most common indication for hysterectomy was placenta accreta (28%) and uterine atony (28%). Although there was no maternal death, intra- and postoperative complications were prevalent including cardiac arrest (1), disseminated intravascular coagulopathy (4), pulmonary oedema (1), septicaemia (1), and bladder injury (1). Placenta accreta is becoming a leading cause of emergency postpartum hysterectomy. Although hysterectomy is a life saving operation, it is associated with high maternal morbidity.

Changes in myometrial 'perfusion' during normal labor as visualized by three-dimensional power Doppler angiography

OBJECTIVES

Myometrial contractions are one of the most important aspects of effective labor. For cells within the myometrium to work efficiently they need to be well oxygenated and this requires an adequate blood supply. This study used quantitative three-dimensional (3D) power Doppler angiography to calculate the percentage change in myometrial blood flow during a relaxation-contraction-relaxation cycle of active labor.

METHODS

Transabdominal 3D power Doppler ultrasound imaging was used to acquire volumetric data during the first stage of spontaneous labor in 20 term, nulliparous women. 3D datasets were acquired during a single cycle of uterine relaxation, contraction and subsequent relaxation for each subject. The resultant datasets were analyzed independently by two investigators on two occasions using Virtual Organ Computer-aided AnaLysis to define a volume of interest within the myometrium; the power Doppler signal within this volume was quantified to provide 3D indices of vascularity: vascularization index (VI), flow index (FI) and vascularization flow index (VFI). The percentage change in these indices, during a uterine contraction, was calculated from the baseline value during the initial uterine relaxation phase (taken as a maximum of 100%).

RESULTS

Myometrial blood flow fell significantly during the uterine contraction and returned during the subsequent relaxation phase of the cycle (P < 0.001 for VI and VFI, P = 0.002 for FI). From the initial baseline relaxation value, VI dropped to 43.9%, FI to 85.5% and VFI to 40.8% during uterine contraction, and returned to 86.7%, 98.1% and 89.1%, respectively, during the subsequent relaxation. The intraclass correlation coefficients in blood flow measurements of 0.982-0.999 between the two investigators were indicative of good interobserver reliability.

CONCLUSIONS

This study confirms that myometrial perfusion, as measured by quantitative 3D power Doppler angiography, significantly falls during uterine contractions, returns during the subsequent relaxation phase, and can be quantified reliably from stored datasets. Further work is now required to establish clinical applicability for this non-invasive investigation.

Treatment for primary postpartum haemorrhage

BACKGROUND

Primary postpartum haemorrhage (PPH) is one of the top five causes of maternal mortality in both developed and developing countries.

OBJECTIVES

To assess the effectiveness and safety of pharmacological, surgical and radiological interventions used for the treatment of primary PPH.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 October 2006).

SELECTION CRITERIA

Randomised controlled trials comparing pharmacological, surgical techniques and radiological interventions for the treatment of PPH.

DATA COLLECTION AND ANALYSIS

We assessed studies for eligibility and quality, and extracted data, independently. We contacted authors of the included studies for more information.

MAIN RESULTS

Three studies (462 participants) were included. Two placebo-controlled randomised trials compared misoprostol (dose 600 to 1000 mcg) with placebo and showed that misoprostol use was not associated with any significant reduction of maternal mortality (two trials, 398 women; relative risk (RR) 7.24, 95% confidence interval (CI) 0.38 to 138.6), hysterectomy (two trials, 398 women; RR 1.24, 95% CI 0.04 to 40.78), the additional use of uterotonics (two trials, 398 women; RR 0.98, 95% CI 0.78 to 1.24), blood transfusion (two trials, 394 women; RR 1.33, 95% CI 0.81 to 2.18), or evacuation of retained products (one trial, 238 women; RR 5.17, 95% CI 0.25 to 107). Misoprostol use was associated with a significant increase of maternal pyrexia (two trials, 392 women; RR 6.40, 95% CI 1.71 to 23.96) and shivering (two trials, 394 women; RR 2.31, 95% CI 1.68 to 3.18). One unblinded trial showed better clinical response to rectal misoprostol compared with a combination of syntometrine and oxytocin. We did not identify any trial dealing with surgical techniques, radiological interventions or haemostatic drugs for women with primary PPH unresponsive to uterotonics.

