Objective
To compare pregnancy outcomes, accounting for allocated group, between methyldopa‐treated and labetalol‐treated women in the CHIPS Trial (ISRCTN 71416914) of ‘less tight’ versus ‘tight’ ...control of pregnancy hypertension.
Design
Secondary analysis of CHIPS Trial cohort.
Setting
International randomised controlled trial (94 sites, 15 countries).
Population or sample
Of 987 CHIPS recruits, 481/566 (85.0%) women treated with antihypertensive therapy at randomisation. Of 981 (99.4%) women followed to delivery, 656/745 (88.1%) treated postrandomisation.
Methods
Logistic regression to compare outcomes among women who took methyldopa or labetalol, adjusted for the influence of baseline factors.
Main outcome measures
CHIPS primary (perinatal loss or high level neonatal care for >48 hours) and secondary (serious maternal complications) outcomes, birthweight <10th centile, severe maternal hypertension, pre‐eclampsia and delivery at <34 or <37 weeks.
Results
Methyldopa and labetalol were used commonly at randomisation (243/987, 24.6% and 238/987, 24.6%, respectively) and post‐randomisation (224/981, 22.8% and 433/981, 44.1%, respectively). Following adjusted analyses, methyldopa (versus labetalol) at randomisation was associated with fewer babies with birthweight <10th centile adjusted odds ratio (aOR) 0.48; 95% CI 0.20–0.87. Methyldopa (versus labetalol) postrandomisation was associated with fewer CHIPS primary outcomes (aOR 0.64; 95% CI 0.40–1.00), birthweight <10th centile (aOR 0.54; 95% CI 0.32–0.92), severe hypertension (aOR 0.51; 95% CI 0.31–0.83), pre‐eclampsia (aOR 0.55; 95% CI 0.36–0.85), and delivery at <34 weeks (aOR 0.53; 95% CI 0.29–0.96) or <37 weeks (aOR 0.55; 95% CI 0.35–0.85).
Conclusion
These nonrandomised comparisons are subject to residual confounding, but women treated with methyldopa (versus labetalol), particularly those with pre‐existing hypertension, may have had better outcomes.
Tweetable
There was no evidence that women treated with methyldopa versus labetalol had worse outcomes.
Tweetable
There was no evidence that women treated with methyldopa versus labetalol had worse outcomes.
Pregnancy in transgender men Thornton, Kimberley G S; Mattatall, Fiona
Canadian Medical Association journal (CMAJ),
08/2021, Letnik:
193, Številka:
33
Journal Article
Recenzirano
Odprti dostop
Thornton and Mattatall present several facts about pregnancy in transgender men. Among other things, testosterone is not a form of contraception, even in patients who are amenorrheic. Transgender men ...with a uterus are at risk of unplanned pregnancy. Limited literature suggests similarly high rates of unplanned pregnancies in this population as in ciswomen and similar uptake of all contraceptive options, from barrier methods to hormonal contraceptives. Oral contraceptives may be used concurrently with androgenic hormone therapy.
We present a study of the growth and reactivity of ultra-thin films of TiO2 grown on W(100). Three approaches to film growth are investigated, each resulting in films that show order in low-energy ...diffraction (LEED) and a low level of non-stoichiometry in X-ray photoelectron spectroscopy (XPS). H2O is used as a probe of the reactivity of the films, with changes in the Ti 2p and O 1s core levels being monitored by XPS. Evidence for the dissociation of H2O on the TiO2(110) ultra-thin film surface is adduced. These results are discussed with reference to related studies on native TiO2(110).
•Three methods for synthesis of ultra-thin rutile TiO2(110) films•Resulting films have been found to be equivalent.•Increase in adsorbed hydroxyls accompanies an increase in Ti3+ states.
To determine the extent to which a sample of NHS labor induction leaflets reflects evidence on labor induction.
