Impact of electronic and blended learning programs for manual perineal support on incidence of obstetric anal sphincter injuries: a prospective interventional study

BACKGROUND

Obstetric anal sphincter injuries (OASIS) are associated with anal incontinence, dyspareunia and perineal pain. Bimanual perineal support technique (bPST) prevents OASIS. The aim of this study was to assess the effect of two different bPST training-methods on OASIS incidence.

METHODS

This is a prospective-interventional quality improvement study conducted in two Palestinian maternity units between June 1 2015 and December 31 2016. Women having spontaneous or operative vaginal-delivery at ≥24 gestational-weeks or a birthweight of ≥1000 g (n = 1694) were recruited and examined vaginally and rectally immediately after vaginal birth by a trained assessor. Data on baseline OASIS incidence were collected during Phase-1 of the study. Subsequently, birth attendants in both maternity units were trained in bPST using two training modalities. A self-directed electronic-learning (e-learning) using an animated video was launched in phase-2 followed by a blended learning method (the animated e-learning video+ structured face-to-face training) in phase-3. OASIS incidence was monitored during phases-2 and 3. Variations in OASIS incidence between the three phases were assessed using Pearson-χ²-test (or Fisher's-Exact-test). The impact of each training-method on OASIS incidence was assessed using logistic-regression analysis.

RESULTS

A total of 1694 women were included; 376 in phase-1, 626 in phase-2 and 692 in phase-3. Compared to Phase-1, OASIS incidence was reduced by 45% (12.2 to 6.7%, aOR: 0.56, CI; 0.35-0.91, p = 0.018) and 74% (12.2 to 3.2%, aOR, 0.29, CI; 0.17-0.50, p < 0.001) in phases-2 and 3, respectively. There was also a significant reduction in OASIS incidence by 52% from phase-2 to phase-3 (6.7% (42/626) to 3.2% (22/692), p = 0.003). These reductions reached statistical significance among parous-women only (aOR: 0.18, CI; 0.07-0.49, p = 0.001) after the first training method tested in phase-2. However, the reduction was significant among both primiparous (aOR: 0.39, CI; 0.21-0.74, p = 0.004) and parous-women (aOR: 0.11, CI; 0.04-0.32, p < 0.001) after implementing the blended learning method in phase-3.

CONCLUSION

The animated e-learning video had a positive impact on reducing OASIS incidence. However, this reduction was enhanced by the use of a blended learning program combining both e- learning and face-to-face training modalities.

STUDY REGISTRATION NUMBER

ClinicalTrialo.gov identifier: NCT02427854 , date: 28 April 2015.

Implementation of guidelines for multidisciplinary team management of pregnancy in women with pre-existing diabetes or cardiac conditions: results from a UK national survey

Abstract

Background

Despite numerous publications stating the importance of multidisciplinary care for women with pre-existing medical conditions, there is a lack of evidence regarding structure or processes of multidisciplinary working, nor impact on maternal or infant outcomes. This study aimed to evaluate the implementation of guidelines for multidisciplinary team (MDT) management in pregnant women with pre-existing diabetes or cardiac conditions. These conditions were selected as exemplars of increasingly common medical conditions in pregnancy for which MDT management is recommended to prevent or reduce adverse maternal and fetal outcomes.

Methods

National on-line survey sent to clinicians responsible for management or referral of women with pre-existing diabetes or cardiac conditions in UK National Health Service (NHS) maternity units. The survey comprised questions regarding the organisation of MDT management for women with pre-existing diabetes or cardiac conditions. Content was informed by national guidance.

Results

One hundred seventy-nine responses were received, covering all health regions in England (162 responses) and 17 responses from Scotland, Wales and Northern Ireland. 132 (74%) related to women with diabetes and 123 (69%) to women with cardiac conditions. MDT referral was reportedly standard practice in most hospitals, particularly for women with pre-existing diabetes (88% of responses vs. 63% for cardiac) but there was wide variation in relation to MDT membership, timing of referral and working practices. These inconsistencies were evident within and between maternity units across the UK. Reported membership was medically dominated and often in the absence of midwifery/nursing and other allied health professionals. Less than half of MDTs for women with diabetes met the recommendations for membership in national guidance, and although two thirds of MDTs for women with cardiac disease met the core recommendations for membership, most did not report having the extended members: midwives, neonatologists or intensivists.

Conclusions

The wide diversity of organisational management for women with pre-existing diabetes or cardiac conditions is of concern and merits more detailed inquiry. Evidence is also required to support and better define the recommendations for MDT care.

Electronic supplementary material

The online version of this article (10.1186/s12884-017-1609-9) contains supplementary material, which is available to authorized users.

Perineal resuturing versus expectant management following vaginal delivery complicated by a dehisced wound (PREVIEW): a nested qualitative study

OBJECTIVE

To explore women's lived experiences of a dehisced perineal wound following childbirth and how they felt participating in a pilot and feasibility randomised controlled trial (RCT).

DESIGN

A nested qualitative study using semistructured interviews, underpinned by descriptive phenomenology.

PARTICIPANTS AND SETTING

A purposive sample of six women at 6-9 months postnatal who participated in the RCT were interviewed in their own homes.

RESULTS

Following Giorgi's analytical framework the verbatim transcripts were analysed for key themes. Women's lived experiences revealed 4 emerging themes: (1) Physical impact, with sub-themes focusing upon avoiding infection, perineal pain and the impact of the wound dehiscence upon daily activities; (2) Psychosocial impact, with sub-themes of denial, sense of failure or self-blame, fear, isolation and altered body image; (3) Sexual impact; and (4) Satisfaction with wound healing. A fifth theme 'participating in the RCT' was 'a priori' with sub-themes centred upon understanding the randomisation process, completing the trial questionnaires, attending for hospital appointments and acceptability of the treatment options.

CONCLUSIONS

To the best of our knowledge, this is the first qualitative study to grant women the opportunity to voice their personal experiences of a dehisced perineal wound and their views on the management offered. The powerful testimonies presented disclose the extent of morbidity experienced while also revealing a strong preference for a treatment option.