AUTHORS' CONCLUSIONS

There is insufficient evidence to show that the addition of misoprostol is superior to the combination of oxytocin and ergometrine alone for the treatment of primary PPH. Large multi-centre, double-blind, randomised controlled trials are required to identify the best drug combinations, route, and dose of uterotonics for the treatment of primary PPH. Further work is required to assess the best way of managing women who fail to respond to uterotonics therapy.

Treatment for primary postpartum haemorrhage

BACKGROUND

Primary postpartum haemorrhage is one of the top five causes of maternal mortality in both developed and developing countries.

OBJECTIVES

The objective of this review was to assess the effectiveness and safety of pharmacological and surgical interventions used for the treatment of primary postpartum haemorrhage.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's trials register (April 2002).

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials comparing pharmacological, surgical and radiological interventions for the treatment of primary postpartum haemorrhage.

DATA COLLECTION AND ANALYSIS

Studies were assessed for eligibility and quality by reviewers independently. Data were extracted into pre-specified data sheets. Authors of the included study were contacted for more information. Analysis was by intention to treat. Results are presented as relative risk with 95% confidence intervals using the fixed effects model.

MAIN RESULTS

One trial, comparing rectally administered misoprostol versus syntometrine combined with an oxytocin infusion, met the eligibility criteria and was included in the review. It was not large enough to evaluate the effects of rectal misoprostol on maternal mortality, serious maternal morbidity or hysterectomy rates in women with primary postpartum haemorrhage. Compared with a combination of intramuscular syntometrine injection and oxytocin infusion, rectal misoprostol administration showed a statistically significant reduction in the number of women who continued to bleed after the intervention and those who required medical co-interventions to control the bleeding (6% versus 34%) (relative risk 0.18, 95% confidence interval 0.04 to 0.67). However, there was no significant difference between the two groups regarding surgical interventions to control intractable haemorrhage including hysterectomy, internal iliac artery ligation and/or uterine packing.

REVIEWER'S CONCLUSIONS

Rectal misoprostol in a dose of 800 micrograms could be a useful 'first line' drug for the treatment of primary postpartum haemorrhage. Further randomised controlled trials are required to identify the best drug combinations, route, and dose for the treatment of postpartum haemorrhage.

Bone infection

Osteomyelitis, or bone infection, affects all age groups and develops from various sources including haematogenously from distant infection foci, from external sources such as post-operative or post-traumatic wound infections and from adjoining soft tissue infections. Staphylococcus aureus, Streptococcus pyogenes and Haemophilus influenzae are the most common pathogens of haematogenous osteomyelitis. Aerobic and facultative gram-negative bacteria have emerged as significant pathogens in some types of osteomyelitis while anaerobic bacteria are increasingly recognized as potential pathogens in non-haematogenous osteomyelitis. The emergence of antibiotic resistance is of increasing concern, although improvements in radiologic imaging, antibiotic treatment and heightened awareness have led to earlier detection such that long-term sequelae and morbidity are now primarily due to delays in diagnosis and inadequate treatment.

Major postpartum hemorrhage: survey of maternity units in the United Kingdom

BACKGROUND

To determine current clinical practice among different maternity units in the United Kingdom for the management of major postpartum hemorrhage.

METHODS

A postal questionnaire was sent to 258 maternity units in the UK. It was developed to identify the definition of major postpartum hemorrhage, and to identify the medical and surgical interventions used for postpartum hemorrhage, as considered by each unit, and the type and use of thromboprophylaxis following surgery for major hemorrhage after delivery.

RESULTS

A total of 212 (82%) returned the questionnaire, but 13 units indicated that the questionnaire was not applicable to them, leaving 199 (82%) for analysis. There was a lack of agreement between the different units regarding the definition and interventions for major postpartum hemorrhage. The majority of the units use oxytocin, ergometrine and carboprost as a 'first-line' for the treatment of postpartum hemorrhage. Hysterectomy was the most common surgical procedure (89% of units had performed at least one hysterectomy for major hemorrhage in the last 5 years). There was a lack of agreement regarding the use and choice of thromboprophylaxis following surgery for major hemorrhage.

CONCLUSIONS

Current management of major postpartum hemorrhage varies considerably. There is an urgent need to identify protocols that will reduce the need for hysterectomy in women with major hemorrhage who are unresponsive to conventional medical therapy.

