Systemic, local, and sclerotherapy drugs: What do we know about drug prescribing in vascular anomalies?

Off-label drug prescribing, frequent in the treatment of vascular anomalies (VA), relies on the quality of the literature reporting drug efficacy and safety. Our objective is to review the level of evidence (LOE) surrounding drug use in VA, which is more prevalent in pediatric care. A list of drugs used in VA was created with a literature review in July 2020. For each drug listed, the article displaying the highest LOE was determined and then compared between efficacy/safety data, routes of administration, pharmacological categories and a subset of VA. The influence of research quality on study results was also explored. The median LOE for the 74 drugs identified poor methodological quality, with a predominance of retrospective studies or case reports. Drug safety is currently inadequately reported. This is alarming as many treatments display significant safety concerns. Also, current literature displays major publication bias that probably leads to overestimation of drug efficacy in VA.

73 Off-label use and safety of drug use in vascular anomalies

Primary Subject area

Clinical Pharmacology and Toxicology

Background

Vascular anomalies (VA) represent a heterogeneous group of disorders associated with an abnormal development and proliferation of blood and/or lymphatic vessels displaying variable clinical presentations and severity. Infantile hemangiomas, venous, and lymphatic malformations, for example, are commonly encountered in children. Other, less frequent diagnostics include Klippel-Trenaunay syndrome and PIK-3CA-related overgrowth spectrum (PROS). Severe phenotypes can alter organ function and/or lead to pain and chronic functional impairment, and are associated with significant morbidity and mortality. Management includes surgical, interventional radiology, and pharmacologic modalities. Drugs are administered by systemic (e.g., oral, intravenous) or local (topical, intralesional) routes, or by sclerotherapy (endovascular or percutaneous venous, lymphatic, or arterial injection). Off-label drug use is common in pediatrics and in rare diseases, two characteristics applying to vascular anomalies (VA). Off-label use is associated with an increased risk of adverse drug reactions.

Objectives

To quantify off-label drug use in VA and assess its safety.

Design/Methods

A guidelines search was conducted to extract a list of drugs used in VA management. The labelling status and safety of each drug was assessed based on the product monograph, Micromedex, and the FDA data. A drug was considered to have significant safety concerns if a black box warning (the FDA’s most stringent warning dedicated to serious or life-threatening risks) or if a serious adverse drug reaction was reported in at least 1% of the patients (leading to hospitalization, congenital malformation, persistent or significant disability or incapacity, life-threatening condition, or death).

Results

Among 87 drugs, 13 were unlicensed and 73 off-label. Figure 1 describes the reason for considering the 73 drugs off-label. Among 74 licensed drugs, only the oral solution of propranolol hydrochloride (Hemangeol®) for the treatment of infantile hemangiomas (IH) is approved. 98.9% of the drugs are used off-label or unlicensed. Except infantile hemangioma, all other VA are exclusively treated with off-label drugs. Significant safety issues concerned 73% of the drugs and were more frequent among systemic than locally delivered drugs (Figure 2).

Conclusion

This first study determining the rate of off-label drug use in vascular anomalies shows that off-label drug use in VA is the rule and not the exception. Significant safety concerns are common. It is needed to carefully weigh risk and benefits for every patient when using systemic and local treatments carrying safety concerns. Patients and families should be openly informed and involved in the decision-making process.

55 Evidence behind drug use in vascular anomalies: From infantile hemangioma to rare vascular anomalies … What do we know about what we do with local, systemic, or sclerotherapy treatment?

Primary Subject area

Clinical Pharmacology and Toxicology

Background

The most common vascular anomaly (VA) requiring medical treatment are infantile hemangiomas, but many other vascular anomalies affecting children are treated with local, systemic drugs or sclerosing agents.

Rational drug prescribing implies assessment of whether a drug’s benefits outweigh the risk of adverse effects for treatment of a specific vascular anomaly. This process relies on the quality of the literature on efficacy and safety for drug treatment of vascular anomalies.

Objectives

To evaluate the level of evidence surrounding drug use in vascular anomalies.

Design/Methods

A list of drugs used in vascular anomalies was created with existing guidelines. For each drug, the article displaying the highest level of evidence was determined, using Oxford criteria. Levels of evidence were compared between efficacy and safety data, routes of administration, pharmacological categories, and a subset of specific vascular anomalies. The influence of research quality on study results was explored by comparing the percentage of clinical efficacy between high- and low-quality studies.

Results

We identified 71 different drugs for treating vascular anomalies. The median level of evidence was low, with a predominance of retrospective cohort studies and case reports. The level of evidence was higher for efficacy than safety data and for common diseases like infantile hemangiomas. The level of evidence was lower for systemic vs. local drugs. Clinical efficacy was more frequently reported in low quality studies (retrospective cohort studies and case reports) than in high quality studies (randomized clinical trial and meta-analysis).

Conclusion

Quality of research on drugs used for treating vascular anomalies in infants is poor and challenges rational drug use. Indeed, knowledge of drug treatment in VA relies mainly on research of poor methodological quality. Despite the use of drugs carrying a significant risk of adverse effects, drug safety is also poorly reported. This is alarming because some treatments, like antineoplastic agents and immunosuppressants, display an unsafe adverse effect profile. A publication bias towards positive results probably leads to overestimation of drug efficacy in vascular anomalies. An independent international pharmacovigilance system for drug use in vascular anomalies is proposed to improve efficacy and safety reporting and promote quality drug prescribing.

Off-Label Use and Safety of Drug Use in Vascular Anomalies

BACKGROUND

Off-label drug use is associated with an increased risk of adverse drug reactions. It is common in pediatrics and in rare diseases, which are two characteristics applying to vascular anomalies (VA).

OBJECTIVES

The aim of this work was to quantify off-label drug use in VA and assess its safety.

METHODS

A review was conducted to extract a list of drugs used in VA management. A drug was considered to have significant safety concerns if a black box warning was present or if a serious adverse drug reaction (SADR) was reported in at least 1% of the patients (SADR is defined as a noxious and unintended response to a drug that occurs at any dose and results in hospitalization, prolongation of existing hospitalization, congenital malformation, persistent or significant disability or incapacity, life-threatening condition, or death). The labelling status and safety of each drug was assessed based on the product monograph, Micromedex, and the FDA data.

RESULTS

We found that 98.9% of the inventoried drugs were used off-label or unlicensed for VA management. Only the oral solution of propranolol hydrochloride (Hemangeol®) for the treatment of infantile hemangiomas is approved. Significant safety issues concerned 73% of the drugs and were more frequent among systemic than locally delivered drugs.

CONCLUSIONS

Off-label drug use in VA is the rule and not the exception. Significant safety concerns are common. It is necessary to carefully weigh risk and benefits for every patient when using systemic and local treatments carrying safety concerns. Patients should be openly informed and involved in the decision-making process.

Graduate students’ mental health: Exploring experiences of isolation and loneliness

Background

A student psychological health survey, conducted in 2015-2016 among over 10,000 students at the University of Montreal (UdeM), gives an alarming picture of psychological distress associated to feelings of loneliness. The objective of this phenomenological study is to better understand the experience of isolation from the perspective of UdeM graduate students.

Methods

As part of a qualitative methods course, five semi-directed interviews and a focus group (n = 8) were conducted with graduate students and a psychologist from UdeM. Hybrid thematic analysis of verbatim and inter-rater debriefing were conducted using NVivo 11 software.