Audit of labor induction patient information leaflets-local from WILL trial (When to ...Induce Labor to Limit risk in pregnancy hypertension) internal pilot sites or national-level available online.
Descriptive analysis
= 21 leaflets, 19 (one shared) in 20 WILL internal pilot sites and 2 NHS online according to NHS "Protocol on the Production of Patient Information" criteria: general information (including indications), why and how induction is offered (including success and alternatives), and potential benefits and harms.
All leaflets described an induction indication. Most leaflets (
= 18) mentioned induction location and 16 the potential for delays due to delivery suite workloads and competing clinical priorities. While 19 leaflets discussed membrane sweeping (17 as an induction alternative), only 4 leaflets mentioned balloon catheter as another mechanical method. Induction success (onset of active labor) was presented by a minority of leaflets (
= 7, 33%), as "frequent" or in the "majority", with "rare" or "occasional" failures. Benefits, harms and outcomes following induction were not compared with expectant care, but rather with spontaneous labor, such as for pain (
= 14, with nine stating more pain with induction). Potential benefits of induction were seldom described
= 7; including avoiding stillbirth (
= 4), but deemed to be likely. No leaflet stated vaginal birth was more likely following induction, but most stated Cesarean was not increased (
= 12); one leaflet stated that Cesarean risks were increased following induction. Women's satisfaction was rarely presented (
= 2).
Information provided to pregnant women regarding labor induction could be improved to better reflect women's choice between induction and expectant care, and the evidence upon which treatment recommendations are based. A multiple stakeholder-involved and evidence-informed process to update guidance is required.
Objective
To identify the most cost‐effective policy for detection and management of fetal macrosomia in late‐stage pregnancy.
Design
Health economic simulation model.
Setting
All English NHS ...antenatal services.
Population
Nulliparous women in the third trimester treated within the UK NHS.
Methods
A health economic simulation model was used to compare long‐term maternal–fetal health and cost outcomes for two detection strategies (universal ultrasound scanning at approximately 36 weeks of gestation versus selective ultrasound scanning), combined with three management strategies (planned caesarean section versus induction of labour versus expectant management) of suspected fetal macrosomia. Probabilities, costs and health outcomes were taken from literature.
Main outcome measures
Expected costs to the NHS and quality‐adjusted life‐years (QALYs) gained from each strategy, calculation of net benefit and hence identification of most cost‐effective strategy.
Results
Compared with selective ultrasound, universal ultrasound increased QALYs by 0.0038 (95% CI 0.0012–0.0076), but also costs by £123.50 (95% CI 99.6–149.9). Overall, the health gains were too small to justify the cost increase given current UK thresholds cost‐effective policy was selective ultrasound coupled with induction of labour where macrosomia was suspected.
Conclusions
The most cost‐effective policy for detection and management of fetal macrosomia is selective ultrasound scanning coupled with induction of labour for all suspected cases of macrosomia. Universal ultrasound scanning for macrosomia in late‐stage pregnancy is not cost‐effective.
Tweetable
Universal late‐pregnancy ultrasound screening for fetal macrosomia is not warranted.
Tweetable
Universal late‐pregnancy ultrasound screening for fetal macrosomia is not warranted.
Objective
Induction of labour at 39 weeks for nulliparous women aged 35 years and over may prevent stillbirths and does not increase caesarean births, so it may be popular. But the overall costs and ...benefits of such a policy have not been compared.
Design
A cost–utility analysis alongside a randomised controlled trial (the 35/39 trial).
Setting
Obstetric departments of 38 UK National Health Service hospitals and one UK primary‐care trust.
Population
Nulliparous women aged 35 years or over on their expected due date, with a singleton live fetus in a cephalic presentation.
Methods
Costs were estimated from the National Health Service and Personal Social Services perspective and quality‐adjusted life‐years (QALYs) were calculated based on patient responses to the EQ‐5D at baseline and 4 weeks.