Major postpartum haemorrhage

Postpartum haemorrhage remains in the top five causes of maternal deaths in both developed and developing countries. Persistent blood loss of more than 1000 ml should prompt predetermined measures to achieve resuscitation and haemostasis. A protocol including guidelines is given and volume replacement is discussed. The range of medical and surgical interventions that may be considered for the modern management of major haemorrhage unresponsive to oxytocin and ergometrine are presented. The review discusses in depth the use of misoprostol, recombinant activated factor VII, the uterine tamponade procedures, artery ligation, and uterine haemostatic suturing techniques. It also evaluates the place of interventional radiology and hysterectomy in modern obstetrics.

Yeast infection of burns

In a prospective study, 132 patients were investigated for yeast infection of burn wounds. Ten patients (7.6%) were infected with Candida species. All patients with yeast infections were also infected with bacteria with the exception of one patient who was infected with Candida tropicalis alone. The predominant yeast recovered was Candida krusei. Yeast infection was found to be more common in the younger age group. The isolation of a Candida species alone from one patient and Candida isolation from patients with sepsis in burn wounds indicate a significant role for yeasts in the production of infection in burn wounds. Therefore, special cultures for yeasts are recommended for all cases of burn wound infection.

Infection following orthopaedic implants and bone surgery

Forty-seven patients were investigated for early or late postoperative infections of orthopaedic implants and/or bone. A total of 88 isolates were recovered (64 aerobes and 24 anaerobes). Pseudomonas aeruginosa and Staphylococcus epidermidis were the most common causative agents. Anaerobic bacteria were isolated from 16 (34%) patients; 50% of patients with late-onset infection and 10.5% with early-onset infection. In 6 (12.8%) patients, infection was with anaerobic organisms alone. All these patients had retained an extramedullary internal fixation device. Anaerobic microorganisms appear to play a significant role in the pathogenesis of late-onset postoperative infection, especially where there is an extramedullary internal fixation device.

Postnatal screening for thrombophilia in women with severe pregnancy complications

OBJECTIVE

To examine the prevalence of maternal thrombophilia in women with severe preeclampsia/eclampsia, placental abruption, fetal growth restriction, and unexplained stillbirth.

METHODS

We studied 102 women who had pregnancy complications and 44 healthy women with uncomplicated pregnancies. All women were tested 10 weeks postpartum for mutations of factor V Leiden, methylenetetrahydrofolate reductase (MTHFR) C677T, and G20210A prothrombin gene; deficiencies of protein C, protein S, and antithrombin III; and the presence of lupus anticoagulant and anticardiolipin antibodies. We aimed to recruit 100 cases and 300 controls to detect a 10% difference in thrombophilia between the groups. However, we were able to recruit only 44 controls.

RESULTS

Abnormal thrombophilia screen was found in 54 women with pregnancy complications (53%) and in 17 women (39%) with normal pregnancies (odds ratio [OR] 1.8; 95% confidence interval [CI] 0.87, 3.67). Mutations encoding for factor V Leiden, G20210A prothrombin gene, and MTHFR C677T (homozygous) were identified in 18% of women with complications compared with 16% of controls (OR 1.1; 95% CI 0.44, 2.94). Activated protein C resistance, not due to factor V Leiden mutation, was the most common thrombophilic defect, found in 26% of women with pregnancy complications compared with 18% of controls (OR 1.5; 95% CI 0.63, 3.73). Twenty women with complications (20%) had multiple thrombophilic defects compared with four controls (9%) (OR 2.4; 95% CI 0.78, 7.61).

CONCLUSION

In our cohort of women with pregnancy complications, maternal thrombophilia was less common than previously thought, and multiple thrombophilias were not a major additional risk factor.

Medium-term clinical outcome of women with menorrhagia treated by rollerball endometrial ablation versus abdominal hysterectomy with conservation of at least one ovary

BACKGROUND

To compare patients' satisfaction, health related quality of life, and sexual function among women who were either treated with rollerball endometrial ablation or abdominal hysterectomy with conservation of at least one ovary for the treatment of menorrhagia.

METHOD

Between March 1992 to June 1997, 91 women underwent rollerball endometrial ablation and 78 women had abdominal hysterectomy with preservation of at least one ovary for the treatment of intractable menorrhagia. Each was sent a detailed questionnaire at least 18 months (range 18-60) after surgery. Case notes were reviewed to collect additional data relating to pre-operative management and operative details.