Results

Thematic analysis illustrates that most graduate students feel isolated at some point during their studies, but also that the impact and the meaning of this loneliness feeling is variable. It can be perceived positively when it is sought, temporary and/or allows one to be more productive. It can be perceived negatively when it is involuntary, constant over time and/or does not improve academic effectiveness. Personality, academic and social contexts, as well as support by peers and supervisors appear to modify feelings of isolation.

Conclusions

This study demonstrates the importance of context for graduate students' feelings of isolation. Further research is needed to move towards saturation of perspectives around this phenomenon.

Key messages

Graduate students reported that the experience and the repercussions of isolation may differ in whether it is sought or involuntary. Factors that seem to influence the feeling of loneliness include academic context and supervisor support. Further research is needed to discriminate the impact of these different contextual factors.

Adverse neuropsychological effects associated with cumulative doses of corticosteroids to treat childhood acute lymphoblastic leukemia: A literature review

Corticosteroids (CS) are an essential component of childhood acute lymphoblastic leukemia treatments (cALL). Although there is evidence that daily doses of CS can have neuropsychological effects, few studies have investigated the role of cumulative doses of CS in short- and long-term neuropsychological effects in cALL. The aims of this review were to identify the measures used for documenting adverse neuropsychological effects (ANEs) of CS treatment and to study the association between cumulative doses of CS and the presence of ANEs. Twenty-two articles met the inclusion criteria. A variety of measures were used to evaluate outcomes in the domains of emotion, behaviour, neurocognition, and fatigue/sleep. The results suggest that we cannot conclude in favour of an association between the cumulative dosage of CS and ANEs. Yet, several factors including the heterogeneity of measures used to evaluate outcomes and reporting biases may limit the scope of the results. We offer several recommendations that could help improve the future published evidence on ANEs in relation to CS treatment in cALL.

A 2-year dyadic longitudinal study of mothers' and fathers' marital adjustment when caring for a child with cancer

OBJECTIVE

Studies examining interrelationships within parental couples confronted with pediatric cancer are scarce. This study explored dyadic longitudinal associations between both partners' family functioning and mood at diagnosis, and marital adjustment 2 years later.

METHOD

Parents of children (n = 47 couples) with acute lymphoblastic leukemia (ALL) completed the Family Well-Being Assessment and Profile of Mood States-Bipolar Form at diagnosis, and the Locke-Wallace Marital Adjustment Test 2 years post diagnosis. Multilevel linear models using the actor-partner interdependence model (APIM) and controlling for baseline marital adjustment were conducted to evaluate within subject and dyadic longitudinal effects.

RESULTS

For mothers, better marital adjustment 2 years post diagnosis was associated with perception of greater family support and less role conflict and role overload at diagnosis. For fathers, better marital adjustment 2 years post-diagnosis was associated with perception of less role conflict, greater role ambiguity, and being more tired at diagnosis, as well as their partner's perception of less role conflict at diagnosis.

CONCLUSIONS

These findings highlight the importance of considering both partners' perspectives in understanding marital adjustment across treatment phases in parents of children with ALL. Early interventions for couples should be tailored to meet each partner's needs in order to foster resilience within the couple.

A simple reconstructed human epidermis: preparation of the culture model and utilization in in vitro studies

The preparation of a reconstructed human epidermis is described with examples of its utilization in in vitro studies. The model was obtained by culturing normal human keratinocytes at high cell density for 14 days in serum-free and high calcium (1.5 m M) medium on an inert polycarbonate filter at the air-liquid interface. These stratified cultures showed histological features similar to those observed in vivo in the epidermis: a proliferating basal layer and differentiating spinous, granular, and cornified layers. Electron microscopy illustrated lamellar bodies, junctions and keratohyalin granules. Immunofluorescent localization of epidermal markers (keratins 14 and 10, involucrin and filaggrin) revealed typical differentiation. This in vitro reconstructed tissue was used in studies of toxic effects of chemicals. The modelled tissue showed progressive cytotoxicity of a skin irritant (benzalkonium chloride) and a sensitizer (dinitrochlorobenzene) as assessed by MTT assay. Moreover, differential release of interleukin-1alpha and interleukin-8 were measured after 20 h of incubation allowing the irritant to be distinguished from the sensitizer. Permeation studies indicated efficient barrier function of the reconstructed epidermis, as well as metabolizing properties towards hormones. This model can be custom-made and is potentially useful for studies involving keratinocytes in the epidermis, in basic science, dermatology or toxicology.

Secular trends in congenital anomaly-related fetal and infant mortality in Canada, 1985-1996

Prenatal diagnosis of major congenital anomalies and subsequent termination of affected pregnancies has been widely available as part of routine obstetric care in recent years. In this study, vital statistical data on stillbirths, live births, and infant deaths were used to examine secular trends in gestational age-specific and category-specific fetal and infant mortality due to congenital anomalies in Canada (excluding Ontario and Newfoundland) from 1985-1996. Comparisons of the rates between 1985-1987 and 1994-1996 were made using relative risks and 95% confidence intervals (CI). The overall fetal mortality rate due to congenital anomalies increased significantly, from 68.0 per 100,000 total births in 1985-1987 to 78.6 per 100,000 total births in 1994-1996, while the overall infant mortality rate due to congenital anomalies decreased significantly over the same period, from 2.47 to 1.79 per 1,000 live births. The fetal death rate due to congenital anomalies at 20-21 weeks of gestation increased approximately five-fold (relative risk [RR] = 4.83, 95% CI = 3.28-7.11) from 4.5 to 21.5 per 100,000 fetuses at risk, while the rate at 37-41 weeks decreased by 30% (RR = 0.70, 95% CI = 0.50-0.97). Fetal death rates among pregnancies at 20-25 weeks of gestation increased in all categories of congenital anomaly except anencephaly and respiratory system anomalies. Congenital anomaly-related fetal and infant deaths have increased at early gestation but declined at later gestation in Canada. These changes suggest an increase in prenatal diagnosis and selective termination of pregnancies with congenital anomalies in recent years.

Changes in stillbirth and infant mortality associated with increases in preterm birth among twins

OBJECTIVE

To examine whether the recent substantial increase in preterm birth among twins has been associated with changes in fetal and infant mortality.

DESIGN

Cohort study based on information in the linked live birth, stillbirth, and mortality databases of Statistics Canada.

SETTING

Ten of 12 provinces and territories in Canada.

PARTICIPANTS

All twin live births and stillbirths between 1985 and 1996, along with information on deaths during infancy (1985-1997).

MAIN OUTCOME MEASURE

Fetal and infant mortality rates.

RESULTS

The rate of preterm birth among twin live births increased significantly by 17% (95% confidence interval: 14%-20%) from 42.5% between 1985 and 1987 to 49.6% between 1994 and 1996. Overall, stillbirth rates among twins declined from 22.4 per 1000 total births in 1985 to 1987 to 18.8 per 1000 total births in 1994 to 1996. Among twin fetuses >/=34 weeks' gestation, stillbirth rates decreased from 9.5 per 1000 in 1985 to 1987 to 5.4 per 1000 fetuses at risk in 1994 to 1996. Infant mortality rates among twin live births declined substantially in all categories of gestational age above 24 weeks except for live births at 32 to 33 and 34 to 36 weeks' gestation.

CONCLUSIONS

The recent increase in preterm birth among twins was associated with a substantial reduction in stillbirth rates at and near term gestation. Infant mortality rates declined concurrently, although the absence of a significant decrease in infant mortality among twin live births at 32 to 33 and 34 to 36 weeks' gestational age needs additional scrutiny.