TRIAL REGISTRATION NUMBER

ISRCTN05754020; results.

Perineal resuturing versus expectant management following vaginal delivery complicated by a dehisced wound (PREVIEW): a pilot and feasibility randomised controlled trial

OBJECTIVE

To establish the feasibility of conducting a definitive randomised controlled trial (RCT) comparing the effectiveness of resuturing versus expectant management for dehisced perineal wounds.

DESIGN

A multicentre pilot and feasibility RCT.

SETTING

Ten UK maternity units from July 2011 to July 2013.

POPULATION

Eligible women with a dehisced perineal wound within 2 weeks of childbirth.

METHODS

The interventions were resuturing or expectancy. Randomisation was via web or telephone, stratified by participating centre. Blinding was not possible due to the nature of the interventions. Analysis was by intention-to-treat.

OUTCOME

The primary outcome measure was wound healing at 6-8 weeks.

RESULTS

The study revealed a number of feasibility issues, particularly strong patient and clinician preference for treatment options at recruiting centres and the timing of the primary outcome measure. Thirty-four women were randomised (17 in each arm). Data from 33 women were analysed on an intention-to-treat analysis to obtain preliminary estimates of effect size. There was a difference in wound healing at 2 weeks favouring resuturing (OR 20.00, 95% CI 2.04 to 196.37, p=0.004). However, by 6-8 weeks all but one wound in both groups had healed.

CONCLUSIONS

PREVIEW revealed a number of feasibility issues, which impacted on recruitment rate. These will have to be taken into account in the design of any future definitive study. In this feasibility study, resuturing was associated with quicker wound healing and women reported higher satisfaction rates with the outcome at 3 months.

TRIAL REGISTRATION NUMBER

ISRCTN05754020.

Fourth consensus of the International Society for Premenstrual Disorders (ISPMD): auditable standards for diagnosis and management of premenstrual disorder

Whilst professional bodies such as the Royal College and the American College of Obstetricians and Gynecologists have well-established standards for audit of management for most gynaecology disorders, such standards for premenstrual disorders (PMDs) have yet to be developed. The International Society of Premenstrual Disorders (ISPMD) has already published three consensus papers on PMDs covering areas that include definition, classification/quantification, clinical trial design and management (American College Obstetricians and Gynecologists 2011; Brown et al. in Cochrane Database Syst Rev 2:CD001396, 2009; Dickerson et al. in Am Fam Physician 67(8):1743-1752, 2003). In this fourth consensus of ISPMD, we aim to create a set of auditable standards for the clinical management of PMDs. All members of the original ISPMD consensus group were invited to submit one or more auditable standards to be eligible in the inclusion of the consensus. Ninety-five percent of members (18/19) responded with at least one auditable standard. A total of 66 auditable standards were received, which were returned to all group members who then ranked the standards in order of priority, before the results were collated. Proposed standards related to the diagnosis of PMDs identified the importance of obtaining an accurate history, that a symptom diary should be kept for 2 months prior to diagnosis and that symptom reporting demonstrates symptoms in the premenstrual phase of the menstrual cycle and relieved by menstruation. Regarding treatment, the most important standards were the use of selective serotonin reuptake inhibitors (SSRIs) as a first line treatment, an evidence-based approach to treatment and that SSRI side effects are properly explained to patients. A set of comprehensive standards to be used in the diagnosis and treatment of PMD has been established, for which PMD management can be audited against for standardised and improved care.

PMS in the perimenopause

Premenstrual syndrome (PMS) and the perimenopause are each difficult conditions to manage. When they co-exist the difficulty is more than doubled. Understanding and recognising the differences and the similarities between these conditions should enable clinicians to provide appropriate treatment and significantly improve women's quality of life. Distinction between the two can be difficult. Anecdotally women seem more prone to PMS symptoms during the perimenopause, or at least they tolerate the symptoms less well. Symptoms of the perimenopause arise from falling oestrogen levels with irregular ovulation, resulting in symptoms of oestrogen lack and heavy irregular periods. Symptoms of the perimenopause are thus relieved by the administration of oestrogen. Premenstrual syndrome frequently results when ovulation occurs. PMS appears to be due directly to the progesterone produced following ovulation in women who have enhanced sensitivity to this steroid. Treatment can thus be achieved by suppressing ovulation or reducing progesterone sensitivity; the latter seems achievable by the administration of selective serotonin re-uptake inhibitors. Ovulation can be suppressed by a variety of methods and oestrogen is an approach which is frequently employed. This will also effectively treat menopausal symptoms. The main problem with using oestrogen is that a progestogen must be administered to prevent endometrial neoplasia; this can result in a return of the PMS symptoms. This article reviews the difficulties encountered in women with both disorders and provides a suggested management strategy.

Methylation of the FGFR2 gene is associated with high birth weight centile in humans

AIMS

This study examined links between DNA methylation and birth weight centile (BWC), and explored the impact of genetic variation.

MATERIALS & METHODS

Using HumanMethylation450 arrays, we examined candidate gene-associated CpGs in cord blood from newborns with low (<15th centile), medium (40-60th centile) and high (>85th centile) BWC (n = 12). Candidates were examined in an investigation cohort (n = 110) using pyrosequencing and genotyping for putative methylation-associated polymorphisms performed using standard PCR.

RESULTS

Array analysis identified 314 candidate genes associated with BWC extremes, four of which showed ≥ 4 BWC-linked CpGs. Of these, PM20D1 and MI886 suggested genetically determined methylation levels. However, methylation at three CpGs in FGFR2 remained significantly associated with high BWC (p = 0.004-0.027).

CONCLUSION

We identified a novel biologically plausible candidate (FGFR2) for with BWC that merits further study.

Perineal support and risk of obstetric anal sphincter injuries: a Delphi survey

OBJECTIVE

To explore the views of a multidisciplinary group of experts and achieve consensus on the importance of perineal support in preventing obstetric anal sphincter injuries (OASIS).

