Proteinuria as a predictor of complications of pre-eclampsia

Proteinuria is a defining criterion for the diagnosis of pre-eclampsia. The amount of protein lost per day has been thought by some to predict both maternal and fetal outcome. The systematic review of 16 primary papers including over 6700 patients by Thangaratinam and colleagues published this month in BMC Medicine suggests otherwise. This finding may influence our management of pre-eclampsia

Non-closure of peritoneal surfaces at caesarean section - a systematic review

Background. Caesarean section (CS) is a very common surgical procedure  worldwide. Suturing the peritoneal layers at CS may or may not confer  benefit, hence the need to evaluate whether this step should be omitted or not.Objectives. To assess the effects of non-closure as an alternative to  closure of the peritoneum at CS on intraoperative, immediate and later  postoperative, and long-term outcomes.Search strategy. We searched the Cochrane Pregnancy and Childbirth   Group Trials Register (November 2002) and the Cochrane Central   Controlled Trials Register (October 2003).Selection criteria. Randomised controlled trials that compared leaving the visceral and/ or parietal peritoneum unsutured at CS with suturing the peritoneum, in women undergoing elective or emergency CS.Data collection and analysis. Trial quality was assessed and data were extracted by two reviewers.Main results. Nine trials involving 1 811 women were included and  analysed. The methodological quality of the trials was variable. Non-closure of the peritoneum reduced operating time when both layers or one layer was not sutured. For both layers, the operating time was reduced by7.33 minutes (95% confidence interval (CI): -8.43 - -6.24). There was significantly less postoperative fever and reduced postoperative stay in hospital for non-closure of the visceral peritoneum and non-closure of both layers. There were no other statistically significant differences. The tr.end for analgesia requirement and wound infection tended to favour non-closure, while endometritis results were variable. Longterm follow-up in 1 trial showed no significant differences. The power of the latter study to show differences was low.Conclusions. There was improved short-term postoperative outcome if the peritoneum was not closed. Long-term studies following CS are limited, but data from other surgical procedures are reassuring. At present there is noevidence to justify the time taken and cost of peritoneal closure

Inter-pregnancy interval and risk of recurrent pre-eclampsia: systematic review and meta-analysis

Background: Women with a history of pre-eclampsia have a higher risk of developing pre-eclampsia in subsequentpregnancies. However, the role of the inter-pregnancy interval on this association is unclear.Objective: To explore the effect of inter-pregnancy interval on the risk of recurrent pre-eclampsia or eclampia.Search strategy: MEDLINE, EMBASE and LILACS were searched (inception to July 2015).Selection criteria: Cohort studies assessing the risk of recurrent pre-eclampsia in the immediate subsequentpregnancy according to different birth intervals.Data collection and analysis: Two reviewers independently performed screening, data extraction, methodologicaland quality assessment.Meta-analysis of adjusted odds ratios (aOR) with 95 % confidence intervals (CI) was used to measure the associationbetween various interval lengths and recurrent pre-eclampsia or eclampsia.Main results: We identified 1769 articles and finally included four studies with a total of 77,561 women. The meta-analysisof two studies showed that compared to inter-pregnancy intervals of 2?4 years, the aOR for recurrent pre-eclampsia was 1.01 [95 % CI 0.95 to 1.07, I2 0 %] with intervals of less than 2 years and 1.10 [95 % CI 1.02 to 1.19, I2 0 %] with intervals longerthan 4 years.Conclusion: Compared to inter-pregnancy intervals of 2 to 4 years, shorter intervals are not associated with an increasedrisk of recurrent pre-eclampsia but longer intervals appear to increase the risk. The results of this review should beinterpreted with caution as included studies are observational and thus subject to possible confounding factors.Keywords: Recurrence, Pre-eclampsia, Eclampsia, Inter-pregnancy interval, Birth interval, Meta-analysis, Systematic review,Birth spacing, Hypertensive disorders of pregnancyFil: Cormick, Gabriela. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; ArgentinaFil: Betran, Ana Pilar. World Health Organization; SuizaFil: Ciapponi, Agustín. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; ArgentinaFil: Hall, David R.. Stellenbosch University; Sudáfrica. Tygerberg Hospital; SudáfricaFil: Hofmyer, G. Justus. University of the Witwatersrand; Sudáfrica. University of Fort Hare; Sudáfrica. Walter Sisulu University; Sudáfric