Women's views on the practice of prenatal perineal massage

OBJECTIVE

To determine how women who practised perineal massage during pregnancy assessed the technique.

DESIGN

Observational study within one arm of a randomised controlled trial.

SETTING

Five secondary and tertiary care hospitals in the Province of Quebec, Canada.

PARTICIPANTS

Among 763 women randomised to the massage arm of a clinical trial of perineal massage during pregnancy, 684 (90%) who completed a questionnaire after delivery.

MAIN OUTCOME MEASURES

A 20-item questionnaire completed a few days after birth. The first 18 questions elicited opinions using a 6-point Likert scale. Based on a factor analysis, 17 of these questions were classified into four categories: acceptability of perineal massage (8 items); preparation for birth (4 items); relationship with the partner (2 items); and effect of massage on delivery (3 items). Scores of each scale varied between 1 (highly negative assessment) to 6 (highly positive assessment). The last two questions asked whether women would perform the massage in their next pregnancy and whether they would recommend perineal massage to another pregnant woman. In addition, 262 also provided comments about their experience in the daily diary provided to record compliance during the trial.

RESULTS

On average, perineal massage was felt to be quite acceptable [mean (standard deviation) 4.09 (0.93)]. Pain and technical problems reported during the first week or two of massage tended to disappear after a few weeks. Women's assessment of the effect of massage on preparation for birth [4.34 (1.08)] and on delivery [4.18 (1.37)] was positive. Women's views about the effect on their relationship with their partner were either positive or negative [3.54 (1.74)] and were proportional to the partner's participation with the massage. Most women said they would massage again if they were to have another pregnancy (79%; 95% CI, 76%-82%) and would recommend it to another pregnant woman (87%; 95% CI 84%-90%).

CONCLUSION

Overall, women's assessment of prenatal perineal massage is positive.

The association between perineal trauma and spontaneous perineal tears

OBJECTIVE

We assessed whether women who had a perineal trauma (episiotomy or spontaneous tear of the second degree or higher) at the first delivery were at increased risk for spontaneous perineal tears at the next delivery, and whether the risk increases with the severity of previous perineal trauma.

DESIGN

Retrospective cohort study.

POPULATION

We included data from 1895 women who had their first and second deliveries at Saint-Sacrement Hospital, Quebec City, Canada, between 1985 and 1994. Our study was restricted to women who gave birth vaginally to a single living neonate at their first 2 deliveries and who did not have an episiotomy at the second delivery. We extracted the data from the Department of Obstetrics computerized database.

OUTCOMES MEASURED

Spontaneous perineal tears (of second degree or higher) at the second delivery.

RESULTS

Having a perineal trauma at the first delivery more than tripled the risk (relative risk=3.3; 95% confidence interval, 2.6-4.2) of spontaneous perineal tears at the second delivery. The risk of spontaneous perineal tears at the second delivery increased with the severity of previous perineal trauma at birth.

CONCLUSIONS

Our results show that the risk of spontaneous perineal tears at subsequent deliveries increases with the presence and the severity of perineal trauma at the first delivery.

Risks of induction of labour in uncomplicated term pregnancies

Our objective was to evaluate the risks of maternal and perinatal morbidity associated with induction of labour in uncomplicated term pregnancies. We conducted a retrospective cohort study including 7,430 women, not referred from another institution, with a single baby in vertex presentation, and delivering between 38 and 40 weeks of pregnancy. Among these women, 3,546 were excluded for prelabour pregnancy complications. Relative risks (RR), adjusted for parity, were computed to compare 3,353 women who went into labour spontaneously with 531 women whose labour was induced. Induction of labour was found to be associated with a higher risk of caesarean section [RR = 2.4, 95% CI 1.8, 3.4]. Use of non-epidural [RR = 1.5, 95% CI 1.2, 1.8] and of epidural analgesia [RR = 1.4, 95% CI 1.1, 1.7] was more frequent after labour induction. Resuscitation [RR = 1.2, 95% CI 1.0, 1.5], admission to the intensive care unit [RR = 1.6, 95% CI 1.0, 2.4] and phototherapy [RR = 1.3, 95% CI 1.0, 1.6] were more frequent after induction of labour. Results were similar when controlling simultaneously for parity, maternal age, gestational age, year of delivery, birthweight and the physician in charge of delivery in a logistic regression analysis. The results of this study suggests that induction of labour is associated with a higher risk of caesarean section and of some perinatal adverse outcomes. Induction of labour should be reserved for cases where maternal and perinatal benefits outweigh the risk of these complications.

Comparison of maternal and infant outcomes between vacuum extraction and forceps deliveries

The authors conducted a population-based historical cohort study in the Canadian province of Quebec to assess the maternal and infant outcomes associated with vacuum extraction and forceps deliveries. The study database contains information on 305,391 mother-infant dyads (linked by a common institutional code and hospital chart number) for singleton live vaginal births with a nonbreech presentation at the gestational age of 37 or more completed weeks and a birth weight between 2,500 and 4,000 g during fiscal years 1991/1992 to 1995/1996. Of the births, 31,015 were delivered by vacuum extraction, and 18,727 were delivered by forceps. Compared with delivery by forceps, the adjusted risk ratios for third-/fourth-degree perineal laceration, intracranial hemorrhage, subdural or cerebral hemorrhage, intraventricular hemorrhage, subarachnoid hemorrhage, cephalhematoma, and neonatal in-hospital death were 0.48 (95% confidence interval: 0.45, 0.50), 1.28 (95% confidence interval: 0.73, 2.25), 0.97 (95% confidence interval: 0.49, 1.93), 0.99 (95% confidence interval: 0.16, 5.97), 5.44 (confidence interval: 1.26, 23.43), 2.02 (95% confidence interval: 1.89, 2.16), and 0.93 (95% confidence interval: 0.32, 2.70), respectively. The authors conclude that vacuum extraction causes less maternal trauma but may increase the risk of cephalhematoma and certain types of intracranial hemorrhage (e.g., subarachnoid hemorrhage).

Maternal asthma and pregnancy outcomes: a retrospective cohort study

OBJECTIVE

We examined the relationship between asthma during pregnancy and selected infant and maternal outcomes.

STUDY DESIGN

A retrospective cohort study was conducted on mother-infant dyads identified from a linked infant and maternal hospital discharge database in the Canadian province of Quebec between fiscal years 1991-1992 and 1995-1996. Mothers with asthma (n = 2193) were compared with a randomly selected control sample (n = 8772) from the remaining population of mothers.

RESULTS

After important confounding variables were accounted for, maternal asthma was significantly associated with several adverse infant outcomes, including preterm birth and birth of infants who are very small for gestational age, and adverse maternal outcomes, such as idiopathic preterm labor, early idiopathic preterm labor, preeclampsia, transient hypertension of pregnancy, pregnancy-associated hypertension, chorioamnionitis, and cesarean delivery.

CONCLUSION

Our results demonstrated that pregnant women with asthma are at substantially increased risk for several adverse infant and maternal outcomes and suggest the need for extra attention to mothers with asthma and their infants.

