309 research outputs found
Vaginal progesterone vs intramuscular 17α-hydroxyprogesterone caproate for prevention of recurrent spontaneous preterm birth in singleton gestations: systematic review and meta-analysis of randomized controlled trials
OBJECTIVE:
Randomized controlled trials (RCTs) have recently compared intramuscular 17α-hydroxyprogesterone caproate (17-OHPC) with vaginal progesterone for reducing the risk of spontaneous preterm birth (SPTB) in singleton gestations with prior SPTB. The aim of this systematic review and meta-analysis was to evaluate the efficacy of vaginal progesterone compared with 17-OHPC in prevention of SPTB in singleton gestations with prior SPTB.
METHODS:
Searches of electronic databases were performed to identify all RCTs of asymptomatic singleton gestations with prior SPTB that were randomized to prophylactic treatment with either vaginal progesterone (intervention group) or intramuscular 17-OHPC (comparison group). No restrictions for language or geographic location were applied. The primary outcome was SPTB < 34 weeks. Secondary outcomes were SPTB < 37 weeks, < 32 weeks, < 28 weeks and < 24 weeks, maternal adverse drug reaction and neonatal outcomes. The summary measures were reported as relative risk (RR) with 95% CI. Risk of bias for each included study was assessed.
RESULTS:
Three RCTs (680 women) were included. The mean gestational age at randomization was about 16 weeks. Women were given progesterone until 36 weeks or delivery. Regarding vaginal progesterone, one study used 90 mg gel daily, one used 100 mg suppository daily and one used 200 mg suppository daily. All included RCTs used 250 mg intramuscular 17-OHPC weekly in the comparison group. Women who received vaginal progesterone had significantly lower rates of SPTB < 34 weeks (17.5% vs 25.0%; RR, 0.71 (95% CI, 0.53-0.95); low quality of evidence) and < 32 weeks (8.9% vs 14.5%; RR, 0.62 (95% CI, 0.40-0.94); low quality of evidence) compared with women who received 17-OHPC. There were no significant differences in the rates of SPTB < 37 weeks, < 28 weeks and < 24 weeks. The rate of women who reported adverse drug reactions was significantly lower in the vaginal progesterone group compared with the 17-OHPC group (7.1% vs 13.2%; RR, 0.53 (95% CI, 0.31-0.91); very low quality of evidence). Regarding neonatal outcomes, vaginal progesterone was associated with a lower rate of neonatal intensive care unit admission compared with 17-OHPC (18.7% vs 23.5%; RR, 0.63 (95% CI, 0.47-0.83); low quality of evidence). For the comparison of 17-OHPC vs vaginal progesterone, the quality of evidence was downgraded for all outcomes by at least one degree due to imprecision (the optimal information size was not reached) and by at least one degree due to indirectness (different interventions).
CONCLUSIONS:
Daily vaginal progesterone (either suppository or gel) started at about 16 weeks' gestation is a reasonable, if not better, alternative to weekly 17-OHPC injection for prevention of SPTB in women with singleton gestations and prior SPTB. However, the quality level of the summary estimates was low or very low as assessed by GRADE, indicating that the true effect may be, or is likely to be, substantially different from the estimate of the effec
Intimate Partner Violence during Pregnancy: Victim or Perpetrator? Does it make a difference?
Objectives: To differentiate between forms of intimate partner violence (IPV)(victim only, perpetrator only, or participating in reciprocal violence) and examine risk profiles and pregnancy outcomes.
Design: Prospective
Setting: Washington, DC, July 2001 to October 2003
Sample: 1044 high-risk African-American pregnant women who participated in a randomized controlled trial to address IPV, depression, smoking, and environmental tobacco smoke exposure.