Side-effects of oral misoprostol in the third stage of labour – a randomised placebo controlled trial

Background. Misoprostol, an irlexpensive, stable, orally active prostaglandirl analogue, has been suggested for use in the prevention of postpartum haemorrhage. Potential side-effects, however, need to be quantified.Objective. To compare the rate of postpartum shivering and pyrexia following oral misoprostol 600 pg and placebo.Design. A double-blind placebo-controlled trial. Women irl labour were randomly allocated to receive either misoprostol 600 pg orally or placebo after delivery. Conventional oxytocics were given immediately if blood loss was thought to be more than usual. Side-effects were recorded. Postpartum blood loss in the first hour was measured by collection in a special flat plastic bedpan.Setting. The labour ward of an academic hospital irl Johannesburg, with 7 000 deliveries per annum.Main outcome measures. Shivering and pyrexia.Results. The groups were well matched. Misoprostol use was associated with more shivering (44% versus 11%, relative risk (RR) 4.03, 95% confidence irlterval (Cl) 2.85 - 5.70), pyrexia ~ 37.8°C (38% v. 6%, RR 6.23, Cl 3.89 - 9.97), I-hour systolic blood pressure ~ 140 mmHg (33% v. 25%, RR 1.32, Cl 1.031.70), and diastolic blood pressure ~ 90 mmHg (10.5% v. 3.0%, RR 3.44, Cl 1.67 -7.11). There were no other significant differences. The study was not designed to be large enough to assess a difference irl blood loss ~ 1 000 ml (9% v. 9.7%, RR 0.93, Cl 0.56 - 1.53). Possible effects on blood loss may have been obscured by the lesser use of additional oxytocics irl the misoprostol group (14% v. 18%, RR 0.78, Cl 0.54 - 1.13). Conclusions. This study has shown the association of postpartum oral misoprostol 600 Jlg with shivering, pyrexia and hypertension. The increased blood pressure, as for the trend towards increased abdominal pain, may be secondary to the uterotonic effect of misoprostol. Large randomised trials are needed to assess the effectiveness of misoprostol in the prevention of postpartum haemorrhage, against which the disadvantages demonstrated here can be weighed

Promoting childbirth companions in South Africa: a randomised pilot study

<p>Abstract</p> <p>Background</p> <p>Most women delivering in South African State Maternity Hospitals do not have a childbirth companion; in addition, the quality of care could be better, and at times women are treated inhumanely. We piloted a multi-faceted intervention to encourage uptake of childbirth companions in state hospitals, and hypothesised that lay carers would improve the behaviour of health professionals.</p> <p>Methods</p> <p>We conducted a pilot randomised controlled trial of an intervention to promote childbirth companions in hospital deliveries. We promoted evidence-based information for maternity staff at 10 hospitals through access to the World Health Organization Reproductive Health Library (RHL), computer hardware and training to all ten hospitals. We surveyed 200 women at each site, measuring companionship, and indicators of good obstetric practice and humanity of care. Five hospitals were then randomly allocated to receive an educational intervention to promote childbirth companions, and we surveyed all hospitals again at eight months through a repeat survey of postnatal women. Changes in median values between intervention and control hospitals were examined.</p> <p>Results</p> <p>At baseline, the majority of hospitals did not allow a companion, or access to food or fluids. A third of women were given an episiotomy. Some women were shouted at (17.7%, N = 2085), and a few reported being slapped or struck (4.3%, N = 2080). Despite an initial positive response from staff to the childbirth companion intervention, we detected no difference between intervention and control hospitals in relation to whether a companion was allowed by nursing staff, good obstetric practice or humanity of care.</p> <p>Conclusion</p> <p>The quality and humanity of care in these state hospitals needs to improve. Introducing childbirth companions was more difficult than we anticipated, particularly in under-resourced health care systems with frequent staff changes. We were unable to determine whether the presence of a lay carer impacted on the humanity of care provided by health professionals. </p> <p><b>Trial registration</b>: Current Controlled Trials ISRCTN33728802</p