Impact of prenatal glucose screening on the diagnosis of gestational diabetes and on pregnancy outcomes

The authors examined the impact of universal screening on the diagnosis of gestational diabetes and its complications. All mothers and newborns registered by the Canadian Institute for Health Information from 1984 to 1996 (even-numbered fiscal years only) were included in the analysis. Over this time period, the proportion of women with gestational diabetes increased ninefold (from 0.3% to 2.7%) while the proportion with prepregnancy diabetes fell from 0.7% to 0.4%. As rates of gestational diabetes increased, a corresponding reduction in the risks of complications (polyhydramnios, amniotic cavity infection, cesarean delivery, and preeclampsia) occurred for women with gestational diabetes. The incidence of gestational diabetes fell in Metro-Hamilton (where screening was discontinued in 1989) but remained high in the rest of Ontario (where screening continued in most areas). No related temporal trends for fetal macrosomia, cesarean delivery, or other diabetes-related complications were observed, regardless of screening policy. The authors concluded that the substantial increase in gestational diabetes in Canada is an artifact caused by universal screening, with no evidence of beneficial effects on pregnancy outcomes.

Placenta praevia and male sex at birth: results from a population-based study

This study examined the relationship between male sex at birth and placenta praevia in 433031 mother/infant dyads (linked by a common institutional code and hospital admission number) in the Canadian province of Quebec, during the fiscal years of 1991/92-1995/96. The male-to-female ratio among pregnancies with and without placenta praevia was calculated and compared. The male-to-female ratio at birth was higher in pregnancies complicated by a placenta praevia (1.19) than in those without it (1.04; P < 0.02). This increased ratio persisted after accounting separately for the potential confounding and/or modifying effects of maternal age, infant birthweight and gestational age by stratified and multiple logistic regression analyses. We conclude that pregnant women with male babies carry a higher risk of placenta praevia.

Rapid detection of group B streptococci in pregnant women at delivery

BACKGROUND

Group B streptococcal infections are an important cause of neonatal morbidity and mortality. A rapid method for the detection of this organism in pregnant women at the time of delivery is needed to allow early treatment of neonates.

METHODS

We studied the efficacy of two polymerase-chain-reaction (PCR) assays for routine screening of pregnant women for group B streptococci at the time of delivery. We obtained anal, vaginal, and combined vaginal and anal specimens from 112 pregnant women; in 57 women, specimens were obtained before and after the rupture of the amniotic membranes. The specimens were tested for group B streptococci by culture in a standard selective broth medium, with a conventional PCR assay, and with a new fluorogenic PCR assay.

RESULTS

Among the 112 women, the results of the culture of the combined vaginal and anal specimens were positive for group B streptococci in 33 women (29.5 percent). The two PCR assays detected group B streptococcal colonization in specimens from 32 of these 33 women: the one negative PCR result was in a sample obtained after the rupture of membranes. As compared with the culture results, the sensitivity of both PCR assays was 97.0 percent and the negative predictive value was 98.8 percent. Both the specificity and the positive predictive value of the two PCR assays were 100 percent. The length of time required to obtain results was 30 to 45 minutes for the new PCR assay, 100 minutes for the conventional PCR assay, and at least 36 hours for culture.

CONCLUSIONS

Colonization with group B streptococci can be identified rapidly and reliably by a PCR assay in pregnant women in labor both before and after the rupture of membranes.

[Multicenter randomized trial of amnioinfusion]

Meconium staining of the amniotic fluid in labor is a frequent problem that is associated with an increase in the risk of neonatal and maternal morbidity. Amnioinfusion is a simple technique that is designed to prevent neonatal and maternal morbidity associated with meconium. Preliminary studies indicate that amnioinfusion is a promising approach to the prevention of such complications of labor. However, further research is required. The primary objective of this multi-centre randomized controlled study is to determine if amnioinfusion for thick meconium stained amniotic fluid results in a reduction in perinatal death or moderate to severe meconium aspiration syndrome. We will also assess the effects of amnioinfusion on other indicators of neonatal morbidity and on cesarean section. The study includes an evaluation of womens views on their childbirth experience and an economic evaluation of a policy of amnioinfusion The study will be achieved with the collaboration of approximately 50 obstetrical centres from across Canada, US, Europe, South America and South Africa. This multicentre trial will provide urgently needed information on the efficacy and effectiveness of amniofusion for the indication of meconium stained amniotic fluid.

Multicenter, randomized, controlled trial of delayed pushing for nulliparous women in the second stage of labor with continuous epidural analgesia. The PEOPLE (Pushing Early or Pushing Late with Epidural) Study Group

OBJECTIVE

This study was undertaken to determine whether a policy of delayed pushing for nulliparous women with continuous-infusion epidural analgesia reduces the risk of difficult delivery (cesarean delivery, operative delivery from a midpelvic position, low-pelvic procedures with rotation >45 degrees ).

STUDY DESIGN

In this multicenter, randomized, controlled trial women in the delayed pushing group (n = 936) were advised to wait > or =2 hours after full dilatation before commencement of pushing. Women in the early pushing group (n = 926) were advised to commence pushing as soon as they had been randomly assigned.

RESULTS

Difficult delivery was reduced with delayed pushing (relative risk, 0.79; 95% confidence interval, 0.66-0.95). The greatest effect was on midpelvic procedures (relative risk, 0.72; 95% confidence interval, 0.55-0.93). Although there was little evidence for an effect on low-pelvic procedures, spontaneous delivery was more frequent among women who practiced delayed pushing (relative risk, 1.09; 95% confidence interval, 1.00-1.18). Abnormal umbilical cord blood pH (<7.15 venous value or <7.10 arterial value) was more frequent in the delayed pushing group (relative risk, 2.45, 95% confidence interval, 1.35-4. 43). However, scores for a summary indicator, the Neonatal Morbidity Index, were similarly distributed in the 2 groups.

CONCLUSION

Delayed pushing is an effective strategy to reduce difficult deliveries among nulliparous women.

Randomized trial of perineal massage during pregnancy: perineal symptoms three months after delivery

OBJECTIVE

The aim of this study was to evaluate the effect of perineal massage performed during pregnancy on perineal symptoms 3 months after delivery.

STUDY DESIGN

Pregnant women from 5 hospitals in the province of Quebec, Canada, participated in this single-blind, randomized, controlled trial. All participants received oral and written information on the prevention of perineal trauma. Women in the experimental group were taught the perineal massage technique and were asked to perform a 10-minute perineal massage daily from the 34th through 35th weeks of pregnancy until delivery. Participants completed a self-administered questionnaire on perineal pain, dyspareunia, sexual satisfaction, and incontinence of urine, flatus, and stool at the time of enrollment and 3 months after delivery.

RESULTS

Among participants without a previous vaginal birth there were no differences between the massage (n = 283) and the control (n = 289) groups with respect to perineal pain, dyspareunia, sexual satisfaction, and incontinence of urine, gas, or stool 3 months post partum. Among women with a previous vaginal birth more women in the massage group (n = 187) than in the control group (n = 190) were free of perineal pain (93.6% vs 85.8%; P =.01) but the frequencies of dyspareunia and incontinence of urine, gas, or stool were similar in the 2 groups.

CONCLUSIONS

Perineal massage during pregnancy neither impairs nor substantially protects perineal function at 3 months post partum.

Job strain and pregnancy-induced hypertension

In a case-control study we assessed whether exposure to high job strain during the first 20 weeks of pregnancy increases the risk of preeclampsia and gestational hypertension. Cases (128 with preeclampsia and 201 with gestational hypertension) and controls (N = 401) were primiparous women who had a paid occupation for at least 1 week during the first 20 weeks of their pregnancy and who delivered between 1984 and 1986 in 10 hospitals of Quebec, Canada. Based on their job title, we assigned women scores of psychological demand and decision latitude derived from the National Population Health Survey and classified these women as exposed to high (high demand, low latitude) versus low (low demand, high latitude) job strain. Women exposed to high job strain were more likely to develop preeclampsia [adjusted odds ratio (aOR) = 2.1; 95% confidence interval (CI) = 1.1-4.1] than women exposed to low job strain. The risk was quite similar for women exposed to a full-time, high strain job (> or =35 hours per week) (aOR = 2.0) than in a part-time, high strain job (aOR = 1.8). High job strain increased the risk of gestational hypertension slightly (aOR = 1.3; 95% CI = 0.8-2.2). These results indicate that women exposed to high job strain are at higher risk of developing preeclampsia and, to a lesser extent, gestational hypertension.