Methods: Multivariable linear and logistic regression
Main outcome measures: Low and very low birth weight, preterm and very preterm birth
Results: 5% of women were victims only, 12% were perpetrators only, 27% participated in reciprocal violence, and 55% reported no IPV. Women reporting reciprocal violence in the past year were more likely to drink, use illicit drugs, and experience environmental tobacco smoke exposure and were less likely to be very happy about their pregnancies. Women reporting any type of IPVwere more likely to be depressed than those reporting no IPV. Women experiencing reciprocal violence reported highest levels of depression. Women who were victims of IPV were more likely to give birth prior prematurely and deliver low and very low birth weight infants.
Conclusions: We conclude that women were at highest risk for pregnancy risk factors when they participated in reciprocal violence and thus might be at higher risk for long-term consequences, but women who were victims of intimate partner violence were more likely to show proximal negative outcomes like preterm birth and low birth weight. Different types of interventions may be needed for these two forms of intimate partner violence
The lady vanishes: what's missing from the stem cell debate
Most opponents of somatic cell nuclear transfer and embryonic stem cell technologies base their arguments on the twin assertions that the embryo is either a human being or a potential human being, and that it is wrong to destroy a human being or potential human being in order to produce stem cell lines. Proponents’ justifications of stem cell research are more varied, but not enough to escape the charge of obsession with the status of the embryo. What unites the two warring sides in ‘the stem cell wars’ is that women are equally invisible to both: ‘the lady vanishes’. Yet the only legitimate property in the body is that which women possess in their reproductive tissue and the products of their reproductive labour. By drawing on the accepted characterisation in law of property as a bundle of rights, and on a Hegelian model of contract as mutual recognition, we can lessen the impact of the tendency to regard women and their eggs as merely receptacles and women’s reproductive labour as unimportant
Is It Time to Rethink Cord Management When Resuscitation Is Needed?
A newborn who receives a placental transfusion at birth, either from cord milking or delayed cord clamping, obtains about 30% more blood volume than the newborn whose cord is cut immediately. Receiving an adequate blood volume from placental transfusion at birth may be protective for the distressed neonate as it prevents hypovolemia and can support optimal perfusion to all organs. New research shows that ventilating before clamping the umbilical cord can reduce large swings in cardiovascular function and help to stabilize the newborn. Hypovolemia, often associated with nuchal cord or shoulder dystocia, may lead to an inflammatory cascade and subsequent ischemic injury. A sudden unexpected neonatal asystole at birth may occur from severe hypovolemia. The restoration of blood volume is an important action to protect the hearts and brains of these neonates. Current protocols for resuscitation imply immediate cord clamping and the care of the newborn away from the mother\u27s bedside. We suggest that an intrapartum care provider can achieve placental transfusion for the distressed neonate by milking the cord several times or resuscitating the neonate at the perineum with an intact cord. Milking the cord can be done quickly within the current Neonatal Resuscitation Program guidelines. Cord blood gases can be collected with delayed cord clamping. Bringing the resuscitation to the mother\u27s bedside is a novel concept and supports an intact cord. Adopting a policy for resuscitation with an intact cord in a hospital setting will take concentrated effort and team work by obstetrics, pediatrics, midwifery, and nursing
The timing of elective caesarean delivery between 2000 and 2009 in England
BACKGROUND: In 2004, the National Institute for Clinical Excellence (NICE) recommended that an elective caesarean section for an uncomplicated pregnancy should not be carried out before 39 completed weeks due to increased risk of respiratory morbidity in newborns. We describe the trends and variation across 63 English NHS trusts in the timing of elective caesarean section (CS) for low-risk singleton deliveries. METHODS: We identified elective CS deliveries between 1st April 2000 and 28th February 2009 in English NHS trusts using the Hospital Episode Statistics. We selected women with uncomplicated pregnancies who had an elective CS delivery after 34 completed weeks of gestation, and analysed the trends and the trust-level variation in the timing of elective CS. The impact of the NICE guidance on the monthly rate of elective CS deliveries