Perineal massage in labour and prevention of perineal trauma: randomised controlled trial

Objective: To determine the effects of perineal massage in the second stage of labour on perineal outcomes. Design: Randomised controlled trial. Participants: At 36 weeks' gestation, women expecting normal birth of a singleton were asked to join the study. Women became eligible to be randomised in labour if they progressed to full dilatation of the cervix or 8 cm or more if nulliparous or 5 cm or more if multiparous. 1340 were randomised into the trial. Intervention: Massage and stretching of the perineum during the second stage of labour with a water soluble lubricant. Main outcome measures: Primary outcomes: rates of intact perineum, episiotomies, and first, second, third, and fourth degree tears. Secondary outcomes: pain at three and 10 days postpartum and pain, dyspareunia, resumption of sexual intercourse, and urinary and faecal incontinence and urgency three months postpartum. Results: Rates of intact perineums, first and second degree tears, and episiotomies were similar in the massage and the control groups. There were fewer third degree tears in the massage group (12 (1.7%) v 23 (3.6%); absolute risk 2.11, relative risk 0.45; 95% confidence interval 0.23 to 0.93, P<0.04), though the trial was underpowered to measure this rarer outcome. Groups did not differ in any of the secondary outcomes at the three assessment points. Conclusions: The practice of perineal massage in labour does not increase the likelihood of an intact perineum or reduce the risk of pain, dyspareunia, or urinary and faecal problems.Georgina Stamp, Gillian Kruzins, Caroline Crowthe

The psychosocial outcomes of antenatal day care for three medical complications of pregnancy: A randomised controlled trial of 395 women

The definitive version is available at www.blackwell-synergy.comBackground: Although antenatal day care is becoming increasingly common, there is little evidence as to the psychosocial efficacy of this model of care. Aim: We aimed to assess the broader psychosocial impact of antenatal day care compared with admission to hospital. Methods: We carried out a randomised trial of 395 women, randomly assigned in a 2 : 1 ratio between day care and antenatal ward, stratified for major diagnostic categories (proteinuric hypertension, non-proteinuric hypertension and preterm premature rupture of membranes). Main outcome measures – self-report questionnaires (response rates ranging from 80 to 90%) were sent to women’s homes four days after randomisation and seven weeks after delivery. Results: Overall, there were statistically significant differences favouring day care in 12 of 28 items at four days post-randomisation, with no differences in the two groups for the other 16 items. At seven weeks postdelivery, we found differences in eight of 28 items favouring day care, with no differences in the two groups for the other 20 items. The types of items indicating a sustained difference covered a range of aspects of care and included satisfaction with staff, continuity of carer, information transfer, and social support. There were no differences in relation to infant feeding and relationship with the baby. Conclusions: Day care has an effect on women’s satisfaction with care but does not produce broader psychosocial outcomes.Deborah A. Turnbull, Chris Wilkinson, Elizabeth C. Griffith, Gillian Kruzins, Karen Gerard, Marian Shanahan and Georgina E. Stam

Clinical, psychological and economic effects of antenatal day care for three medical complications of pregnancy: a randomised controlled trial of 395 women

Background: Day care is increasingly being used for complications of pregnancy, but there is little published evidence on its efficacy. We assessed the clinical, psychosocial, and economic effects of day care for three pregnancy complications in a randomised trial of day care versus standard care on an antenatal ward.Methods: 395 women were randomly assigned day (263) or ward (132) care in a ratio of two to one, stratified for major diagnostic categories (non-proteinuric hypertension, proteinuric hypertension, and preterm premature rupture of membranes). The research hypothesis was that for these disorders, as an alternative to admission, antenatal day care will reduce specified interventions and investigations, result in no differences in clinical outcome, lead to greater satisfaction and psychological wellbeing, and be more cost-effective. Data were collected through case-note review, self-report questionnaires (response rates 81·0% or higher) and via the hospital's financial system. Analysis was by intention to treat.Findings: All participants were included in the analyses. There were no differences between the groups in antenatal tests or investigations or intrapartum interventions. The total duration of antenatal care episodes was shorter in the day-care group than in the ward group (median 17 [IQR 5–9] vs 57 [35–123] h; p=0·001). Overall stay was also significantly shorter in the day-care group (mean 7·22 [SE 0·31] vs 8·53 [0·44]; p=0·014). The median number of care episodes was three (range one to 14) in the day-care group and two (one to nine) in the ward group (p=0·01). There were no statistically or clinically significant differences in maternal or perinatal outcomes. The day-care group reported greater satisfaction, with no evidence of unintended psychosocial sequelae. There was no significant difference in either average cost per patient or average cost per day of care.Interpretation: Since clinical outcomes and costs are similar, adoption by maternity services of a policy providing specified women with the choice between admission and day-unit care seems appropriate