Sweeping of the membranes to prevent post-term pregnancy and to induce labour: a systematic review

OBJECTIVE

To evaluate the effectiveness of sweeping of the membranes to prevent post-term pregnancy and to induce labour.

DESIGN

A systematic review of randomised controlled trials.

METHODS

Potentially eligible trials were identified in Medline and in the Cochrane Controlled Trials Register. Inclusion of studies and data extraction were performed by two reviewers working independently. Summary estimates of the effect of the intervention were computed as relative risks, risk differences and weighted mean differences.

MAIN OUTCOME MEASURES

Use of formal methods of labour induction, delay before spontaneous onset of labour, prevention of post-term pregnancy, side effects, maternal and perinatal morbidity.

RESULTS

Sixteen reports were identified. Thirteen were included in the review, with a total of 1992 women. Sweeping of the membranes, when performed at term, reduced the duration of pregnancy and the proportion of women continuing pregnancy beyond 41 and 42 weeks. When sweeping of the membranes was performed, a reduction in the use of formal methods for labour induction was observed (RR = 0.48; 95% CI 0.28-0.85). There was no difference between groups in the mode of delivery or in the risk of infection. Discomfort during vaginal examination and other side effects (e.g. bleeding, irregular contractions) were more frequently reported by women allocated to sweeping.

CONCLUSIONS

While sweeping of the membranes reduces the interval to spontaneous onset of labour, there is no evidence of a reduction in maternal or neonatal morbidity. When used as a means of induction of labour, the reduction in the use of formal methods must be balanced against women's discomfort and other side effects attributable to the procedure.

Randomized controlled trial of prevention of perineal trauma by perineal massage during pregnancy

OBJECTIVE

The aim of the study was to evaluate the effectiveness of perineal massage during pregnancy for the prevention of perineal trauma at birth.

STUDY DESIGN

Pregnant women with (n = 493) and without (n = 1034) a previous vaginal birth from 5 hospitals in the province of Québec, Canada, participated in this single-blind, randomized, controlled trial. All participants received oral and written information on the prevention of perineal trauma. Women in the experimental groups were requested to perform a 10-minute perineal massage daily from the 34th or 35th week of pregnancy until delivery.

RESULTS

Among participants without a previous vaginal birth, 24.3% (100/411) from the perineal massage group and 15.1% (63/417) from the control group were delivered vaginally with an intact perineum, for a 9.2% absolute difference (95% confidence interval 3.8%-14.6%). The incidence of delivery with an intact perineum increased with compliance with regular practice of perineal massage (chi2 for trend 13.2, P = 0.0003). Among women with a previous vaginal birth, 34.9% (82/235) and 32.4% (78/241) in the massage and control groups, respectively, were delivered with an intact perineum, for an absolute difference of 2.5% (95% confidence interval -6.0% to 11.0%). There were no differences between the groups in the frequency of sutured vulvar and vaginal tears, women's sense of control, and satisfaction with the delivery experience.

CONCLUSION

Perineal massage is an effective approach to increasing the chance of delivery with an intact perineum for women with a first vaginal delivery but not for women with a previous vaginal birth.

Determinants of preterm birth rates in Canada from 1981 through 1983 and from 1992 through 1994

BACKGROUND

The rates of preterm birth have increased in many countries, including Canada, over the past 20 years. However, the factors underlying the increase are poorly understood.

METHODS

We used data from the Statistics Canada live-birth and stillbirth data bases to determine the effects of changes in the frequency of multiple births, registration of births occurring very early in gestation, patterns of obstetrical intervention, and use of ultrasonographic dating of gestational age on the rates of preterm birth in Canada from 1981 through 1983 and from 1992 through 1994. All births in 9 of the 12 provinces and territories of Canada were included. Logistic-regression analysis and Poisson regression analysis were used to estimate changes between the two three-year periods, after adjustment for the above-mentioned determinants of the likelihood of preterm births.

RESULTS

Preterm births increased from 6.3 percent of live births in 1981 through 1983 to 6.8 percent in 1992 through 1994, a relative increase of 9 percent (95 percent confidence interval, 7 to 10 percent). Among singleton births, preterm births increased by 5 percent (95 percent confidence interval, 3 to 6 percent). Multiple births increased from 1.9 percent to 2.1 percent of all live births; the rates of preterm birth among live births resulting from multiple gestations increased by 25 percent (95 percent confidence interval, 21 to 28 percent). Adjustment for the determinants of the likelihood of preterm birth reduced the increase in the rate of preterm birth to 3 percent among all live births and 1 percent among singleton births.

CONCLUSIONS

The recent increase in preterm births in Canada is largely attributable to changes in the frequency of multiple births, obstetrical intervention, and the use of ultrasound-based estimates of gestational age.

Characteristics related to the prevalence of minimal or mild endometriosis in infertile women. Canadian Collaborative Group on Endometriosis

The objective of this case-control study is to identify factors associated with the prevalence of minimal or mild endometriosis among infertile women. Cases (N = 329) were women diagnosed by laparoscopy with minimal or mild endometriosis and without any other factors explaining their infertility. Controls (N = 262) were women in whom the infertility remained unexplained after a diagnostic laparoscopy. Selected characteristics were documented by means of a face-to-face interview before the laparoscopy. The prevalence of minimal or mild endometriosis was higher in women age 25 years or older, in those who reported menarche at the age of 13 years [prevalence odds ratio (POR) = 1.63; 95% confidence interval (CI) = 1.02-2.60] or older (POR = 1.73; 95% CI = 1.07-2.78), menstrual cycles of 27 days or less (POR = 1.63; 95% CI = 1.02-2.60), or caffeine intake of 300 mg per day or more (POR = 1.33; 95% CI = 0.91-1.94). The prevalence of minimal or mild endometriosis was inversely related to body mass index. Parous women were less likely to have endometriosis (POR = 0.61; 95% CI = 0.39-0.96) than were nulliparous women. Education, duration of infertility, and smoking status were not related to the presence of endometriosis.

Fecundity of infertile women with minimal or mild endometriosis and women with unexplained infertility. The Canadian Collaborative Group on Endometriosis

OBJECTIVE

To assess whether infertile women with minimal or mild endometriosis have lower fecundity than women with unexplained infertility.

DESIGN

Prospective cohort study.

SETTING

Twenty-three infertility clinics across Canada.

PATIENT(S)

Three hundred thirty-one infertile women aged 20-39 years.

INTERVENTION(S)

Diagnostic laparoscopy for infertility. Infertile women with minimal or mild endometriosis (n = 168) were compared with women with unexplained infertility (n = 263). Both groups were managed expectantly. The women were followed up for 36 weeks after the laparoscopy or, for those who became pregnant, for up to 20 weeks of the pregnancy.

MAIN OUTCOME MEASURE(S)

Fecundity refers to the probability of becoming pregnant in the first 36 weeks after laparoscopy and carrying the pregnancy for > or = 20 weeks. The fecundity rate is the number of pregnancies per 100 person-months.