Main outcome measures
Data on antenatal care, mode of delivery, analgesia in labour, method of induction, EQ‐5D (baseline and 4 weeks postnatal) and participant‐administered postnatal health resource use data were collected.
Results
The intervention was associated with a mean cost saving of £263 and a small additional gain in QALYs (though this was not statistically significant), even without considering any possible QALY gains from stillbirth prevention.
Conclusion
A policy of induction of labour at 39 weeks for women of advanced maternal age would save money.
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A policy of induction of labour at 39 weeks of gestation for women of advanced maternal age would save money.
Tweetable
A policy of induction of labour at 39 weeks of gestation for women of advanced maternal age would save money.
Surface X-ray diffraction has been employed to quantitatively determine the geometric structure of an X-ray-induced superhydrophilic rutile-TiO
(110)(1 × 1) surface. A scatterer, assumed to be ...oxygen, is found at a distance of 1.90 ± 0.02 Å above the five-fold-coordinated surface Ti atom, indicating surface hydroxylation. Two more oxygen atoms, situated further from the substrate, are also included to achieve the optimal agreement between experimental and simulated diffraction data. It is concluded that these latter scatterers are from water molecules, surface-localized through hydrogen bonding. Comparing this interfacial structure with previous studies suggests that the superhydophilicity of titania is most likely to be a result of the depletion of surface carbon contamination coupled to extensive surface hydroxylation.
Background
Women with a suspected large‐for‐dates fetus or a fetus with suspected macrosomia (birthweight greater than 4000 g) are at risk of operative birth or caesarean section. The baby is also at ...increased risk of shoulder dystocia and trauma, in particular fractures and brachial plexus injury. Induction of labour may reduce these risks by decreasing the birthweight, but may also lead to longer labours and an increased risk of caesarean section.
Objectives
To assess the effects of a policy of labour induction at or shortly before term (37 to 40 weeks) for suspected fetal macrosomia on the way of giving birth and maternal or perinatal morbidity.
Search methods
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2016), contacted trial authors and searched reference lists of retrieved studies.
Selection criteria
Randomised trials of induction of labour for suspected fetal macrosomia.
Data collection and analysis
Review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We contacted study authors for additional information. For key outcomes the quality of the evidence was assessed using the GRADE approach.
Main results
We included four trials, involving 1190 women. It was not possible to blind women and staff to the intervention, but for other 'Risk of bias' domains these studies were assessed as being at low or unclear risk of bias.
Compared to expectant management, there was no clear effect of induction of labour for suspected macrosomia on the risk of caesarean section (risk ratio (RR) 0.91, 95% confidence interval (CI) 0.76 to 1.09; 1190 women; four trials, moderate‐quality evidence) or instrumental delivery (RR 0.86, 95% CI 0.65 to 1.13; 1190 women; four trials, low‐quality evidence). Shoulder dystocia (RR 0.60, 95% CI 0.37 to 0.98; 1190 women; four trials, moderate‐quality evidence), and fracture (any) (RR 0.20, 95% CI 0.05 to 0.79; 1190 women; four studies, high‐quality evidence) were reduced in the induction of labour group. There were no clear differences between groups for brachial plexus injury (two events were reported in the control group in one trial, low‐quality evidence). There was no strong evidence of any difference between groups for measures of neonatal asphyxia; low five‐minute infant Apgar scores (less than seven) or low arterial cord blood pH (RR 1.51, 95% CI 0.25 to 9.02; 858 infants; two trials, low‐quality evidence; and, RR 1.01, 95% CI 0.46 to 2.22; 818 infants; one trial, moderate‐quality evidence, respectively).
Mean birthweight was lower in the induction group, but there was considerable heterogeneity between studies for this outcome (mean difference (MD) ‐178.03 g, 95% CI ‐315.26 to ‐40.81; 1190 infants; four studies; I2 = 89%). In one study with data for 818 women, third‐ and fourth‐degree perineal tears were increased in the induction group (RR 3.70, 95% CI 1.04 to 13.17).
