Objective
International comparison of complete uterine rupture.
Design
Descriptive multi‐country population‐based study.
Setting
International.
Population
International Network of Obstetric Survey ...Systems (INOSS).
Methods
We merged individual data, collected prospectively in nine population‐based studies, of women with complete uterine rupture, defined as complete disruption of the uterine muscle and the uterine serosa, regardless of symptoms and rupture of fetal membranes.
Main outcome measures
Prevalence of complete uterine rupture, regional variation and correlation with rates of caesarean section (CS) and trial of labour after CS (TOLAC). Severe maternal and perinatal morbidity and mortality.
Results
We identified 864 complete uterine ruptures in 2 625 017 deliveries. Overall prevalence was 3.3 (95% CI 3.1–3.5) per 10 000 deliveries, 22 (95% CI 21–24) in women with and 0.6 (95% CI 0.5–0.7) in women without previous CS. Prevalence in women with previous CS was negatively correlated with previous CS rate (ρ = −0.917) and positively correlated with TOLAC rate of the background population (ρ = 0.600). Uterine rupture resulted in peripartum hysterectomy in 87 of 864 women (10%, 95% CI 8–12%) and in a perinatal death in 116 of 874 infants (13.3%, 95% CI 11.2–15.7) whose mother had uterine rupture. Overall rate of neonatal asphyxia was 28% in neonates who survived.
Conclusions
Higher prevalence of complete uterine ruptures per TOLAC was observed in countries with low previous CS and high TOLAC rates. Rates of hysterectomy and perinatal death are about 10% following complete uterine rupture, but in women undergoing TOLAC the rates are extremely low (only 2.2 and 3.2 per 10 000 TOLACs, respectively.)
Tweetable
Prevalence of complete uterine rupture is higher in countries with low previous CS and high TOLAC rates.
Tweetable
Prevalence of complete uterine rupture is higher in countries with low previous CS and high TOLAC rates.
Please cite this paper as: Tajik P, van der Tuuk K, Koopmans C, Groen H, van Pampus M, van der Berg P, van der Post J, van Loon A, de Groot C, Kwee A, Huisjes A, van Beek E, Papatsonis D, Bloemenkamp ...K, van Unnik G, Porath M, Rijnders R, Stigter R, de Boer K, Scheepers H, Zwinderman A, Bossuyt P, Mol B. Should cervical favourability play a role in the decision for labour induction in gestational hypertension or mild pre‐eclampsia at term? An exploratory analysis of the HYPITAT trial. BJOG 2012;119:1123–1130.
Objective To examine whether cervical favourability (measured by cervical length and the Bishop score) should inform obstetricians’ decision regarding labour induction for women with gestational hypertension or mild pre‐eclampsia at term.
Design A post hoc analysis of the Hypertension and Pre‐eclampsia Intervention Trial At Term (HYPITAT).
Setting Obstetric departments of six university and 32 teaching and district hospitals in the Netherlands.
Population A total of 756 women diagnosed with gestational hypertension or pre‐eclampsia between 36 + 0 and 41 + 0 weeks of gestation randomly allocated to induction of labour or expectant management.
Methods Data were analysed using logistic regression modelling.
Main outcome measures The occurrence of a high‐risk maternal situation defined as either maternal complications or progression to severe disease. Secondary outcomes were caesarean delivery and adverse neonatal outcomes.
Results The superiority of labour induction in preventing high‐risk situations in women with gestational hypertension or mild pre‐eclampsia at term varied significantly according to cervical favourability. In women who were managed expectantly, the longer the cervix the higher the risk of developing maternal high‐risk situations, whereas in women in whom labour was induced, cervical length was not associated with a higher probability of maternal high‐risk situations (test of interaction P = 0.03). Similarly, the beneficial effect of labour induction on reducing the caesarean section rate was stronger in women with an unfavourable cervix.
Conclusion Against widely held opinion, our exploratory analysis showed that women with gestational hypertension or mild pre‐eclampsia at term who have an unfavourable cervix benefited more from labour induction than other women.
Trial registration The trial has been registered in the clinical trial register as ISRCTN08132825.