DESIGN

A three-generational Delphi survey.

SETTING

A UK-wide survey of experts.

POPULATION

A panel of 20 members consisting of obstetricians, midwives and urogynecologists recommended by UK professional bodies.

METHODS

A 58-item web-based questionnaire was sent to all participants who were asked to anonymously rate the importance of each item on a six-point Likert scale. They were asked to rate their level of agreement on statements related to hands-on/hands-poised techniques, the association of hands-poised/hands-off approach with OASIS, the need to implement perineal support and the need to improve the evidence to support it. Systematic feedback of responses from previous rounds was provided to participants.

MAIN OUTCOME MEASURES

To achieve consensus on key areas related to perineal support.

RESULTS

The response rate was 100% in all three iterations. There was consensus that current UK practice regarding perineal protection was not based on robust evidence. The respondents agreed that hands-poised/hands-off and OASIS are causally related and that hands-poised was misinterpreted by clinicians as hands-off. Although 90% of experts agreed that some form of randomized trial was required and that all would be prepared to take part, there was also consensus (75%) that in the meantime, hands-on should be the recommended technique.

CONCLUSIONS

Our results highlight the current lack of evidence to support policies of perineal support at time of birth and the need to address this controversial issue.

Developing Objective Metrics for Unit Staffing (DOMUS) study

OBJECTIVE

Safe midwifery staffing levels on delivery suites is a priority area for any maternity service. Escalation policies are tools that provide an operational response to emergency pressures. The aim of this study was to assess the feasibility of using a scoring system to contemporaneously assess the required staffing level based on demand and use this to determine delivery suite escalation level and utilise the information generated regarding clinical activity (Demand) and staffing levels (Capacity) to generate unit-specific calculation for the actual number of midwifery staff required.

SETTING

A maternity unit of a university-affiliated tertiary referral hospital.

DESIGN

Over a 12-month period, specifically designed scoring sheets were completed by delivery suite shift co-ordinators four times a day (04:00, 10:00, 16:00 and 22:00). Based on the dependency score (Demand) and the number of midwifery staff available (Capacity), an escalation level was determined for each shift. The 80th centile of the demand was used to determine optimal capacity.

RESULTS

A total of 1160 scoring sheets were completed. Average staff number throughout the year on any shift was 7 (range 3-11). Average dependency score was 7 (range 1-14). The 80th centile for demand was calculated to be 11.

CONCLUSIONS

This study stresses the importance and usefulness of a simple tool that can be used to determine the level of escalation on delivery suite based on an objective scoring system and can also be used to determine the appropriate staffing on delivery suite.

Perinatal psychiatric disorders: an overview

Perinatal mental illness has a significant implication on maternal health, birth outcomes, and the offspring's development. Prevalence estimates of perinatal psychiatric illnesses range widely, with substantial heterogeneity in different population studies, with a lower prevalence rate in high- rather than low- or middle-income countries. Because of the potential negative impact on maternal and child outcomes and the potential lability of these disorders, the perinatal period is a critical time to identify psychiatric illnesses. Thus, obstetricians and midwives play a crucial role in assessing women's mental health needs and to refer identified women promptly for multidisciplinary specialist assessment. However, there is still limited evidence on best practice assessment and management policies during pregnancy and postpartum. This review focuses on the prevalence of common perinatal mental disorders and antenatal screening policies to identify women at risk. The effect of these conditions and their management on pregnancy, fetal outcomes, and child development are discussed.

Secondary suturing compared to non-suturing for broken down perineal wounds following childbirth

BACKGROUND

Each year approximately 350,000 women in the United Kingdom and millions more worldwide, experience perineal suturing following childbirth. The postpartum management of perineal trauma is a core component of routine maternity care. However, for those women whose perineal wound dehisces (breaks down), the management varies depending on individual practitioners preferences as there is limited scientific evidence and no clear guidelines to inform best practice. For most women the wound will be managed expectantly whereas, others may be offered secondary suturing.

OBJECTIVES

To evaluate the therapeutic effectiveness of secondary suturing of dehisced perineal wounds compared to non-suturing (healing by secondary intention, expectancy).

SEARCH METHODS

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

SELECTION CRITERIA

Randomised controlled trials of secondary suturing of dehisced perineal wounds (second-, third- or fourth-degree tear or episiotomy), following wound debridement and the removal of any remaining suture material within the first six weeks following childbirth compared with non-suturing.

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

Two small studies of poor methodological quality including 52 women with a dehisced and/or infected episiotomy wound at point of entry have been included.Only one small study presented data in relation to wound healing at less than four weeks, (the primary outcome measure for this review), although no reference was made to demonstrate how healing was measured. There was a trend to favour this outcome in the resuturing group, however, this difference was not statistically significant (risk ratio (RR) 1.69, 95% confidence interval (CI) 0.73 to 3.88, one study, 17 women).Similarly, only one trial reported on rates of dyspareunia (a secondary outcome measure for this review) at two months and six months with no statistically significant difference between both groups; two months, (RR 0.44, 95% CI 0.18 to 1.11, one study, 26 women) and six months, (RR 0.39, 95% CI 0.04 to 3.87, one study 32 women). This trial also included data on the numbers of women who resumed sexual intercourse by two months and six months. Significantly more women in the secondary suturing group had resumed intercourse by two months (RR 1.78, 95% CI 1.10 to 2.89, one study, 35 women), although by six months there was no significant difference between the two groups (RR 1.08, 95% CI, 0.91 to 1.28).Neither of the trials included data in relation to the following prespecified secondary outcome measures: pain at any time interval; the woman's satisfaction with the aesthetic results of the perineal wound; exclusive breastfeeding; maternal anxiety or depression.

AUTHORS' CONCLUSIONS

Based on this review, there is currently insufficient evidence available to either support or refute secondary suturing for the management of broken down perineal wounds following childbirth. There is an urgent need for a robust randomised controlled trial to evaluate fully the comparative effects of both treatment options.