RESULT(S)

Fecundity was 18.2% in infertile women with minimal or mild endometriosis and 23.7% in women without endometriosis (log-rank test). The fecundity rate was 2.52 per 100 person-months in women with endometriosis and 3.48 per 100 person-months in women with unexplained infertility. The crude and adjusted fecundity rate ratios were 0.72 and 0.83 (95% confidence interval = 0.53-1.32), respectively.

CONCLUSION(S)

The fecundity of infertile women with minimal or mild endometriosis is not significantly lower than that of women with unexplained infertility.

Trends and variations in length of hospital stay for childbirth in Canada

BACKGROUND

Early discharge after childbirth is widely reported. In this study the authors examined trends in maternal length of hospital stay in Canada from fiscal year 1984-85 through fiscal year 1994-95. They also examined variations in length of stay in 1994-95 in most of the Canadian provinces and the territories.

METHODS

Epidemiologic analyses of the temporal and geographic variations in maternal length of hospital stay in Canada from 1984-85 to 1994-95 (even years only), based on hospital discharge data collected by the Canadian Institute for Health Information, with a total of 1,456,800 women for the 6 study years.

RESULTS

Mean length of hospital stay decreased during the decade, from 5.3 days in 1984-85 to 3.0 days in 1994-95, with similar trends for both cesarean and vaginal delivery. The decrease resulted from both increasing rates of short stay (less than 2 days) and decreasing rates of long stay (more than 4 days). Substantial temporal and interprovincial variations in several medical and obstetric complications were also observed but did not explain the corresponding variations in length of stay. The reduction in length of hospital stay was not restricted to uncomplicated cases: there was an equivalent decrease in cases with complications. In 1994-95 the average length of hospital stay in Alberta was 2.6 days, 0.3 to 1.7 days shorter than in the other provinces and the territories.

INTERPRETATION

Length of hospital stay for childbirth has decreased substantially in Canada in recent years, but there remain important interprovincial variations. These trends and variations are not likely due to changes or differences in patient-specific factors.

Organochlorine exposure and the risk of endometriosis

OBJECTIVE

To compare mean concentrations of organochlorine in women with a new diagnosis of endometriosis and in controls.

DESIGN

Case-control study.

SETTING

Women attending an institutional clinic of reproductive endocrinology.

PATIENT(S)

Cases and controls were selected among women who underwent laparoscopy for chronic pelvic pain, infertility, or tubal fulguration between January 1994 and December 1994. Eighty-six women with endometriosis and 70 controls, matched for the indication for laparoscopy, were recruited.

MAIN OUTCOME MEASURE(S)

Mean organochlorine plasma concentrations of 14 polychlorinated biphenyl congeners and 11 chlorinated pesticides were compared between the cases and controls. Analysis of covariance was used to adjust means for confounding variables, and odds ratios were estimated by logistic regression.

RESULT(S)

Crude geometric mean concentrations did not differ significantly between cases and controls for any of the organochlorine compounds. Similarly, crude or adjusted means of the sum of polychlorinated biphenyl congeners, the sum of chlordanes, or the sum of dichlorodiphenyltrichloroethanes did not differ between the groups. There was no significant linear trend in the adjusted odds ratios for endometriosis as organochlorine concentrations increased.

CONCLUSION(S)

These results suggest that exposure to polychlorinated biphenyls and chlorinated pesticides during adulthood is not associated with endometriosis in the general population.

Incidence of venographically proved deep vein thrombosis after knee arthroscopy

BACKGROUND

Deep vein thrombosis is a common, important complication of major orthopedic surgery, particularly knee arthroplasty. Knee arthroscopy is performed more frequently and in younger patients than knee arthroplasty. However, the true risk of deep vein thrombosis in patients who undergo this procedure is unknown.

OBJECTIVE

To determine the incidence of deep vein thrombosis after knee arthroscopy in a large cohort of patients.

METHODS

Consecutive patients scheduled for knee arthroscopy were eligible for the study. Enrolled study patients received no thromboprophylaxis. They were discharged home the day of surgery and underwent unilateral contrast venography approximately 1 week after their operation. The primary outcome measure was the incidence of venous thromboembolism. Risk factors for deep vein thrombosis were evaluated.

RESULTS

Among the 184 patients who had adequate venography, deep vein thrombosis was detected in 33 (17.9%; 95% confidence interval, 12.7%-24.3%). Of these, 9 were proximal (4.9%; 95% confidence interval, 2.3%-9.1%). No patient died and no patient presented with clinically suspected pulmonary embolism. Of 33 patients, only 20 (60.6%) with deep vein thrombosis had symptoms while 13 (39.4%) were asymptomatic. The risk of deep vein thrombosis was significantly higher among patients who had a tourniquet applied for more than 60 minutes.

CONCLUSIONS

The results of our study demonstrate that 17.9% of patients develop deep vein thrombosis after knee arthroscopy (most being either proximal or extensive). It is reasonable to perform a randomized trial to determine whether the incidence of deep vein thrombosis can be safely reduced in patients undergoing knee arthroscopy.

Does sweeping of the membranes reduce the need for formal induction of labour? A randomised controlled trial

OBJECTIVE

1. To evaluate the effectiveness of sweeping of the membranes to reduce the need for a formal induction of labour; 2. to evaluate the side effects of this intervention.

DESIGN

A randomised controlled clinical trial.

SETTING

Three tertiary care hospitals of the province of Quebec, Canada.

POPULATION

Two hundred women for whom non-urgent induction of labour was medically indicated.

METHODS

Women were randomly allocated to sweeping of membranes, or vaginal examination for Bishop scoring only.

MAIN OUTCOME MEASURES

1. Cumulative incidence and relative risk of induction of labour by either oxytocin, prostaglandins or amniotomy; 2. women's discomfort and side effects attributable to sweeping of the membranes.

RESULTS

Women allocated to sweeping of the membranes required formal induction of labour less frequently than women in the control group, but this difference was not statistically significant (49% vs 60%, RR 0.83, 95% CI 0.64-1.07). Pain during vaginal examination and other side effects were more frequently reported by women allocated to the sweeping group.

CONCLUSIONS

The observed reduction in the need for formal induction of labour is smaller than in previous studies. Side effects and discomfort associated with sweeping of the membranes must be taken into account when counselling women who require induction of labour.

Uses and limitations of routine hospital admission/separation records for perinatal surveillance

This study examined the quality of data for delivering mothers and their newborns (April 1, 1984 to March 31, 1995) recorded by the Canadian Institute for Health Information (CIHI). The number of illogical and out-of-range values in the CIHI data were quite few; the occurrence of maternal and infant diseases estimated from CIHI data was quite similar to that in the literature; and major medical/obstetric complications recorded in CIHI were, in general, good predictors of adverse pregnancy outcomes. The authors conclude that CIHI data contain some of the information pertinent to perinatal surveillance that may be used to monitor maternal and infant health and to assess intrapartum care and hospital resource utilization. To adequately monitor and analyze patterns of health determinants and outcomes in all pregnant women and their infants in Canada, additional data collection mechanisms are needed to cover all recognized pregnancies and to collect antenatal and postpartum information and more detailed information on intrapartum care.

Laparoscopic surgery in infertile women with minimal or mild endometriosis. Canadian Collaborative Group on Endometriosis

BACKGROUND

Minimal or mild endometriosis is frequently diagnosed in infertile women. It is often treated by resection or ablation of the lesions, but whether this improves fertility has not been established. We carried out a randomized, controlled trial to determine whether laparoscopic surgery enhanced fecundity in infertile women with minimal or mild endometriosis.