RESULTS

Of 169 women, 120 (71%) returned a completed questionnaire [80/91 women (88%) had ablation and 40/78 women (51%) had hysterectomy]. Non-response analysis did not reveal any differences in prognostic characteristics between responders and non-responders. The length of hospital stay and time taken to return to normal daily activity were significantly less in the ablation group. Pre-menstrual symptoms improved over time but more so in the hysterectomy group, who also rated their improvement in general health higher. Women who had hysterectomy were more satisfied (100% versus 79%) and would be more likely to recommend it to a friend (100% versus 91%).

CONCLUSION

Both procedures are effective for the treatment of menorrhagia but hysterectomy is associated with better general health and fewer pre-menstrual symptoms. Rollerball ablation is a useful alternative with many short term benefits and acceptable satisfaction rate. Further work is required to evaluate long term effects.

Thrombophilia and adverse pregnancy outcome

Congenital and acquired thrombophilias are the most common predisposing factors for thromboembolism, but they may also contribute to pathophysiological processes involved in recurrent pregnancy loss, fetal death, intrauterine growth restriction, placental abruption, placental infarction, and pre-eclampsia. The most common thrombophilias are deficiencies of antithrombin III, protein C, and protein S, acquired protein C resistance, genetic mutation encoding for factor V Leiden, prothrombin gene, and inherited hyperhomocysteinemia, and antiphospholipid syndrome. Although adverse pregnancy outcomes are more common in women with thrombophilia, the current evidence does not support routine thrombophilia screening of all pregnant women. Selective thrombophilia screening may be justified in certain group of women, particularly those with a history of thromboembolism. More research is required to confirm or refute the causal link between thrombophilia and abnormal placentation, and assess effectiveness and safety of thromboprophylaxis in pregnant women.

Do practice guidelines guide practice? A prospective audit of induction of labor three years experience

BACKGROUND

To examine the effect of implementation of guidelines for induction of labor on the process of care and outcome measures.

METHOD

Guidelines for induction of labor were implemented in January 1996 following an audit report identifying inconsistency in clinical practice. A prospective audit was carried out following the implementation of a new strategy directed towards pre-induction cervical ripening in nulliparae with unfavorable cervices and the use of low dosages of vaginal prostaglandin E2 for induction of labor. Level of compliance and outcome measures were compared before and after implementation of guidelines.

RESULTS

In the period of January 1995 to November 1997, 1,230 women were induced with a singleton viable pregnancy in a cephalic presentation with a gestational age > or = 37 weeks with no history of rupture of membranes or cesarean section. Completed forms were available for 1,147 women (370, 421 and 356 in 1995, 1996 and 1997, respectively). Among nulliparous women, there was a reduction in the number of women who were admitted with cervical score of < or = 4 (24%, 40%, and 54% in 1997, 1996, and 1995, respectively; p=0.0001), an increase in the number of women who had amniotomy on admission (32%, 25% and 12% in 1997, 1996, and 1995, respectively; p=0.0001) and a shorter induction-delivery interval. No change in outcome measures was noted among multiparous women despite reduced dose of prostaglandin E2 used for induction of labor. A marginal reduction of both Cesarean section and failed induction rates were noted in both nulliparae and multiparae. Level of compliance improved with successive rounds of audit.

CONCLUSION

Explicit guidelines do improve clinical practice, when introduced and monitored in the context of rigorous evaluations. However, the size of improvement could vary.

Medium-term follow-up of women with menorrhagia treated by rollerball endometrial ablation

BACKGROUND

To assess medium-term efficacy of rollerball endometrial ablation in a district general hospital.

METHOD

From March 1992 to June 1997, 91 women underwent rollerball endometrial ablation for uncontrolled menorrhagia unresponsive to medical treatment. Each was sent a detailed questionnaire after at least 18 months (range 18-55). There was an overall response rate of 88% (80/91). Case notes were reviewed to collect additional data related to pre-operative management and actual operative procedure. The main outcome measures included treatment satisfaction, relief of symptoms, improvement in health related quality of life, at least 18 months after surgery.

RESULTS

Thirty-five of the 80 women (44%) had achieved amenorrhea. Ten women required further treatment; of these seven had a hysterectomy (9%). None of the non-responders had a hysterectomy. Following rollerball endometrial ablation, many women reported improvement in cyclical pelvic pain (73%), pre-menstrual symptoms (65%), ability to do housework (85%), and an improved sexual life (96%). Seventy-nine (99%) women were able to return to normal work within 4 weeks following surgery. The majority of them remained satisfied with treatment (79%) and they would recommend it to a friend (91%).

