A comparative study of the non-pneumatic anti-shock garment for the treatment of obstetric hemorrhage in Egypt

Objective

To assess the impact of the non-pneumatic anti-shock garment (NASG) on maternal outcome following severe obstetric hemorrhage.

Methods

A non-randomized pre-intervention/intervention study was conducted in 2 tertiary hospitals in Egypt from June 2006 to May 2008. Women with obstetric hemorrhage (estimated blood loss ≥ 1000 mL and/or ≥ 1 sign of shock [systolic blood pressure < 100 mm Hg or pulse > 100 beats per minute]) were treated with either a standardized protocol (pre-intervention) or a standardized protocol plus the NASG (intervention). The primary outcome was extreme adverse outcome (EAO), combining maternal mortality and severe morbidity (cardiac, respiratory, renal, or cerebral dysfunction). Secondary outcomes were measured blood loss, urine output, emergency hysterectomy, and (individually) mortality or morbidity. Analyses were performed to examine independent association of the NASG with EAO.

Results

Mean measured blood loss decreased from 379 mL pre-intervention to 253 mL in the intervention group (P < 0.01). In a multiple logistic regression model, the NASG was associated with reduced odds of EAO (odds ratio 0.38; 95% confidence interval, 0.17-0.85).

Conclusion

The NASG, in addition to standardized protocols at tertiary facilities for obstetric hemorrhage and shock, resulted in lower measured blood loss and reduced EAO.     

Body Mass Index and spontaneous miscarriage

Objective

We compared the incidence of spontaneous miscarriage in women categorised as obese, based on a Body Mass Index (BMI) >29.9 kg/m², with women in other BMI categories.

Study design

In a prospective observational study conducted in a university teaching hospital, women were enrolled at their convenience in the first trimester after a sonogram confirmed an ongoing singleton pregnancy with fetal heart activity present. Maternal height and weight were measured digitally and BMI calculated. Maternal body composition was measured by advanced bioelectrical impedance analysis.

Results

In 1200 women, the overall miscarriage rate was 2.8% (n = 33). The mean gestational age at enrolment was 9.9 weeks. In the obese category (n = 217), the miscarriage rate was 2.3% compared with 3.3% in the overweight category (n = 329), and 2.3% in the normal BMI group (n = 621). There was no difference in the mean body composition parameters, particularly fat mass parameters, between those women who miscarried and those who did not.

Conclusions

In women with sonographic evidence of fetal heart activity in the first trimester, the rate of spontaneous miscarriage is low and is not increased in women with BMI > 29.9 kg/m² compared to women in the normal BMI category.     

Cost-effectiveness of misoprostol and prenatal iron supplementation as maternal mortality interventions in home births in rural India

Objective

To determine the cost-effectiveness of prenatal iron supplementation and misoprostol use as interventions to prevent maternal mortality in home births in rural India.

Methods

A cost-effectiveness analysis depicted three hypothetical cohorts of 10 000 pregnant women delivering at home in rural India: one with no intervention, one receiving standard prenatal iron supplements, and 1 receiving 600 µg of misoprostol in the third stage of labor.

Results

Misoprostol used to prevent postpartum hemorrhage resulted in a 38% (95% CI, 5%-73%) decrease in maternal deaths, while prenatal iron supplementation resulted in a 5% (95% CI, 0%-47%) decrease. Misoprostol cost a median US $1401 (IQR US $1008-$1848) prenatal iron supplementation cost a median US $2241 (IQR No Lives Saved-$3882) per life saved compared with the standard care outcome.

Conclusion

Misoprostol is a cost-effective maternal mortality intervention for home births. Iron supplementation may be worthwhile to improve women's health, but it is uncertain whether it can prevent mortality after hemorrhage.     

Impact of a structured, hands-on, surgical skills training program for midwives performing perineal repair

Objective

To evaluate the effect of structured hands-on training for midwives performing perineal repair.

Methods

The training was performed using models and ox tongues. A total of 719 midwives completed an anonymous questionnaire prior to and immediately after training. Out of 300 participants, 151 completed a follow-up questionnaire 4 months later. Participants rated their knowledge and skills in the domains of instrument handling, knot tying, and subcuticular perineal repair.

Results

Compared with the situation before receiving the training, there was a significant increase in the use of the recommended evidence-based technique for perineal repair 4 months after training (28% vs 100%; P < 0.001), and in the mean scores for knowledge and skills in all the domains (P < 0.001). Participants believed that their patients were happier with the new technique.