performed after 39 weeks was estimated using an interrupted time-series design with autoregressive integrated moving average (ARIMA). RESULTS: There were 118,456 elective CS deliveries at the 63 NHS trusts. The overall proportion of elective CS deliveries done after 39 completed weeks steadily increased from 39% in 2000/01 to 63% in 2008/09. The proportions rose from 43% to 67% for women with breech presentation and from 35% to 62% for women with a previous CS. There was significant variation across NHS trusts in each year; in 2008/09, with the proportions of elective CS done after 39 weeks ranging from 28% to 89% (Inter-quartile range limits: 54% to 72%). We found a small but statistically significant increase in the proportion immediately after the publication of the NICE guidance, but its rate of growth rate declined slightly thereafter. CONCLUSIONS: NHS trusts in our study have responded to the new evidence on the benefits of delaying elective CS to after 39 weeks gestation. However, substantial differences between NHS trusts remain, which indicates there is room for further improvement. We suggest that maternity services and commissioners adopt the "timing of elective caesarean" as a quality indicator to support clinical practice
Clinical evaluation of women with PMB. Is it always necessary an endometrial biopsy to be performed? A review of the literature
Knowledge, attitudes and use of labour analgesia among women at a low-income country antenatal clinic
The DIAMIND study: postpartum SMS reminders to women who have had gestational diabetes mellitus to test for type 2 diabetes: a randomised controlled trial - study protocol
BACKGROUND Postpartum follow up of women who have been found to have gestational diabetes during pregnancy is essential because of the strong association of gestational diabetes with subsequent type 2 diabetes. Postal reminders have been shown to increase significantly attendance for oral glucose tolerance testing postpartum. It is possible that a short message service (text) reminder system may also be effective. This trial aims to assess whether a text message reminder system for women who have experienced gestational diabetes in their index pregnancy will increase attendance for oral glucose tolerance testing within six months after birth. METHODS/DESIGN Design: Single centre (Women’s and Children’s Hospital, South Australia), parallel group randomised controlled trial. Inclusion criteria: Women diagnosed with gestational diabetes in their index pregnancy (oral glucose tolerance test with fasting glucose ≥ 5.5 mmol/L and/or two hour glucose ≥ 7.8 mmol/L), with access to a mobile phone, whose capillary blood glucose profile measurements prior to postnatal discharge are all normal (fasting glucose < 6.0 mmol/L, postprandial glucoses < 8.0 mmol/L). Exclusion criteria: Pregestational diabetes mellitus, triplet/higher order multiple birth or stillbirth in the index pregnancy, requirement for interpreter. Trial entry and randomisation: Allocation to intervention will be undertaken using a telephone randomisation service (computer-generated random number sequence generation, with balanced variable blocks, and stratification by insulin requirement). Study groups: Women in the intervention group will receive a text reminder to attend for an oral glucose tolerance test at 6 weeks postpartum, with further reminders at 3 months and 6 months if they do not respond to indicate test completion. Women in the control group will receive a single text message reminder at 6 months postpartum. Blinding: Baseline data collection will be undertaken blinded. Blinding of participants and blinded collection of primary outcome data will not be possible for this study. Primary study outcome: Attendance for the oral glucose tolerance test within 6 months postpartum. Sample size: 276 subjects will be required to show an 18% absolute increase in the rate of attendance (α=0.05 two tailed, β=80%, 5% loss to follow up) from 37% to 55% in the intervention group. DISCUSSION Given the heightened risk of impaired glucose tolerance and type 2 diabetes in women who have had gestational diabetes, ensuring the highest possible rate of attendance for postpartum glucose tolerance testing, so that early diagnosis and intervention can occur, is important. A text message reminder system may prove to be an effective method for achieving improved attendance for such testing. This randomised controlled trial will assess whether such a system will increase rates of attendance for postpartum oral glucose tolerance testing in women who have experienced gestational diabetes. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry - ACTRN12612000621819Emer Heatley, Philippa Middleton, William Hague and Caroline Crowthe
Is the hypothesis of preimplantation genetic screening (PGS) still supportable? A review
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