Preterm birth, an unresolved issue

Premature birth is the world's leading cause of neonatal mortality with worldwide estimates indicating 11.1% of all live births were preterm in 2010. Preterm birth rates are increasing in most countries with continual differences in survival rates amongst rich and poor countries. Preterm birth is currently an important unresolved global issue with research efforts focusing on uterine quiescence and activation, the 'omics' approaches and implementation science in order to reduce the incidence and increase survival rates of preterm babies. The journal Reproductive Health has published a supplement entitled Born Too Soon which addresses factors in the preconception and pregnancy period which may increase the risk of preterm birth and also outlines potential interventions which may reduce preterm birth rates and improve survival of preterm babies by as much as 84% annually. This is critical in order to achieve the Millennium Development Goal (MDG 4) for child survival by 2015 and beyond.Fil: Belizan, Jose. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Hofmeyr, Justus. University of The Witwatersrand;Fil: Buekens, Pierre. University of Tulane; Estados UnidosFil: Salaria, Natasha. BioMed Central; Reino Unid

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

Obstetric use of misoprostol: innovations, evidence, controversy and global health perspectives

Thesis (D.Sc.)--University of the Witwatersrand, Faculty of Health Sciences, 2012

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

Calcium supplementation commencing before or early in pregnancy, or food fortification with calcium, for preventing hypertensive disorders of pregnancy

Background Pre-eclampsia is considerably more prevalent in low- than high-income countries. One possible explanation for this discrepancy is dietary diKerences, particularly calcium deficiency. Calcium supplementation in the second half of pregnancy reduces the serious consequences of pre-eclampsia and is recommended by the WorldHealthOrganization (WHO) for women with low dietary calcium intake, but has limited eKect on the overallrisk of pre-eclampsia. It is important to establish whether calcium supplementation before and in early pregnancy has added benefit. Such evidence would be justification for population-level fortification of staple foods with calcium. Objectives To determine the eKect of calcium supplementation or food fortification with calcium, commenced before or early in pregnancy and continued at least until mid-pregnancy, on pre-eclampsia and other hypertensive disorders, maternal morbidity and mortality, as well as fetal and neonatal outcomes. Search methods We searched the Cochrane Pregnancy and Childbirth Trials Register (10 August 2017), PubMed (29 June 2017), ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (10 August 2017) and reference lists of retrieved studies. Selection criteria Randomised controlled trials of calcium supplementation orfood fortification which include women of child bearing age not yet pregnant, or in early pregnancy. Cluster-RCTs, quasi-RCTs and trials published in abstract form only would have been eligible for inclusion in this review but none were identified. Cross-over designs are not appropriate for this intervention. The scope of this review is to consider interventions including calcium supplementation with or without additional supplements or treatments, compared with placebo or no intervention. Data collection and analysis Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. Main results This review is based on one RCT (involving 60 women) which looked at calcium plus additional supplements versus control. The women (who had lowantioxidant status)were in the early stages of pregnancy.We did notidentify any studieswhere supplementation commenced pre-pregnancy. Another RCT comparing calcium versus placebo is ongoing but not yet complete. We did not identify any studies looking at any of our other planned comparisons. Calcium plus antioxidants and other supplements versus placebo We included one small study (involving 60 women with low antioxidantlevels) which was conducted in an academic hospital in Indondesia. The study was at low risk of bias for all domains with the exception of selective reporting, for which it was unclear. Women in the intervention group received calcium (800 mg) plus N-acetylcysteine (200 mg), Cu (2 mg), Zn (15 mg), Mn (0.5 mg) and selenium (100 mcg) and vitamins A (1000 IU), B6 (2.2 mg), B12 (2.2 mcg), C (200 mg), and E (400 IU) versus the placebo control group of women who received similar looking tablets containing iron and folic acid. Both groups received iron (30 mg) and folic acid (400 mcg). Tablets were taken twice daily from eight to 12 weeks of gestation and then throughout pregnancy. The included study found that calcium supplementation plus antioxidants and other supplements may slightly reduce pre-eclampsia (gestational hypertension and proteinuria) (risk ratio (RR) 0.24, 95% confidence interval (CI) 0.06 to 1.01; low-quality evidence), but this is uncertain due to wide confidence intervals just crossing the line of no eKect, and small sample size. It appears that earlypregnancy loss before 20 weeks' gestation (RR 0.06, 95% CI 0.00 to 1.04; moderate-quality evidence) may be slightly reduced by calcium plus antioxidants and other supplements, but this outcome also has wide confidence intervals, which just cross the line of no eKect. Very few events were reported under the composite outcome, severe maternal morbidity and mortality index and no clear diKerence was seen between groups (RR 0.36, 95% CI 0.04 to 3.23; low-quality evidence). However, the included study observed a reduction in the composite outcome pre-eclampsia and/or pregnancy loss at any gestational age (RR 0.13, 95% CI 0.03 to 0.50; moderate-quality evidence), and pregnancy loss/stillbirth at any gestational age (RR 0.06, 95% CI 0.00 to 0.92;moderate-quality evidence)in the calcium plus antioxidant/supplement group. Other outcomes reported (placental abruption, severe pre-eclampsia and preterm birth (less than 37 weeks' gestation)) were too infrequent for meaningful analysis. No data were reported for the outcomes caesarean section, birthweight less 2500 g, Apgar score less than seven at five minutes, death or admission to neonatal intensive care unit (ICU), or pregnancy loss, stillbirth or neonatal death before discharge from hospital. Authors' conclusions The results of this review are based on one small study in which the calcium intervention group also received antioxidants and other supplements. Therefore, we are uncertain whether any of the eKects observed in the study were due to calcium supplementation or not. The evidence in this review was graded low to moderate due to imprecision. There is insuKicient evidence on the eKectiveness or otherwise of pre- or early-pregnancy calcium supplementation, or food fortification for preventing hypertensive disorders of pregnancy. Furtherresearch is needed to determine whether pre- or early-pregnancy supplementation, orfood fortification with calcium is associated with a reduction in adverse pregnancy outcomes such as pre-eclampsia and pregnancy loss. Such studies should be adequately powered, limited to calcium supplementation, placebo-controlled, and include relevant outcomes such as those chosen for this review. There is one ongoing study of calcium supplementation alone versus placebo and this may provide additional evidence in future update

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