Perineal Assessment and Repair Longitudinal Study (PEARLS): a matched-pair cluster randomized trial

BACKGROUND

Perineal trauma during childbirth affects millions of women worldwide every year. The aim of the Perineal Assessment and Repair Longitudinal Study (PEARLS) was to improve maternal clinical outcomes following childbirth through an enhanced cascaded multiprofessional training program to support implementation of evidence-based perineal management.

METHODS

This was a pragmatic matched-pair cluster randomized controlled trial (RCT) that enrolled women (n = 3681) sustaining a second-degree perineal tear in one of 22 UK maternity units (clusters), organized in 11 matched pairs. Units in each matched pair were randomized to receive the training intervention either early (group A) or late (group B). Outcomes within each cluster were assessed prior to any training intervention (phase 1), and then after the training intervention was given to group A (phase 2) and group B (phase 3). Focusing on phase 2, the primary outcome was the percentage of women who had pain on sitting or walking at 10 to 12 days post-natal. Secondary outcomes included use of pain relief at 10 to 12 days post-natal, need for suture removal, uptake and duration of exclusive breastfeeding, and perineal wound infection. Practice-based measures included implementation of evidence into practice to promote effective clinical management of perineal trauma. Cluster-level paired t-tests were used to compare groups A and B.

RESULTS

There was no significant difference between the clusters in phase 2 of the study in the average percentage of women reporting perineal pain on sitting and walking at 10 to 12 days (mean difference 0.7%; 95% CI -10.1% to 11.4%; P = 0.89). The intervention significantly improved overall use of evidence-based practice in the clinical management of perineal trauma. Following the training intervention, group A clusters had a significant reduction in mean percentages of women reporting perineal wound infections and of women needing sutures removed.

CONCLUSION

PEARLS is the first RCT to assess the effects of a 'training package on implementation of evidence-based perineal trauma management. The intervention did not significantly improve the primary outcome but did significantly improve evidence-based practice and some of the relevant secondary clinical outcomes for women.

TRIAL REGISTRATIONS

ISRCTN28960026 NIHR UKCRN portfolio no: 4785.

Clinical subtypes of core premenstrual disorders: a Delphi survey

The purpose of this study was to classify the clinical subtypes of core premenstrual disorders during the International Society for Premenstrual Disorders' second consensus meeting. Multiple iterations were used to achieve consensus between a group of experts; these iterations included a two-generational Delphi technique that was preceded and followed by open group discussions. The first round was to generate a list of all potential clinical subtypes, which were subsequently prioritized using a Delphi methodology and then finalised in a final round of open discussion. On a six-point scale, 4 of the 12 potential clinical subtypes had a mean score of ≥5.0 following the second iteration and only 3 of the 4 still had a mean score of ≥5.0 after the third iteration. The final list consisted of these three subtypes and an additional subtype, which was introduced and agreed upon, in the final iteration. There is consensus amongst experts that core premenstrual disorder is divided into three symptom-based subtypes: predominantly physical, predominantly psychological and mixed. A proportion of psychological and mixed subtypes may meet the DSM-IV diagnostic criteria for premenstrual dysphoric disorder.

Pregnancy outcome after elective cervical cerclage in relation to type of suture material used

Cervical weakness is an important cause of late miscarriage and extreme preterm labour. Women have been traditionally offered a cervical cerclage procedure, though studies failed to demonstrate a therapeutic effect. None of these studies has addressed the effect of non-braided to braided suture material on cerclage outcome. Type of suture material is an important determinant of surgical outcomes. This issue is of particular relevance to cerclage because the traditionally braided suture has been associated with increased risk of infection in other surgical procedures. Indeed, infection is an important underlying cause for cerclage failure. It is for this reason that some surgeons use non-braided suture material. Therefore, we hypothesise that the unrealised benefit of cervical cerclage is at least in part due to the type of suture material used. In this article, we present the rationale behind our hypothesis and a proposed way of testing it.

The development and validation of an internet-based training package for the management of perineal trauma following childbirth: MaternityPEARLS

BACKGROUND

Birth-related perineal trauma has a major impact on women's health. Appropriate management of perineal injuries requires clinical knowledge and skill. At present, there is no agreement as to what constitutes an effective clinical training programme, despite the presence of sufficient evidence to support standardised perineal repair techniques. To address this deficiency, we developed and validated an interactive distance learning multi-professional training package called MaternityPEARLS.

METHOD

MaternityPEARLS was developed as a comprehensive e-learning package in 2010. The main aim of the MaternityPEARLS project was to develop, refine and validate this multi-professional e-learning tool. The effect of MaternityPEARLS in improving clinical skills and knowledge was compared with two other training models; traditional training (lectures + model-based hands on training) and offline computer lab-based training. Midwives and obstetricians were recruited for each training modality from three maternity units. An analysis of covariance was done to assess the effects of clinical profession and years of experience on scoring within each group. Feedback on MaternityPEARLS was also collected from participants. The project started in January 2010 and was completed in December 2010.

RESULTS

Thirty-eight participants were included in the study. Pretraining and post-training scores in each group showed considerable improvement in skill scores (p<0.001 in all groups). Mean changes were similar across all three groups for knowledge (3.24 (SD 5.38), 3.00 (SD 3.74), 3.30 (SD 3.73)) and skill (25.34 (SD 8.96), 22.82 (SD 9.24), 20.7 (SD 9.76)) in the traditional, offline computer lab-based and e-learning groups, respectively. There was no evidence of any effect of clinical experience and baseline knowledge on outcomes.

CONCLUSIONS

MaternityPEARLS is the first validated perineal trauma management e-learning package. It provides a level of improvement in skill and knowledge comparable to traditional methods of training. However, as an e-learning system, it has the advantage of ensuring the delivery of a standardised, continuously updated curriculum that has global accessibility.