CONCLUSIONS

Rollerball endometrial ablation is a simple, effective, and acceptable procedure for the treatment of menorrhagia in selected cases. Longer-term follow up is still needed to establish the ultimate effectiveness of the procedure.

Do placental lesions reflect thrombophilia state in women with adverse pregnancy outcome?

We examined the relationship between placental histology and thrombophilia status in women who were admitted with severe pre-eclampsia/eclampsia, placental abruption, intrauterine growth restriction or unexplained stillbirth. All women had thrombophilia screen at least 10 weeks after delivery (antithrombin III, protein C, protein S, activated protein C resistance, anticardiolipin antibodies, lupus anticoagulant, fasting plasma homocysteine and specific mutations to methylenetetrahydrofolate reductase C677T, G20210A prothrombin gene and factor V Leiden. Placental histology reports were examined to identify the frequency of thrombotic lesions in the placenta including fetal stem vessel thrombosis, fetal thrombotic vasculopathy, placental infarction, perivillous fibrin deposition, intervillous thrombosis and placental floor infarction. During a 17 month period, a cohort of 79 women met the study criteria. Thirty (70%) out of 43 women with abnormal thrombophilia screen had abnormal placental histology. Twenty-eight (78%) out of 36 women with negative thrombophilia screen had abnormal placentae. No specific histological pattern could be identified when thrombophilia positive and thrombophilia negative groups were compared. We propose that there is a poor correlation between thrombophilia status and pathological changes of the placenta in women with severe pregnancy complications.

Acute haematogenous osteomyelitis: microbial conversion and unusual age presentation

From 1983 to 1989, 110 cases of haematogenous osteomyelitis were studied retrospectively. The most commonly affected were children under 1 year. No adult cases were reported. Staphylococcus aureus was isolated from 72.7% of cases. During 1992-1997, 80 cases were studied prospectively. The most commonly affected were children aged 9 years. This group included 19 adults. S. aureus was isolated from 43.7% of the cases. There was a clear difference in the incidence of S. aureus and age presentation in the cases before and after the Gulf conflict. Working children and malnutrition might have caused changes in the infecting organisms and age presentation in recent years.

Fungal infection of burn wounds in patients with open and occlusive treatment methods

Fungal infection of burn wounds was investigated in a prospective study of 130 patients managed either with open or occlusive treatment methods. In all, 30 fungal isolates were recovered from 26 patients all of whom had bacterial infection also, except for one patient. The predominant fungi recovered were Aspergillus spp. and Candida spp. Fungal infection was more common in patients treated with open dressing (25.5%) than occlusive dressing (16.0%). Fungal culture from tissue specimens gave a better isolation rate of fungi than from cotton swab specimens.

Correlation between fungi isolated from burn wounds and burn care units

A comparison was made prospectively between fungal isolates from patients and burn care units. Aspergillus niger was the most frequent isolate in both patients and burn care units whereas Ulocladium was the commonest isolate in the control group. Aspergillus terreus, Penicillium and Zygomycetes, which were recovered from burned patients, were also found more frequently in the burn care units than in the control group (other areas in the hospital). These findings indicate a potential risk of fungal infection which can be acquired from the immediate surroundings of patients in burn care units. Periodical burn ward decontamination is therefore recommended.

Tuberculosis of bones and joints: diagnostic approaches

Mycobacterial and routine aerobic and anaerobic cultures were made prospectively from 22 patients with bone and/or joint tuberculosis. Mycobacteria were found on direct smear in 6 patients (27.3%), on culture in 14 (63.6%) and on histological section in 5 (22.7%). In one patient routine culture at operation revealed growth of Nocardia asteroides and Moraxella catarrhalis in addition to a positive culture of mycobacteria. Routine sinus culture showed growth of Staphylococcus epidermis in 3 out of 8 patients with draining sinuses. Thus, isolation of avirulent pyogenic bacteria from an operative or sinus specimen does not exclude the possibility of tuberculosis. Mycobacteria can often be identified from sinus-track culture in patients in whom operative culture, histopathological and clinical examination have failed to confirm the diagnosis of tuberculosis. Tuberculosis should be suspected if there are pus cells without pyogenic bacteria on direct smear, if there is no growth of any pyogenic bacteria or if there is growth of Staphylococcus epidermidis alone on routine aerobic and anaerobic sinus cultures.