Conclusions

Structured hands-on training is an effective way of improving the skills of midwives performing perineal repair and leads to modification of clinical practice.     

Meperidine versus valethamate bromide in shortening the duration of active labor

Objective

To compare the efficacy and safety of meperidine hydrochloride and valethamate bromide against placebo in shortening the duration of active labor.

Method

We randomly assigned 160 nulliparous women with a singleton pregnancy at term who needed induction of labor to one of 3 treatments: 50 mg of meperidine (n = 53), 16 mg of valethamate bromide (n = 53), or a normal saline solution as placebo (n = 54). All medications were given by slow intravenous infusion. Labor duration was the main outcome measure.

Results

The intervals between infusion and complete cervical dilation and between infusion and delivery were significantly reduced (P < 0.001 and P < 0.01) in the meperidine group (103.0 ± 64.5 minutes and 119.8 ± 70.2 minutes), in contrast to the placebo group (173.9 ± 74.8 minutes and 192.2 ± 82.8 minutes). However, differences were not significant between the 2 treatment groups (139.6 ± 63.1 minutes and 160.6 ± 71.9 minutes), or between the valethamate bromide and the placebo group.

Conclusion

Meperidine, but not valethamate bromide, significantly shortened the duration of active labor in nulliparous women with a singleton pregnancy at term.     

National maternal mortality ratio for Jordan, 2007-2008

Objective

To estimate the number of maternal deaths per 100 000 live births during 2007-2008 among Jordanian women; to identify the causes of maternal mortality; and to compare the results with those of the last report for 1995-1996.

Methods

Reproductive-age mortality study of maternal deaths among women aged 15-49 years in Jordan in 2007-2008.

Results

Among 1406 identified deaths of reproductive-aged women, 76 maternal deaths were identified out of 397 588 live births, for a maternal mortality ratio of 19.1 deaths per 100 000 live births. Forty-three (56.6%) deaths were attributable to hemorrhage, thrombosis and thromboembolism, and sepsis. Avoidable factors were present in 53.9% of women, 52.6% had substandard care, and 31.5% had 3 or fewer antenatal visits. Of those with available information on family planning, only 29.4% had ever used any form of contraception.

Conclusions

Maternal deaths in Jordan are declining. The maternal mortality ratio of 19.1 deaths per 100 000 live births reported for 2007-2008 showed a remarkable reduction of 53.9% achieved in the 12 years since the 1995-1996 report (a 4.5% annual reduction), which is approaching the 75% reduction recommended by Millennium Development Goal 5.     

Oral misoprostol versus intracervical prostaglandin E2 gel for active management of premature rupture of membranes at term

Objective

To compare the efficacy and safety of oral misoprostol with intracervical prostaglandin E2 (PGE2) gel for the active management of premature rupture of membranes (PROM) at term.

Methods

Women with pregnancies between 37 and 42 weeks presenting with PROM at term and a Bishop score of 5 or less were randomly assigned to receive either a 4-hourly oral dose of 50 µg of misoprostol up to a maximum of 3 doses or 2 applications of intracervical PGE2 gel at a 6-hour interval. Oxytocin was given if labor had not started after 12 hours.

Results

Twenty women in the misoprostol group (n = 31) delivered within 12 hours compared with 5 in the PGE2 group (n = 30) (P < 0.001). The induction-to-delivery interval in the misoprostol group was shorter than in the PGE2 gel group (615 min vs 1070 min; P < 0.001). The mode of delivery was comparable between the 2 groups (P = 0.821). Abnormalities in uterine contractions and neonatal outcomes were also comparable. The requirement for oxytocin was lower and patient satisfaction was better in the misoprostol group.

Conclusion

Oral misoprostol is a safe and efficacious alternative to intracervical PGE2 gel in the active management of PROM at term.     

Is acupuncture in addition to conventional medicine effective as pain treatment for endometriosis?: A randomised controlled cross-over trial

Objective

The aim of the study was to examine whether acupuncture is an effective additional pain treatment for endometriosis.