For outcomes assessed using GRADE, we based our downgrading decisions on high risk of bias from lack of blinding and imprecision of effect estimates.
Authors' conclusions
Induction of labour for suspected fetal macrosomia has not been shown to alter the risk of brachial plexus injury, but the power of the included studies to show a difference for such a rare event is limited. Also antenatal estimates of fetal weight are often inaccurate so many women may be worried unnecessarily, and many inductions may not be needed. Nevertheless, induction of labour for suspected fetal macrosomia results in a lower mean birthweight, and fewer birth fractures and shoulder dystocia. The unexpected observation in the induction group of increased perineal damage, and the plausible, but of uncertain significance, observation of increased use of phototherapy, both in the largest trial, should also be kept in mind.
Findings from trials included in the review suggest that to prevent one fracture it would be necessary to induce labour in 60 women. Since induction of labour does not appear to alter the rate of caesarean delivery or instrumental delivery, it is likely to be popular with many women. In settings where obstetricians can be reasonably confident about their scan assessment of fetal weight, the advantages and disadvantages of induction at or near term for fetuses suspected of being macrosomic should be discussed with parents.
Although some parents and doctors may feel the evidence already justifies induction, others may justifiably disagree. Further trials of induction shortly before term for suspected fetal macrosomia are needed. Such trials should concentrate on refining the optimum gestation of induction, and improving the accuracy of the diagnosis of macrosomia.
BACKGROUND
The prevalence of congenital uterine anomalies in high-risk women is unclear, as several different diagnostic approaches have been applied to different groups of patients. This review aims ...to evaluate the prevalence of such anomalies in unselected populations and in women with infertility, including those undergoing IVF treatment, women with a history of miscarriage, women with infertility and recurrent miscarriage combined, and women with a history of preterm delivery.
METHODS
Searches of MEDLINE, EMBASE, Web of Science and the Cochrane register were performed. Study selection and data extraction were conducted independently by two reviewers. Studies were grouped into those that used 'optimal' and 'suboptimal' tests for uterine anomalies. Meta-analyses were performed to establish the prevalence of uterine anomalies and their subtypes within the various populations.
RESULTS
We identified 94 observational studies comprising 89 861 women. The prevalence of uterine anomalies diagnosed by optimal tests was 5.5% 95% confidence interval (CI), 3.5-8.5 in the unselected population, 8.0% (95% CI, 5.3-12) in infertile women, 13.3% (95% CI, 8.9-20.0) in those with a history of miscarriage and 24.5% (95% CI, 18.3-32.8) in those with miscarriage and infertility. Arcuate uterus is most common in the unselected population (3.9%; 95% CI, 2.1-7.1), and its prevalence is not increased in high-risk groups. In contrast, septate uterus is the most common anomaly in high-risk populations.
CONCLUSIONS
Women with a history of miscarriage or miscarriage and infertility have higher prevalence of congenital uterine anomalies compared with the unselected population.
Objective The Growth Restriction Intervention Trial found little difference in overall mortality or 2-year outcomes associated with immediate or deferred delivery following signs of impaired fetal ...health in the presence of growth restriction when the obstetrician was unsure whether to deliver. Because early childhood assessments have limited predictive value, we reevaluated them. Study Design Children were tested with standardized school-based evaluations of cognition, language, motor performance, and behavior. Analysis and interpretation were Bayesian. Results Of 376 babies, 302 (80%) had known outcome: either dead or evaluated at age 6-13 years. Numbers of children dead, or with severe disability: 21 (14%) immediate and 25 (17%) deferred groups. Among survivors, the mean (SD) cognition scores were 95 (15) and 96 (14); motor scores were 8. 9 (7. 0) and 8. 7 (6. 7); and parent-assessed behavior scores were 10. 5 (7. 1) and 10. 5 (6. 9), respectively, for the 2 groups. Conclusion Clinically significant differences between immediate and deferred delivery were not found.
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