Prioritisation of teaching topics in obstetrics and gynaecology: a Delphi survey of postgraduate trainees

Topics for theoretical teaching during the obstetrics and gynaecology specialty training programme are often chosen by tutors, with little input from the trainees. However, it is important to actively involve adults in their learning process to maintain their learning ownership and motivation. The Delphi methodology is a generic social science technique used to aggregate views and opinions of experts, the community and service users. In this study, we conducted a two generational Delphi study to achieve consensus between a group of trainees in obstetrics and gynaecology, regarding what they considered important topics for inclusion in their protected teaching programme. A total of 25 trainees from one deanery, participated in this study. We were able to produce a list of 26 topics in obstetrics and 30 in gynaecology, prioritised according to their importance for inclusion in the specialty protected teaching programme, as viewed by these trainees.

Accuracy of liver function tests for predicting adverse maternal and fetal outcomes in women with preeclampsia: a systematic review

BACKGROUND

Liver function tests are routinely performed in women as part of a battery of investigations to assess severity at admission and later to guide appropriate management.

OBJECTIVE

To determine the accuracy with which liver function tests predict complications in women with preeclampsia by a systematic review.

DATA

We conducted electronic searches without language restrictions in (1951-2010), (1980-2010) and the Cochrane Library (2009).

METHODS OF STUDY SELECTION

Primary articles that evaluated the accuracy of liver function tests in predicting complications in women with preeclampsia were chosen. Data was extracted by two reviewers independently. A bivariate model estimated area under the curve, sensitivity and specificity.

RESULTS

There were 13 primary articles including a total of 3 497 women assessing maternal (30 2×2 tables) and fetal (19 2×2 tables) outcomes. For predicting adverse maternal outcome, the point estimates of specificity were >70% in 18 tables with 0.79 (95%CI 0.51, 0.93). For predicting adverse fetal outcomes the specificity of the test was >70% in 2×2 tables. Sensitivity of the test was poor for both maternal and fetal outcomes.

CONCLUSION

In women with preeclampsia, function tests performed better in predicting adverse maternal than fetal outcomes. The presence of increased liver enzymes was associated with an increased probability of maternal and fetal complications, but normal liver enzyme levels did not rule out disease, as specificity was often higher than sensitivity.

Towards a consensus on diagnostic criteria, measurement and trial design of the premenstrual disorders: the ISPMD Montreal consensus

Premenstrual disorders (PMD) are characterised by a cluster of somatic and psychological symptoms of varying severity that occur during the luteal phase of the menstrual cycle and resolve during menses (Freeman and Sondheimer, Prim Care Companion J Clin Psychiatry 5:30-39, 2003; Halbreich, Gynecol Endocrinol 19:320-334, 2004). Although PMD have been widely recognised for many decades, their precise cause is still unknown and there are no definitive, universally accepted diagnostic criteria. To consider this issue, an international multidisciplinary group of experts met at a face-to-face consensus meeting to review current definitions and diagnostic criteria for PMD. This was followed by extensive correspondence. The consensus group formally became established as the International Society for Premenstrual Disorders (ISPMD). The inaugural meeting of the ISPMD was held in Montreal in September 2008. The primary aim was to provide a unified approach for the diagnostic criteria of PMD, their quantification and guidelines on clinical trial design. This report summarises their recommendations. It is hoped that the criteria proposed here will inform discussions of the next edition of the World Health Organisation's International Classification of Diseases (ICD-11), and the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V) criteria that are currently under consideration. It is also hoped that the proposed definitions and guidelines could be used by all clinicians and investigators to provide a consistent approach to the diagnosis and treatment of PMD and to aid scientific and clinical research in this field.

Quantitative, high-resolution epigenetic profiling of CpG loci identifies associations with cord blood plasma homocysteine and birth weight in humans

Supplementation with folic acid during pregnancy is known to reduce the risk of neural tube defects and low birth weight. It is thought that folate and other one-carbon intermediates might secure these clinical effects via DNA methylation. We examined the effects of folate on the human methylome using quantitative interrogation of 27,578 CpG loci associated with 14,496 genes at single-nucleotide resolution across 12 fetal cord blood samples. Consistent with previous studies, the majority of CpG dinucleotides located within CpG islands exhibited hypo-methylation while those outside CpG islands showed mid-high methylation. However, for the first time in human samples, unbiased analysis of methylation across samples revealed a significant correlation of methylation patterns with plasma homocysteine, LINE-1 methylation and birth weight centile. Additionally, CpG methylation significantly correlated with either birth weight or LINE-1 methylation were predominantly located in CpG islands. These data indicate that levels of folate-associated intermediates in cord blood reflect their influence and consequences for the fetal epigenome and potentially on pregnancy outcome. In these cases, their influence might be exerted during late gestation or reflect those present during the peri-conceptual period.

Triply troubled: criminal behaviour and mental health in a cohort of teenage pregnant substance misusers in treatment

BACKGROUND

Teenage substance misuse and pregnancy are major public health problems in the UK, where the most recent figures on maternal deaths suggest that they have doubled among young substance misusers. In general, little is known about their pregnancy outcomes.

AIMS

The aims of this study were to describe the characteristics of a sample of teenage pregnant drug users in the UK, to examine their psychosocial risk and complicating factors at presentation, to evaluate adherence to current national guidelines and to assess the adequacy of guidelines in relation to identified characteristics.

METHODS

A six-year records survey of young people attending a specialist adolescent drug misuse service in the west midlands of the UK.

RESULTS

Ten pregnant adolescents were identified from records. These girls have had unstable or abusive experiences through childhood, half having other substance misusers in the family. All were with substantially older partners, who were also substance misusers. All had required a mental health assessment and 90% had a history of self-harm. There were no maternal or neonatal deaths, and only one girl had a miscarriage, but in four cases, the child had to be fostered.

CONCLUSIONS

To our knowledge, this is the first analysis of this kind in the UK. Available guidelines were followed, but our findings suggest that more detailed and comprehensive guidelines are required. Preventive measures through education are likely to be hampered by the early age at which these girls cease attending school.