Study design

One hundred and one women aged 20-40 years participated and were randomised into two groups, each receiving two units of 10 acupuncture treatments, twice a week over a period of five weeks. Group 1 (n = 47) received verum-acupuncture during the first series, and group 2 (n = 54) received non-specific acupuncture. After the first unit of 10 treatments, an observation period of at least two menstruation cycles was set, followed by a second unit, according to a cross-over design. Prior to the study (during a two-week run-in period) the patients’ actual pain intensity was surveyed. Throughout the study period, participants were asked to keep a ‘pain protocol’, in which they defined and recorded their pain according to the 10-point visual analogue scale (VAS).

Results

Eighty-three out of a total of 101 patients finished the study. Group 1 showed a significant reduction of pain intensity after the first 10 treatments. In comparison, group 2 showed significant pain relief only after the cross-over.

Conclusion

Acupuncture treatment on specific acupuncture points appears to be an effective pain treatment for endometriosis, but this has to be confirmed in further study.     

The impact of anesthesia and mode of delivery on the urinary bladder in the postdelivery period

Objective

To evaluate the effect of regional anesthesia and mode of delivery on the function of the urinary bladder. The primary outcome was the time taken for urinary bladder sensation to return following various modes of delivery and analgesia/anesthesia. The secondary outcome was the volume of urine present in the bladder when sensation returned.

Methods

The study was conducted at the Birmingham Women's Foundation Trust, Birmingham, UK. A total of 120 postnatal patients were studied between January 2007 and March 2008. The volume of urine in the bladder when sensation first returned was measured by release of a clamp for women fitted with an indwelling catheter, and/or estimated using ultrasound.

Results

The median times for sensation to return to the bladder in patients who had a vaginal delivery without epidural analgesia, vaginal delivery with epidural analgesia, and after elective cesarean delivery under spinal anesthesia were 122 minutes (IQR, 112-136 minutes), 234 minutes (IQR, 202-291 minutes), and 374 minutes (IQR, 311-425 minutes), respectively. The median urine volumes were 144 mL (IQR, 112-192 mL), 200 mL (IQR, 136-336 mL), and 152.5 mL (IQR, 125-270 mL), respectively.

Conclusion

These results should be taken into consideration when formulating a postdelivery bladder care protocol.     

A qualitative study of the experiences of women who are obese and pregnant in the UK

Objective

to explore the experiences related to obesity in women with a body mass index (BMI)>35 kg/m² during the childbearing process.

Design

a qualitative design was used. Data were collected using semi-structured interviews and field notes. Women were interviewed in the third trimester of pregnancy and between three and nine weeks after the birth. Transcribed data were analysed using framework analysis methods.

Setting

one maternity service in the North of England.

Participants

19 women with BMI>35 kg/m².

Findings

these women highlighted their feelings of humiliation, and the stigma associated with being pregnant, when obese. Interactions with health professionals and the general public reinforced their discomfort about their size. The high-risk status of their pregnancy increased the medicalisation of their pregnancy. The ultrasound scan was a significant source of distress if difficulties imaging the fetus were not clearly explained during the procedure.

Key conclusions

pregnant women who are obese are sensitive of their size. The interactions with health professionals and others that they encounter may increase distress.

Implications for practice

health professionals should be more aware of the psychological implications of being obese. Communication strategies about care should be clear and honest, and conveyed in a sensitive manner. Written comments related to size on ‘hand-held’ notes should be explained at the time of writing.     

Efficacy of desmopressin (Minirin) in the treatment of nocturia: a double-blind placebo-controlled study in women

Objective

The purpose of this study was to investigate the efficacy and safety of oral desmopressin in the treatment of nocturia in women.

Study design

Women aged 18 years or older with nocturia (≥2 voids per night with a nocturia index score >1) received desmopressin (0.1 mg, 0.2 mg, or 0.4 mg) during a 3-week dose-titration period. After a 1-week washout period, patients who responded in this period received desmopressin or placebo in a double-blind fashion for 3 weeks.

Results

In double-blind phase, 144 patients were randomly assigned to groups (desmopressin, n = 72; placebo, n = 72). For desmopressin, 33 (46%) patients had a 50% or greater reduction in nocturnal voids against baseline levels compared with 5 (7%) patients receiving placebo (P<.0001). The mean number of nocturnal voids, duration of sleep until the first nocturnal void, nocturnal diuresis, and ratios of nocturnal per 24 hours and nocturnal per daytime urine volumes changed significantly in favor of desmopressin versus placebo (P<.0001). In the dose-titration phase headache (22%), nausea (8%), and hyponatremia (6%) were reported. Two deaths occurred, although neither could be directly associated with the study drug.