Objective
To assess the effect of red blood cell (RBC) transfusion on quality of life in acutely anaemic women after postpartum haemorrhage.
Design
Randomised non‐inferiority trial.
Setting
...Thirty‐seven Dutch university and general hospitals.
Population
Women with acute anaemia (haemoglobin 4.8–7.9 g/dl 3.0–4.9 mmol/l 12–24 hours postpartum) without severe anaemic symptoms or severe comorbidities.
Methods
Women were allocated to RBC transfusion or non‐intervention.
Main outcome measures
Primary outcome was physical fatigue 3 days postpartum (Multidimensional Fatigue Inventory, scale 4–20; 20 represents maximal fatigue). Non‐inferiority was demonstrated if the physical fatigue difference between study arms was maximal 1.3. Secondary outcomes were health‐related quality of life and physical complications. Health‐related quality of life questionnaires were completed at five time‐points until 6 weeks postpartum.
Results
In all, 521 women were randomised to non‐intervention (n = 262) or RBC transfusion (n = 259). Mean physical fatigue score at day 3 postpartum, adjusted for baseline and mode of delivery, was 0.8 lower in the RBC transfusion arm (95% confidence interval: 0.1–1.5, P = 0.02) and at 1 week postpartum was 1.06 lower (95% confidence interval: 0.3–1.8, P = 0.01). A median of two RBC units was transfused in the RBC transfusion arm. In the non‐intervention arm, 33 women received RBC transfusion, mainly because of anaemic symptoms. Physical complications were comparable.
Conclusions
Statistically, non‐inferiority could not be demonstrated as the confidence interval crossed the non‐inferiority boundary. Nevertheless, with only a small difference in physical fatigue and no differences in secondary outcomes, implementation of restrictive management seems clinically justified.
The progestogen component of oral contraceptives (OC) has undergone changes since it was first recognised that their chemical structures could influence the spectrum of minor adverse and beneficial ...effects. The major determinants of OCs are effectiveness, cycle control and common side effects. The rationale of this review is to provide a systematic comparison of OCs containing the progestogens currently in use worldwide.
The objective of this review is to compare currently available low-dose OCs containing ethinyl estradiol and different progestogens in terms of contraceptive effectiveness, cycle control, side effects and continuation rates.
The Cochrane Controlled Trials Register, MEDLINE and EMBASE databases have been searched systematically. Relevant pharmaceutical companies and the authors of articles included in this review have been contacted for clarification.
Randomised trials reporting clinical outcomes were considered for inclusion. We excluded studies comparing mono- with multiphasic pills, and crossover trials with trials in which the difference in total content of ethinyl estradiol between preparations exceeded 105 micro g.
The methodological quality and validity of studies were assessed based on the above-mentioned inclusion criteria. Both application of inclusion criteria and data extraction were performed independently by the reviewers. Results are expressed as relative risk (RR) with 95% confidence interval (CI) using a random-effects model.
Twenty-two trials have been included in this review, thus generating 14 comparisons. Eighteen trials were sponsored by pharmaceutical companies and in only 5 cases had a blind trial been attempted. Most comparisons between different interventions included 1-3 trials. There was less discontinuation with second- compared to first-generation progestogens (RR: 0.79, 95% CI: 0.69-0.91). Cycle control appears to be better when using second- compared to first-generation progestogens for both mono- (RR: 0.69; 95% CI: 0.52-0.91) and triphasic (RR: 0.61; 95% CI: 0.43-0.85) preparations.Contraceptive effectiveness, spotting, breakthrough bleeding and the absence of withdrawal bleeding was similar when using GSD compared to LNG, although there was less intermenstrual bleeding in the GSD group (RR: 0.71, 95% CI: 0.55, 0.91). Drospirenone (DRSP) appeared to be similar to DSG.
Based on data from one trial, compared to pills containing LNG, those containing GSD may be associated with less intermenstrual bleeding although they show similar patterns of spotting, breakthrough bleeding and the absence of withdrawal bleeds. GSD is also comparable to DSG. Regarding acceptability, all the indices show that third- and second-generation progestogens are preferred over first-generation preparations. Future research should focus on independently conducted, well-designed randomised trials that compare third- and second-generation progestogens in particular.
PDF