METHODS

We studied 341 infertile women 20 to 39 years of age with minimal or mild endometriosis. During diagnostic laparoscopy the women were randomly assigned to undergo resection or ablation of visible endometriosis or diagnostic laparoscopy only. They were followed for 36 weeks after the laparoscopy or, for those who became pregnant during that interval, for up to 20 weeks of pregnancy.

RESULTS

Among the 172 women who had resection or ablation of endometriosis, 50 became pregnant and had pregnancies that continued for 20 weeks or longer, as compared with 29 of the 169 women in the diagnostic-laparoscopy group (cumulative probabilities, 30.7 percent and 17.7 percent, respectively; P=0.006 by the log-rank test). The corresponding rates of fecundity were 4.7 and 2.4 per 100 person-months (rate ratio, 1.9; 95 percent confidence interval, 1.2 to 3.1). Fetal losses occurred in 20.6 percent of all the recognized pregnancies in the laparoscopic-surgery group and in 21.6 percent of all those in the diagnostic-laparoscopy group (P=0.91). Four minor operative complications (intestinal contusion, slight tear of the tubal serosa, difficult pneumoperitoneum, and vascular trauma) were reported (three in the surgery group and one in the control group).

CONCLUSIONS

Laparoscopic resection or ablation of minimal and mild endometriosis enhances fecundity in infertile women.

Epidural corticosteroid injections for sciatica due to herniated nucleus pulposus

BACKGROUND

Although epidural corticosteroid injections are commonly used for sciatica, their efficacy has not been established.

METHODS

In a randomized, double-blind trial, we administered up to three epidural injections of methylprednisolone acetate (80 mg in 8 ml of isotonic saline) or isotonic saline (1 ml) to 158 patients with sciatica due to a herniated nucleus pulposus. All patients had Oswestry disability scores higher than 20 (on a scale of 1 to 100, with scores of 20 or less indicating minimal disability, and higher scores greater disability).

RESULTS

At three weeks, the Oswestry score had improved by a mean of -8.0 in the methylprednisolone group and -5.5 in the placebo group (95 percent confidence interval for the difference, -7.1 to 2.2). Differences in improvements between the groups were not significant, except for improvements in the finger-to-floor distance (P=0.006) and sensory deficits (P=0.03), which were greater in the methylprednisolone group. After six weeks, the only significant difference was the improvement in leg pain, which was greater in the methylprednisolone group (P=0.03). After three months, there were no significant differences between the groups. The Oswestry score had improved by a mean of -17.3 in the methylprednisolone group and -15.4 in the placebo group (95 percent confidence interval for the difference, -9.3 to 5.4). At 12 months, the cumulative probability of back surgery was 25.8 percent in the methylprednisolone group and 24.8 percent in the placebo group (P=0.90).

CONCLUSIONS

Although epidural injections of methylprednisolone may afford short-term improvement in leg pain and sensory deficits in patients with sciatica due to a herniated nucleus pulposus, this treatment offers no significant functional benefit, nor does it reduce the need for surgery.

Early amniotomy increases the frequency of fetal heart rate abnormalities. Amniotomy Study Group

OBJECTIVE

To determine whether early amniotomy, when practised as an isolated intervention, increases the hourly rate of fetal heart rate record abnormalities.

DESIGN

This is a secondary analysis of the results of a multicentre randomised trial of early versus late amniotomy in labour.

SETTING

Secondary and tertiary level teaching hospitals.

INTERVENTION

Early amniotomy versus an attempt to conserve the amniotic membranes.

MAIN OUTCOME MEASURES

The hourly rates of early, mild variable, severe variable and late decelerations; caesarean section rates.

RESULTS

Severe variable decelerations, when classified as categorical events (> or = 1/h to 2/h, > or = 2/h to < 4/h, > or = 4/h), were more frequent in the amniotomy group (chi2 for trend = 5.7, P = 0.017). The mean hourly rates of severe variable and late fetal heart rate decelerations were increased in the amniotomy group (severe variable: amniotomy group 1.4/h, control 0.7/h, P = 0.021; late: amniotomy group 3.3/h, control 2.3/h, P = 0.011). Although the overall rate of caesarean was similar in the two groups (OR 1.2; 95% CI 0.8-1.8), there was an increase in caesarean section for fetal distress (OR 2.3; 95% CI 1.1-4.5) associated with amniotomy.

CONCLUSION

Our data suggest that early amniotomy increases the hourly rate of severe variable fetal heart rate decelerations without evidence of an adverse effect on neonatal outcome. In settings where the diagnosis of fetal compromise is based primarily on electronic monitoring, caesarean section for fetal distress may be increased by early amniotomy.

Multivariate analysis of risk factors for operative delivery in nulliparous women. Canadian Early Amniotomy Study Group

OBJECTIVE

Our purpose was to develop predictive models of operative delivery in nulliparous women on the basis of sociodemographic, anthropometric, and obstetric risk factors.

STUDY DESIGN

Data were obtained prospectively on 925 nulliparous women in spontaneous term labor with a single fetus in cephalic presentation. Operative delivery was defined as either a midforceps or a cesarean delivery. Variables were grouped into two categories: those that could be assessed at admission and those appearing during labor. Multiple logistic regression was used to identify variables predictive of operative delivery.

RESULTS

Among variables that can be documented at admission, independent predictors of operative delivery were maternal age and height, pregnancy weight gain, smoking status, gestational age, and admission cervical dilatation. Of these, maternal age > or = 35 years was the most strongly related to operative delivery. When variables documented later during labor were added to this first model, variables retained in the second model were age and height, smoking status, presence of dystocia, epidural analgesia, and fetal heart rate tracing abnormalities. The adjusted odds ratio of operative delivery in the presence of epidural anesthesia was 3.4 (95% confidence interval 2.0 to 5.8). This association was similar in the presence or absence of dystocia. When the specificity was in the range of 85%, the first and second models have sensitivities of 34% and 48%, respectively, and positive predictive values of 39% and 46%, respectively, which is higher than the a priori risk of operative delivery in the study population (21%).

CONCLUSIONS

The models, based on data easily available, may help to predict the need for midforceps or cesarean section in low-risk nulliparous women. Before application in a clinical setting, these statistical models require validation in a separate cohort. The observed association between epidural anesthesia and operative delivery deserves interest but clinical trials are required to determine whether this relation is causal.

Correlation between the gross motor function measure scores and gait spatiotemporal measures in children with neurological impairments

Twenty six children with a diagnosis of cerebral palsy and four with a diagnosis of head injury, aged between 1 and 8 years, participated in this study, undertaken to determine the relation between spatiotemporal measures (STM) of gait (velocity, cadence, stride length, and cycle duration) and the results of a standardized clinical test of motor function. STM were assessed by a clinical videographic gait test (VGT) whereas the Gross Motor Function Measure (GMFM) was used to assess motor function. For the total group of children, significant linear relations (r = 0.91, r = 0.93; p < 0.0001) were obtained between gait velocity and the GMFM sections D and E which include gait-related activities. These indicate that velocity is a parameter capable of reflecting functional locomotor behavior of these children. The results suggest that GMFM sections D and E may be used as locomotor predictors. The effect of walking with or without support was also investigated. The correlation between gait velocity and the GMFM(E) score was higher (r = 0.69) in the group of children walking with support than in those walking without (r = 0.35). The first group were younger and walked at velocities under 45 cm/s whereas children walking without support were older and walked at velocities ranging from 55 to 110 cm/s. These results suggest that the GMFM(E) score becomes less discriminant at gait velocities above 45 cm/s.