PErineal Assessment and Repair Longitudinal Study (PEARLS): protocol for a matched pair cluster trial

Background

The Perineal Assessment and Repair Longitudinal Study (PEARLS) is a national clinical quality improvement initiative designed to improve the assessment and management of perineal trauma. Perineal trauma affects around 85% of women who have a vaginal birth in the UK each year and millions more world-wide. Continuous suturing techniques compared with traditional interrupted methods are more effective in reducing pain and postnatal morbidity, however they are not widely used by clinicians despite recommendations of evidence based national clinical guidelines. Perineal suturing skills and postnatal management of trauma remain highly variable within and between maternity units in the UK as well as worldwide. Implementation of a standardised training package to support effective perineal management practices could reduce perineal pain and other related postnatal morbidity for a substantial number of women.

Methods/Design

PEARLS is a matched pair cluster trial, which is being conducted in maternity units across the UK. Units within a matched pair will be randomised to implement the study intervention either early or late in the study period. The intervention will include the cascading of a multi-professional training package to enhance midwifery and obstetric skills in the assessment, repair and postnatal management of perineal trauma. Women who have had an episiotomy or second degree perineal tear will be eligible for recruitment. Prior to developing the intervention and deciding on study outcomes, a Delphi survey and a consensus conference were held to identify what women, who previously suffered perineal trauma during childbirth, considered to be important outcomes for them. Findings from this preliminary work (which will be reported elsewhere) and other outcomes including women's experiences of perineal pain and pain on activity, breastfeeding uptake and duration and psychological well-being as assessed using the Edinburgh Postnatal Depression Scale (EPDS) will be assessed at 10 days and three months post-birth.

Discussion

Implementation of evidence-based perineal assessment and management practices, could lead to significantly improved physical and psychological health outcomes for women in the UK and world-wide.

Trial registration

PEARLS is registered with the Current Controlled Trials Registry (no: ISRCTN28960026). NIHR UKCRN portfolio no: 4785.

LINE-1 DNA methylation is inversely correlated with cord plasma homocysteine in man: a preliminary study

Folic acid supplementation during pregnancy has known beneficial effects. It reduces risk of neural tube defects and low birth weight. Folate and other one-carbon intermediates might secure these clinical effects via DNA methylation. However, most data on the effects of folate on the epigenome is derived from animal or in vitro models. We examined the relationship between cord blood methylation and maternal folic acid intake, cord blood folate and homocysteine using data from 24 pregnant women. Genome-wide methylation was determined by the level of methylation of LINE-1 repeats using Pyrosequencing. We show that cord plasma homocysteine (p = 0.001, r = -0.688), but not serum folate or maternal folic acid intake, is inverse correlated with LINE-1 methylation. This remained significant after correction for potential confounders (p = 0.004). These data indicate that levels of folate-associated intermediates in cord blood during late pregnancy have significant consequences for the fetal epigenome.

Estimation of proteinuria as a predictor of complications of pre-eclampsia: a systematic review

BACKGROUND

Proteinuria is one of the essential criteria for the clinical diagnosis of pre-eclampsia. Increasing levels of proteinuria is considered to be associated with adverse maternal and fetal outcomes. We aim to determine the accuracy with which the amount of proteinuria predicts maternal and fetal complications in women with pre-eclampsia by systematic quantitative review of test accuracy studies.

METHODS

We conducted electronic searches in MEDLINE (1951 to 2007), EMBASE (1980 to 2007), the Cochrane Library (2007) and the MEDION database to identify relevant articles and hand-search of selected specialist journals and reference lists of articles. There were no language restrictions for any of these searches. Two reviewers independently selected those articles in which the accuracy of proteinuria estimate was evaluated to predict maternal and fetal complications of pre-eclampsia. Data were extracted on study characteristics, quality and accuracy to construct 2 x 2 tables with maternal and fetal complications as reference standards.

RESULTS

Sixteen primary articles with a total of 6749 women met the selection criteria with levels of proteinuria estimated by urine dipstick, 24-hour urine proteinuria or urine protein:creatinine ratio as a predictor of complications of pre-eclampsia. All 10 studies predicting maternal outcomes showed that proteinuria is a poor predictor of maternal complications in women with pre-eclampsia. Seventeen studies used laboratory analysis and eight studies bedside analysis to assess the accuracy of proteinuria in predicting fetal and neonatal complications. Summary likelihood ratios of positive and negative tests for the threshold level of 5 g/24 h were 2.0 (95% CI 1.5, 2.7) and 0.53 (95% CI 0.27, 1) for stillbirths, 1.5 (95% CI 0.94, 2.4) and 0.73 (95% CI 0.39, 1.4) for neonatal deaths and 1.5 (95% 1, 2) and 0.78 (95% 0.64, 0.95) for Neonatal Intensive Care Unit admission.

CONCLUSION

Measure of proteinuria is a poor predictor of either maternal or fetal complications in women with pre-eclampsia.

Serotonin receptor 1A C(-1019)G polymorphism associated with premenstrual dysphoric disorder

OBJECTIVE

To assess whether the G allele of the serotonin receptor 1A C(-1019)G polymorphism is associated with premenstrual dysphoric disorder.

METHODS

The study sample comprised 53 women with clinically diagnosed premenstrual dysphoric disorder (age range 27-46 years, mean 37.7 years) and 51 healthy control subjects (age range 22-48 years, mean 36.2 years). The serotonin receptor 1A C(-1019)G polymorphism was genotyped and compared between the two groups.

RESULTS

In contrast to the postulated "high-risk" G/G genotype, there was a marked overrepresentation of the C/C genotype in the premenstrual dysphoric disorder group (P=.034; odds ratio 3.63, 95% confidence interval 1.22-10.78). The presence of at least one C allele was associated with a 2.5-fold increased risk of premenstrual dysphoric disorder (P=.053; odds ratio 2.46, 95% confidence interval 1.03-5.88).

CONCLUSION

Our hypothesis that the high-risk G allele is associated with the occurrence of premenstrual dysphoria was not proved in this study. However, due to the increased prevalence of the C variant, we suggest that the C(-1019) allele may contribute to the risk of premenstrual dysphoria.

LEVEL OF EVIDENCE

II.