Clinical, psychological and economic effects of antenatal day care for three medical complications of pregnancy: a randomised controlled trial of 395 women

Background: Day care is increasingly being used for complications of pregnancy, but there is little published evidence on its efficacy. We assessed the clinical, psychosocial, and economic effects of day care for three pregnancy complications in a randomised trial of day care versus standard care on an antenatal ward.Methods: 395 women were randomly assigned day (263) or ward (132) care in a ratio of two to one, stratified for major diagnostic categories (non-proteinuric hypertension, proteinuric hypertension, and preterm premature rupture of membranes). The research hypothesis was that for these disorders, as an alternative to admission, antenatal day care will reduce specified interventions and investigations, result in no differences in clinical outcome, lead to greater satisfaction and psychological wellbeing, and be more cost-effective. Data were collected through case-note review, self-report questionnaires (response rates 81·0% or higher) and via the hospital's financial system. Analysis was by intention to treat.Findings: All participants were included in the analyses. There were no differences between the groups in antenatal tests or investigations or intrapartum interventions. The total duration of antenatal care episodes was shorter in the day-care group than in the ward group (median 17 [IQR 5–9] vs 57 [35–123] h; p=0·001). Overall stay was also significantly shorter in the day-care group (mean 7·22 [SE 0·31] vs 8·53 [0·44]; p=0·014). The median number of care episodes was three (range one to 14) in the day-care group and two (one to nine) in the ward group (p=0·01). There were no statistically or clinically significant differences in maternal or perinatal outcomes. The day-care group reported greater satisfaction, with no evidence of unintended psychosocial sequelae. There was no significant difference in either average cost per patient or average cost per day of care.Interpretation: Since clinical outcomes and costs are similar, adoption by maternity services of a policy providing specified women with the choice between admission and day-unit care seems appropriate

Mass cytometry discovers two discrete subsets of CD39⁻ treg which discriminate MGUS from multiple myeloma

© 2019 Marsh-Wakefield, Kruzins, McGuire, Yang, Bryant, Fazekas de St. Groth, Nassif, Byrne, Gibson, Brown, Larsen, McCulloch, Boyle, Clark, Joshua, Ho and Vuckovic. Multiple Myeloma (MM) is preceded by the clinically stable condition monoclonal gammopathy of undetermined significance (MGUS). Critical immune events that discriminate MGUS from newly diagnosed MM (ND)MM patients remain unknown, but may involve changes in the regulatory T cell (Treg) compartment that favor myeloma growth. To address this possibility, we used mass cytometry and the unsupervised clustering algorithm Flow self-organizing map (FlowSOM) to interrogate the distribution of multiple subsets within CD25+ CD127low/neg Treg in matched bone marrow (BM) and peripheral blood (PB) of MGUS and NDMM patients. Both mass cytometry and flow cytometry confirmed a trend toward prevalence of CD39− Treg within the Treg compartment in BM and PB of NDMM patients compared to CD39− Treg in MGUS patients. FlowSOM clustering displayed a phenotypic organization of Treg into 25 metaclusters that confirmed Treg heterogeneity. It identified two subsets which emerged within CD39− Treg of NDMM patients that were negligible or absent in CD39− Treg of MGUS patients. One subset was found in both BM and PB which phenotypically resembled activated Treg based on CD45RO, CD49d, and CD62L expression; another subset resembled BM-resident Treg based on its tissue-resident CD69+ CD62L− CD49d− phenotype and restricted location within the BM. Both subsets co-expressed PD-1 and TIGIT, but PD-1 was expressed at higher levels on BM-resident Treg than on activated Treg. Within BM, both subsets had limited Perforin and Granzyme B production, whilst activated Treg in PB acquired high Perforin and Granzyme B production. In conclusion, the use of mass cytometry and FlowSOM clustering discovered two discrete subsets of CD39− Treg which are discordant in MGUS and NDMM patients and may be permissive of myeloma growth which warrants further study. Understanding the regulatory properties of these subsets may also advance MGUS and MM diagnosis, prognosis, and therapeutic implications for MM patients