Maternal work during pregnancy and the risks of delivering a small-for-gestational-age or preterm infant

OBJECTIVE

The objective of this study was to assess the relation of some maternal job characteristics to the risks of delivering a small-for-gestational-age or preterm infant.

METHODS

Altogether 4390 women who lived in Quebec City, Canada, and the surrounding area, and who gave birth between January and October 1989 to a singleton liveborn neonate were included. Information on gestational age at delivery, job characteristics, nonoccupational physical activities, and several potential confounders was obtained in a telephone interview a few weeks after the delivery. Birthweight was recorded from the birth certificate.

RESULTS

The risk of having a small-for-gestational-age infant (birthweight lower than the 10th percentile for gestational age and gender) was increased among the women who worked at least 6 h a day in a standing position. The adjusted odds ratios (OR) were 1.00, 1.13 [95% confidence interval (95% CI) 0.83-1.55], and 1.42 (95% CI 1.02-1.95) for the women working in a standing position < 3, 3-5, and > or = 6 h a day, respectively. The risk for a small-for-gestational-age infant also slightly increased as the gestational age at work cessation increased. A modest increment in the risk of delivering preterm (OR, 1.45, 95% CI 0.84-2.49) was observed for the women working regularly in the evening or at night. Physical effort, lifting heavy objects, and long workhours were not related to either a small-for-gestational-age or a preterm infant.

CONCLUSIONS

The results indicate that prolonged standing and working late into pregnancy may increase the risk of delivering a small-for-gestational-age infant, whereas regular evening or night work may be a risk factor for preterm birth.

Relation between infant feeding and infections during the first six months of life

We assessed the effect of the method of feeding on respiratory and gastrointestinal illnesses during the first 6 months of life among 776 infants born in New Brunswick, Canada. During a 1-year period, these infants were drawn from the offspring of a population of primiparous women in the province who, after at least 36 weeks of pregnancy, gave birth to one normal infant weighing 2500 gm or more. Data were collected by means of a self-administered standardized questionnaire mailed to every mother a week before her infant reached 6 months of age. The crude incidence density ratio (IDR) revealed a protective effect of breast-feeding on respiratory illnesses (IDR = 0.66; 95% confidence interval (CI), 0.52 to 0.83), on gastrointestinal illnesses (IDR = 0.53; 95% CI, 0.27 to 1.04) and on all illnesses (IDR = 0.67; 95% CI, 0.54 to 0.82). The protective effect of breast-feeding on respiratory illnesses persisted even after adjustment for age of the infant, socioeconomic class, maternal age, and cigarette consumption (adjusted IDR = 0.78; 95% CI, 0.61 to 1.00). Moreover, if we distinguished ear infection from other respiratory illnesses, we observed a separate protective effect for these two types of events. The results of this retrospective cohort study suggest a protective effect of breast-feeding in our population during the first 6 months of life.

Factors associated with the obtaining of a second-trimester induced abortion

This study investigated the factors associated with the obtaining of a second-trimester induced abortion in women consulting the Family Planning Clinic of Le Centre Hospitalier de l'Université Laval in Quebec City, between September 6, 1988 and May 11, 1990. During the study period, 2,771 women obtained abortions at between six and 16 weeks of gestation in a multidisciplinary setting. Of 18 independent variables entered in a stepwise multiple regression analysis, ten made independent contributions to explain the variance at least at the p < 0.05 level of statistical significance. Taken together, these ten variables explained 9.4% of the total variance in gestational age: being young; having a low level of education; living far from the clinic; having other children; having a sexually transmitted disease before the abortion; not using contraception or using oral contraceptives at the time of conception, or being sterilized or having a sexual partner who has had a vasectomy; having had few sexual partners in the year preceding the abortion; not having a significant relationship with a regular sexual partner; being ambivalent about the decision to abort; and having a delay between the first consultation with the clinic and the abortion.

Factors associated with the inability of children with cerebral palsy to walk at six years: a retrospective study

The objective of this study was to describe the locomotion level of children with cerebral palsy at six years and to identify the factors associated with the inability to walk. 264 quadriplegic or diplegic children were assessed. Characteristics of the neurological impairment, neuromotor activities, other medical conditions and sociodemographic variables were studied. 47 per cent of the children could not walk at six years. Topography of the impairment, persistence of certain primitive reflexes, inability to retain a sitting position at the time of the initial evaluation and a history of epilepsy were significantly associated with inability to walk. The sensitivity and specificity of the model for classifying the subjects as unable or able to walk at six years were 82 and 93 per cent, respectively.

Prevention of perineal trauma by perineal massage during pregnancy: a pilot study

Although the performance of perineal massage by a woman or her partner during the last weeks of pregnancy may help to prevent perineal trauma at delivery, the technique has never been evaluated rigorously. This study examined the feasibility of a randomized, controlled trial, and more specifically assessed the participation rate, the acceptability of the intervention, and whether or not an attending physician could remain blind to participants' groups. The pilot study was a single-blinded, randomized, controlled trial. Nulliparous women, 32 to 34 weeks pregnant, were recruited from June 8 to July 31, 1992, at the offices of family physicians and obstetricians who practice at the Hôpital du Saint-Sacrement in Quebec City. Women assigned to the intervention group practiced daily 10-minute perineal massage and completed a diary, and those in the control group had standard care. Women and attending physicians completed a questionnaire about the aspect of blindness. Among the 174 women who delivered during the study period, 104 (59.8%) were approached by a midwife and 46 (26.4%) were randomized. Twenty (91.0%) of the 22 women in the massage group returned their perineal massage diaries. Based on the postpartum questionnaire, 20 women practiced the technique at least four times a week for three weeks or longer. No woman in the control group practiced massage. The attending physician was aware of the woman's group in only three instances (6.7%). Based on the results of this pilot study, a randomized, controlled trial to evaluate the efficacy of perineal massage in preventing perineal trauma at birth appears feasible.

Passive smoking during pregnancy and the risk of delivering a small-for-gestational-age infant

The objective of this population-based study was to assess the association between environmental exposure to tobacco smoke during pregnancy and the risk of delivering a small-for-gestational-age (SGA) infant (< 10th percentile). A total of 4,644 nonsmoking women who lived in the Quebec City area and who gave birth between January and October 1989 to a singleton liveborn neonate were included in the analysis. Information on gestational age at delivery, maternal passive smoking at home and at work, and several potential confounders was obtained by a telephone interview with the mother a few weeks after delivery. Birth weight was abstracted from the birth certificate. Overall, passive smokers were at little or no higher risk of having a SGA infant than unexposed women (adjusted odds ratio = 1.09, 95% confidence interval (CI) 0.85-1.39). Passive exposure to tobacco smoke at home only was not related to SGA. However, small increments in risks were observed in women exposed to passive smoking at work only, and risks increased consistently with weekly duration, number of weeks, and intensity of exposure. When compared with unexposed mothers, women exposed to tobacco smoke in the workplace for 1-14, 15-34, and > or = 35 hours per week had adjusted odds ratios of 1.13 (95% CI 0.79-1.61), 1.17 (95% CI 0.73-1.87), and 1.36 (95% CI 0.91-2.09), respectively. This latter odds ratio was close to that observed among women who smoked actively 1-5 cigarettes per day. Although not conclusive, the results are compatible with the hypothesis that environmental exposure to tobacco smoke during pregnancy may be related to a modest increase in the risk of delivering a SGA infant.