Continuous versus interrupted sutures for repair of episiotomy or second degree tears

BACKGROUND

Millions of women worldwide undergo perineal suturing after childbirth and the type of repair may have an impact on pain and healing. For more than 70 years, researchers have been suggesting that continuous non-locking suture techniques for repair of the vagina, perineal muscles and skin are associated with less perineal pain than traditional interrupted methods.

OBJECTIVES

To assess the effects of continuous versus interrupted absorbable sutures for repair of episiotomy and second degree perineal tears following childbirth.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (June 2007).

SELECTION CRITERIA

Randomised trials comparing continuous versus interrupted sutures for repair of episiotomy and second-degree tears after vaginal delivery.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed trial quality. Two of the three authors independently extracted data and a third author checked them. We contacted study authors for additional information.

MAIN RESULTS

Seven studies, involving 3822 women at point of entry, from four countries, have been included. The trials were heterogeneous in respect of operator skill and training. Meta-analysis showed that continuous suture techniques compared with interrupted sutures for perineal closure (all layers or perineal skin only) are associated with less pain for up to 10 days postpartum (relative risk (RR) 0.70, 95% confidence interval 0.64 to 0.76). Subgroup analysis showed that there is a greater reduction in pain when continuous suturing techniques are used for all layers (RR 0.65, 95% CI 0.60 to 0.71). There was an overall reduction in analgesia use associated with the continuous subcutaneous technique versus interrupted stitches for repair of perineal skin (RR 0.70, 95% CI 0.58 to 0.84). Subgroup analysis showed some evidence of reduction in dyspareunia experienced by participants in the groups that had continuous suturing for all layers (RR 0.83, 95% CI 0.70 to 0.98). There was also a reduction in suture removal in the continuous suturing groups versus interrupted (RR 0.54, 95% CI 0.45 to 0.65), but no significant differences were seen in the need for re-suturing of wounds or long-term pain.

AUTHORS' CONCLUSIONS

The continuous suturing techniques for perineal closure, compared to interrupted methods, are associated with less short-term pain. Moreover, if the continuous technique is used for all layers (vagina, perineal muscles and skin) compared to perineal skin only, the reduction in pain is even greater.

Acceptability of perinatal rapid point-of-care HIV testing in an area of low HIV prevalence in the UK

OBJECTIVE

To determine the uptake of current antenatal HIV testing, the prevalence of risk factors for HIV in pregnant women and the acceptability of the rapid point-of-care HIV test (RPOCT) among pregnant women and their midwives.

DESIGN

A retrospective review of 717 notes to determine current HIV screening practices and a cross-sectional survey using a self-completed questionnaire for pregnant women and midwives.

SETTING

The antenatal clinic (ANC) and postnatal wards (PNW) at a university teaching hospital in the West Midlands.

PARTICIPANTS

486 women attending the ANC or admitted to the PNW during a fortnight in May-June 2006. 72 midwives on the delivery ward completed a second questionnaire.

RESULTS

The questionnaire showed that 90.4% of those offered the standard HIV test accepted it, with 7.2% having at least one risk factor for HIV. Over half of the decliners perceived themselves as not at risk. 85.2% would accept the rapid test, including 35.6% of the decliners. 92.8% of midwives agreed/strongly agreed the RPOCT has a role on the delivery ward and 97.2% would be happy to offer the test with appropriate training and guidance.

CONCLUSIONS

Midwives deem the RPOCT to be appropriate for a variety of perinatal settings. It is also acceptable to a clinically significant proportion of those who decline the standard test (21 of 59) and therefore has the potential to increase screening and detection rates. Hence, by allowing early diagnosis and the initiation of antenatal interventions, it could reduce the rate of mother-to-child transmission (MTCT) in the UK.

Serotonin transporter, tryptophan hydroxylase, and monoamine oxidase A gene polymorphisms in premenstrual dysphoric disorder

OBJECTIVE

The purpose of this study was to investigate whether common polymorphisms of key genes that control the serotonin (5-hydroxytryptamine) pathway are associated with premenstrual dysphoric disorder.

STUDY DESIGN

The study sample comprised 53 women with clinically diagnosed premenstrual dysphoric disorder (age range, 27-46 years; mean age, 37.7 years) and 52 healthy control subjects (age range, 22-48 years; mean age, 36.2 years). Eight polymorphisms that encode the 5-hydroxytryptamine transporter (LPR, VNTR-2, and 3' UTR G/T), tryptophan hydroxylase 1 (TPH1 G-6526A, G-5806T, and A218C), and monoamine oxidase A (monoamine oxidase A promoter VNTR-1 and exon 8 Fnu 4H1) were genotyped. Genotype and allelic frequencies were analyzed by chi-square test and stepwise logistic regression analysis.

RESULTS

There was no significant association between any genotype and clinical category and no significant allelic distribution profiles in either the premenstrual dysphoric disorder group or the control group.

CONCLUSION

These findings do not support a major role for common 5-hydroxytryptamine transporter, TPH1, and monoamine oxidase A polymorphisms in contributing to susceptibility to premenstrual dysphoric disorder.

Accuracy of serum uric acid in predicting complications of pre-eclampsia: a systematic review

BACKGROUND

Pre-eclampsia is one of the largest causes of maternal and fetal mortality and morbidity. Hyperuricemia is often associated with pre-eclampsia.

OBJECTIVE

To determine the accuracy with which serum uric acid predicts maternal and fetal complications in women with pre-eclampsia.

STUDY DESIGN

Systematic quantitative review of test accuracy studies.

SEARCH STRATEGY

We conducted electronic searches in MEDLINE (1951-2004), EMBASE (1980-2004), the Cochrane Library (2004:4) and the MEDION database to identify relevant articles. A hand-search of selected specialist journals and reference lists of articles obtained was then carried out. There were no language restrictions for any of these searches.

SELECTION CRITERIA

Two reviewers independently selected the articles in which the accuracy of serum uric acid was evaluated to predict maternal and fetal complications of pre-eclampsia.