Effects of the copper intrauterine device versus injectable progestin contraception on pregnancy rates and method discontinuation among women attending termination of pregnancy services in South Africa: a pragmatic randomized controlled trial

Background: The copper intrauterine device (IUD) is under-utilised in South Africa, where injectable progestin contraception (IPC) dominates contraception usage. There is a lack of robust comparative data on these contraceptive options to inform policy, programs, clinical counseling, and women’s choices. Methods: Within the context of a South African program to increase women’s access to the IUD, we conducted a pragmatic, open-label, parallel-arm, randomised controlled trial of the IUD versus IPC at two South African hospitals. The target sample size was 7,000 women and the randomisation ratio was 1:1. The random sequence was computer-generated and group allocation was concealed in sealed, opaque, consecutively-numbered envelopes. Counselled, consenting women attending termination of pregnancy services were randomly assigned to IUD or IPC immediately post-termination. Condoms were promoted for the prevention of sexually-transmitted infections. The primary outcome was pregnancy; secondary outcomes were discontinuation, side-effects, and HIV acquisition and disease progression. Pregnancy and discontinuation outcomes are reported here. Results: The trial closed early with 2,493 participants randomised (IUD = 1,247, IPC = 1,246), due to international concerns regarding a possible association between IPC and HIV acquisition. Median follow-up was 20 months; 982 and 1000 participants were followed up in the IUD and IPC groups, respectively. Baseline group characteristics were comparable. Pregnancy occurred significantly less frequently among women allocated to the IUD than IPC: 56/971 (5.8 %) versus 83/992 (8.4 %), respectively; risk ratio (RR) 0.69, 95 % confidence interval (CI) 0.50 to 0.96; P = 0.025. There were more protocol violations in the IUD group; however, discontinuation rates were similar between IUD and IPC groups (141/855 [16.5 %] and 143/974 [14.7 %], respectively). Women in the IUD group were more likely to discontinue contraceptive use due to abdominal pain or backache and non-specific symptoms, and those in the IPC group due to oligo- or amenorhoea and lack of sexual activity. Conclusions: The IUD was significantly more effective in preventing pregnancy than IPC. Efforts to expand contraception options and improve access to the IUD in settings where it is under-utilised are worthwhile. This trial shows that randomising long-acting, reversible contraceptives is feasible. Trial registration: Pan African Clinical Trials Registry number PACTR201409000880157 (04-09-2014)

Effects of injectable progestogen contraception versus the copper intrauterine device on HIV acquisition: sub-study of a pragmatic randomised controlled trial

Background: Evidence from observational studies suggests an increased risk of HIV acquisition among women using depot medroxyprogesterone acetate (DMPA) contraception. Methods: Within the context of a South African programme to increase women\u27s access to the intrauterine contraceptive device (IUD), we conducted a pragmatic, open-label, parallel-arm, randomised controlled trial (RCT) of the IUD versus injectable progestogen contraception (IPC) at two South African hospitals. The primary outcome was pregnancy; secondary outcomes included HIV acquisition. Consenting women attending termination of pregnancy services were randomised after pregnancy termination between July 2009 and November 2012. Condoms were promoted for the prevention of sexually transmitted infections. Voluntary HIV testing was offered at baseline and at 12 or more months later. Findings on HIV acquisition are reported in this article. Results: HIV acquisition data were available for 1290 initially HIV-negative women who underwent a final study interview at a median of 20 months after randomisation to IPC or an IUD. Baseline group characteristics were comparable. In the IPC group, 545/656 (83%) of participants received DMPA, 96 (15%) received injectable norethisterone enanthate, 14 (2%) received the IUD and one received oral contraception. In the IUD group 609 (96%) received the IUD, 20 (3%) received IPC and 5 (1%) had missing data. According to intention-to-treat analysis, HIV acquisition occurred in 20/656 (3.0%) women in the IPC arm and 22/634 (3.5%) women in the IUD arm (IPC vs IUD, risk ratio 0.88; 95% confidence interval 0.48–1.59; p=0.7). Conclusions: This sub-study was underpowered to rule out moderate differences in HIV risk, but confirms the feasibility of randomised trial methodology to address this question. Larger RCTs are needed to determine the relative risks of various contraceptive methods on HIV acquisition with greater precision