Conclusion

Oral desmopressin is an effective and well-tolerated treatment for nocturia in women.     

Using audits to reduce the incidence of uterine rupture in a Malawian district hospital

Objectives

To improve obstetric care and reduce the incidence of uterine rupture through the use of audits.

Methods

Data were collected from medical records and from questioning women who sustained uterine rupture over a 12-month period in Thyolo District Hospital, Malawi. Audit sessions were performed every 2-3 weeks for the first 3 months with relevant members of the hospital staff, after which an extended audit was held with input from two external expert obstetricians. Cases were also audited by the principal investigator for delays in referral, diagnosis, and treatment.

Results

Thirty-five cases of uterine rupture were diagnosed at the facility during the study period. Sixteen ruptures were diagnosed during the first 3 months, an incidence of 19.2 per 1000 deliveries. Following audit and implementation of recommendations, the incidence of uterine rupture decreased by 68% (OR 0.32; 95% CI, 0.16-0.63) to 6.1 per 1000 deliveries over the next 9 months. The overall case fatality rate was 11.4%, and the perinatal mortality rate was 829 per 1000 live births.

Conclusions

Audit is an inexpensive, appropriate, and effective intervention to improve the quality of facility-based maternal care and decrease the incidence of uterine rupture in low-resource settings. Ensuring constructive self-criticism, continuous professional learning, and good participation by district health managers in audit sessions may be important requirements for their success.     

Transabdominal amnioinfusion in preterm premature rupture of membranes

Objective

To evaluate the effect of transabdominal amnioinfusion on prolongation of pregnancy, and maternal and neonatal outcomes in preterm premature rupture of membranes (pPROM).

Methods

We conducted a prospective randomized controlled study of women with pPROM during singleton live pregnancy—between 26 and 33 + 6 weeks—whose amniotic fluid index (AFI) was less than the 5th percentile. The study group underwent transabdominal amnioinfusion at admission and then weekly if their AFI fell below the 5th percentile again. The control group received expectant management.

Results

The difference in the mean interval from pPROM to delivery between the groups was not statistically significant. Neonatal and maternal outcomes were significantly improved in the study group compared with the control group (fetal distress [10% vs 37%]; early neonatal sepsis [17% vs 63%]; neonatal mortality [17% vs 63%]; spontaneous delivery [83% vs 53%]; and postpartum sepsis [7% vs 33%]).

Conclusion

Transabdominal amnioinfusion reduced fetal distress, early neonatal sepsis, and neonatal mortality. In the study group, more participants delivered spontaneously and there were fewer cases of postpartum sepsis, although the pPROM-delivery interval was not increased.     

Community-based distribution of misoprostol for treatment or prevention of postpartum hemorrhage: Cost-effectiveness, mortality, and morbidity reduction analysis

Objective

To compare the cost-effectiveness of community-based distribution of misoprostol for prevention with misoprostol for treatment of postpartum hemorrhage (PPH).

Methods

A Monte Carlo simulation depicted mortality and anemia-related morbidity attributable to PPH among 3 scenarios of 10 000 women delivering at home in rural India: (1) standard management; (2) standard management plus 800 µg of sublingual misoprostol for PPH treatment; and (3) standard management plus 600 µg of prophylactic oral misoprostol. The model included costs of drugs, birth attendant training, and transport for women who did not respond to misoprostol.

Results

Misoprostol lowered mortality by 70% and 81% in scenarios 2 and 3, respectively. Scenarios 2 and 3 raise costs by 6% and 35%, respectively. Incremental cost per disability-adjusted life year (DALY) saved is estimated at $6 and $170, respectively.

Conclusion

Both interventions were more effective at decreasing mortality and anemia than standard management. The most efficient scale-up plan would focus initially on increasing coverage with the treatment strategy ($6 per DALY).     

Dienogest in the treatment of endometriosis-associated pelvic pain: a 12-week, randomized, double-blind, placebo-controlled study

Objective

To investigate the efficacy and safety of oral dienogest 2 mg compared with placebo in the treatment of endometriosis-associated pelvic pain (EAPP).

Study design

This was a 12-week, randomized, double-blind, placebo-controlled, multicenter (n = 33) study in Germany, Italy, and Ukraine of 198 women aged 18-45 years with laparoscopically confirmed endometriosis and EAPP score ≥30 mm on a visual analog scale (VAS). Dienogest 2 mg or placebo was administered orally once daily. The primary efficacy variable was absolute change in EAPP from baseline to Week 12, as determined by the target variables of change in VAS score and change in intake of supportive analgesic medication (ibuprofen) for pelvic pain.