DATA COLLECTION AND ANALYSIS

Data were extracted on study characteristics, quality and accuracy to construct 2 x 2 tables with maternal and fetal complications as reference standard. Summary likelihood ratios for positive (LR+) and negative LR(-) test results are generated for various threshold levels of uric acid.

MAIN RESULTS

There were 18 primary articles that met the selection criteria, including a total of 3913 women and forty-one 2 x 2 tables. In women with pre-eclampsia, a positive test result of uric acid greater than or equal to a 350-micromol/l threshold predicted eclampsia with a pooled likelihood ratio (LR) of 2.1 (95% CI 1.4-3.5), while a negative test result had a pooled LR of 0.38 (95% CI 0.18-0.81). For severe hypertension as the outcome measure, the LRs were 1.7 (95% CI 1.3-2.2) and 0.49 (95% CI 0.38-0.64) for positive and negative test results, respectively, and for caesarean section the LRs were 2.4 (95% CI 1.3-4.7) and 0.39 (95% CI 0.20-0.76). For stillbirths and neonatal deaths the respective LRs were 1.5 (95% CI 0.91-2.6) and 0.51 (95% CI 0.20-1.3). For the prediction of small-for-gestational-age fetus, the pooled LRs were 1.3 (95% CI 1.1-1.7) and 0.60 (95% CI 0.43-0.83) for positive and negative results, respectively. AUTHOR'S CONCLUSION: Serum uric acid is a poor predictor of maternal and fetal complications in women with pre-eclampsia.

Increase of acetone emitted by urine in relation to ovulation

BACKGROUND

Selected ion flow tube mass spectrometry allows trace gas quantification in exhaled breath and in the air/vapor above liquids (headspace) down to the 10 parts-per-billion level. During selected ion flow tube mass spectrometry investigation of the volatile compounds emitted by urine, high acetone levels were incidentally identified in the headspace of urine from healthy female volunteers around their mid-cycle. Hence, this study was designed to measure urine headspace acetone levels throughout the menstrual cycle.

METHODS

Using selected ion flow tube mass spectrometry we measured daily urine headspace acetone concentrations of seven ovulating (group 1) and three postmenopausal volunteers (group 2).

RESULTS

A several-fold increase in urine headspace acetone level was detected 2-3 days after the predicted day of ovulation in 5 of the 7 volunteers in group 1. No such rise was detected in group 2.

CONCLUSION

This study provides the basis for future research to understand the reason for and the potential utility of this phenomenon.

The effectiveness of GnRHa with and without 'add-back' therapy in treating premenstrual syndrome: a meta analysis

OBJECTIVE

To determine the effectiveness of gonadotrophin-releasing hormone analogues (GnRHa) with and without hormonal add-back therapy in the management of premenstrual syndrome.

DESIGN

Randomised controlled trials were identified by searching multiple databases.

SETTING

Exeter and North Devon Research and Development Support Unit and Keele University Academic Unit of Obstetrics and Gynaecology.

POPULATION

Women with pre-diagnosed premenstrual syndrome and/or premenstrual dysphoric disorder.

METHODS

A meta-analysis of published randomised placebo-controlled trials assessing the use of GnRHa in the management of premenstrual syndrome. The standardised mean difference for each individual study and subsequently an overall standardised mean difference were calculated after demonstrating the consistency or homogeneity of the study results.

MAIN OUTCOME MEASURES

Overall improvement in premenstrual symptomatology and effectiveness of GnRHa with additional hormonal add-back therapy were the main outcome measures assessed in this analysis. A secondary analysis was performed to assess the effectiveness of GnRHa in treating physical and emotional symptoms.

RESULTS

Overall standardised mean difference for all trials that assessed the efficacy of GnRHa was -1.19 (95% confidence interval [CI] -1.88 to -0.51). The equivalent odds ratio was 8.66 (95% CI 2.52 to 30.26) in favour of GnRHa. GnRHa were more efficacious for physical than behavioural symptoms, although the difference was not statistically significant. The addition of hormonal add-back therapy to GnRHa did not appear to reduce the efficacy of GnRHa alone; standardised mean difference 0.12 (95% CI -0.35 to 0.58).

CONCLUSIONS

GnRHa appear to be an effective treatment in the management of premenstrual syndrome. The addition of hormonal add-back therapy to reduce side effects does not reduce efficacy.

Fetal magnetic resonance imaging in prenatal diagnosis of central nervous system abnormalities: 3-year experience

OBJECTIVE

To evaluate the comparative merits of ultrasound and fetal magnetic resonance imaging (MRI) in the correct antenatal diagnosis of suspected central nervous system abnormalities.

METHODS

A retrospective review of 27 consecutive pregnancies referred for fetal MRI for suspected central nervous system abnormalities between July 1998 and July 2001. Women were referred for the MRI examination when further anatomical and/or pathological clarification of the ultrasound scan findings was needed. Antenatal ultrasound scan and MRI were reviewed in relation to the findings on postpartum investigations.

RESULTS

Data were complete for 26 pregnancies. The median gestational age at the time of the ultrasound examination was 26 weeks (95% CI 24 weeks 2 days to 28 weeks 1 day). The median gestational age at the time of magnetic resonance imaging was 27 weeks' gestation (95% Cl 26 weeks 1 day to 29 weeks 2 days). Eight fetuses had associated skeletal, renal and/or cardiac abnormalities previously noted on ultrasound examination. MRI confirmed the ultrasound diagnosis in 15/26 cases (58%). It changed the diagnosis to the correct one in 7/26 (27%) and misdiagnosed four cases (15%). Three of the four cases that were misdiagnosed on MRI occurred in the first 18 months of our 36-month experience.

CONCLUSION

Ultrasound remains the primary imaging modality for prenatal diagnosis. Fetal MRI appears to be a useful adjunct to ultrasound to confirm or exclude certain abnormalities; this will consequently help in the counselling of parents and assist in planning further management. However, like any imaging technique, the sensitivity and specificity of the test are likely to improve with experience.