Results

Mean reductions in VAS score between baseline and Week 12 in the full analysis set were 27.4 mm and 15.1 mm in the dienogest and placebo groups, respectively—a significant score difference of 12.3 mm in favor of dienogest (P < 0.0001). Changes in intake of supportive analgesic medication were modest in both groups. The primary efficacy measure of absolute change in EAPP demonstrated the superiority of dienogest over placebo. Dienogest was generally well tolerated and few adverse events were associated with therapy.

Conclusions

Dienogest at a dose of 2 mg daily for 12 weeks was significantly more effective than placebo for reducing EAPP.     

The evolution of oocyte donation in China

Objective

To review the experience with and clinical outcomes for recipients of embryos from oocytes donated under different regulatory standards in China. Initially, the oocytes were provided by one of the patient's consanguineous sisters. Then, the oocytes were obtained from another patient treated with assisted reproduction techniques (ART). Presently, oocytes thus produced are cryopreserved for at least 6 months before transfer.

Methods

The records from all women treated with ART at First Affiliated Hospital of Zhengzhou University since 2001 were reviewed and the pregnancy rates and clinical outcomes were determined for each of the 3 periods.

Results

In the second period, the mean implantation and clinical pregnancy rates were significantly higher for the 22 oocyte recipients than for their donors. In the third period, the rates for the 56 recipients were compared with the 78 other regular ART patients fertilized with their own oocytes. There were 40 live births for 32 of the recipients over 28 cycles, and the rates of implantation and clinical pregnancy were much higher for the recipients than for the other ART patients (P < 0.001).

Conclusion

Using freshly donated eggs yields a higher pregnancy rate but there is a risk of infectious disease. Using frozen oocytes can significantly decrease this risk but implantation rates are lower.     

Assessment of ischemia-modified albumin level in patients with recurrent pregnancy loss during the first trimester

Objective

The finding that ischemia-modified albumin (IMA) is increased in pre-eclamptic pregnancy suggests a role for IMA as a potential biomarker for abnormal placental development related to miscarriage. This study was undertaken to evaluate IMA levels in women with recurrent pregnancy loss (RPL).

Study design

This case-control study was performed between March 2008 and September 2009, at the Department of Obstetrics and Gynecology of Meram School of Medicine. Serum IMA and albumin concentrations were assessed in 43 women with a history of two or more unexplained first trimester miscarriages (group 1), and 42 healthy pregnant women (group 2) in the first trimester. IMA, adjusted IMA and albumin concentrations were compared between the groups. Statistical analysis was performed using Student's t-test and Mann-Whitney U test.

Results

IMA and adjusted IMA levels were significantly higher in women with RPL (1.11 + 0.08 and 1.09 + 0.09, respectively) compared to women in group 2 (0.88 + 0.10 and 0.88 + 0.11, respectively). Albumin levels in group 1 were significantly lower compared with group 2. There was a negative correlation between IMAand albumin levels in each group.

Conclusion

Maternal IMA levels appear to be elevated in women with early RPL. This finding may suggest that an abnormally high hypoxic intrauterine environment may be associated with abnormal placental development that contributes to early miscarriage.     

A pilot randomized controlled trial of controlled cord traction to reduce postpartum blood loss

Objective

To evaluate whether controlled cord traction (CCT) for management of the third stage of labor reduced postpartum blood loss compared with a “hands-off” management protocol.

Methods

Women with imminent vaginal delivery were randomly assigned to either a CCT group or a hands-off group. The women received prophylactic oxytocin. The primary outcome was blood loss during the third stage of labor.

Results

In total, 103 women were allocated to the CCT group and 101 were allocated to the hands-off group. Median blood loss in the CCT group and the hands-off group was 282.0 mL and 310.2 mL, respectively. The difference in blood loss (- 28.2 mL) was not significant (95% confidence interval, - 92.3 to 35.9; P = 0.126). Blood collection in the hands-off group took 1.2 minutes longer than in the CCT group, which may have contributed to this difference.

Conclusion

CCT may reduce postpartum blood loss. The present findings support conducting a large trial to determine whether CCT can prevent postpartum hemorrhage.