Preterm labour and delivery: a genetic predisposition

Preterm delivery (PTD) complicates as many as 10% of pregnancies in the United States. Moreover, prematurity accounts for more than 70% of the consequent neonatal and infantile morbidity and mortality. Serious long-term complications include cerebral palsy, respiratory disease, blindness and deafness. Despite substantial basic scientific, translational and clinical investigation in recent years, the PTD rate (10%) and the low birthweight rate (7%) remain largely unchanged. Indeed, the very aetiology and pathophysiology of PTD remain unknown in most cases. In short, PTD continues to constitute a major clinical and public health challenge of the highest order, a circumstance further compounded by the controversy surrounding the efficacy of current therapeutic regimens. In an effort to address the relevant knowledge gap, we put forth the hypothesis that PTD results, at least in part, from a genetic predisposition. Evidence supporting the hypothesis that certain women have a genetic predisposition to deliver preterm is growing. Moreover, the discovery of a gene mutation predisposing to PTD would constitute a major breakthrough for future research into the biology, prediction, and therapy of preterm labour. Presented here is a discussion of the evidence to support a genetic predisposition to PTD, molecular techniques proposed to study the genetics of preterm labour, and plausible candidate genes that warrant further investigation.     

An analysis of the economic implications of elective induction of labour at term

Summary The economic implications of induction of labour were assessed by scrutinizing the case records of 228 women who participated in a randomized controlled trial. The trial group of 111 women who had elective induction of labour performed at between 39 and 40 weeks was compared with 117 controls who were managed expectantly until 41 weeks. The trial and control groups had induction rates in excess of 90 per cent and 45 per cent respectively. As approximately 50 per cent of the total hospital population was excluded from the study, however, the figures when expressed as a percentage of the hospital population would reflect induction rates of approximately 45 per cent and 23 per cent respectively for the alternative management approaches. The only economic resources used more frequently by the trial group were those associated with the induction procedure itself. The patients managed expectantly required significantly more subsequent visits to the antenatal clinic but the additional costs were insignificant when related to total expenditure. Induction of labour did not increase the use of paediatric facilities or prolong postpartum stay in hospital. The patients in the trial group had significantly fewer procedures performed on them during the hours between 1 a.m. and 9 a.m. but the changes were insufficient to lead to cost saving. It was concluded that decisions to induce labour or to manage patients conservatively had negligible economic consequences.     

Decision-making about mode of delivery after previous caesarean section: development and piloting of two computer-based decision aids

OBJECTIVE: To develop and pilot two computer-based decision aids to assist women with decision-making about mode of delivery after a previous caesarean section (CS), which could then be evaluated in a randomized-controlled trial. BACKGROUND: Women with a previous CS are faced with a decision between repeat elective CS and vaginal birth after caesarean. Research has shown that women may benefit from access to comprehensive information about the risks and benefits of the delivery options. DESIGN: A qualitative pilot study of two novel decision aids, an information program and a decision analysis program, which were developed by a multidisciplinary research team. PARTICIPANTS AND SETTING: 15 women who had recently given birth and had previously had a CS and 11 pregnant women with a previous CS, recruited from two UK hospitals. Women were interviewed and observed using the decision aids. RESULTS: Participants found both decision aids useful and informative. Most liked the computer-based format. Participants found the utility assessment of the decision analysis program acceptable although some had difficulty completing the tasks required. Following the pilot study improvements were made to expand the program content, the decision analysis program was accompanied by a training session and a website version of the information program was developed to allow repeat access. CONCLUSIONS: This pilot study was an essential step in the design of the decision aids and in establishing their acceptability and feasibility. In general, participating women viewed the decision aids as a welcome addition to routine antenatal care. A randomized trial has been conducted to establish the effectiveness and cost-effectiveness of the decision aids.     

Elective primary caesarean delivery: accuracy of administrative data

The caesarean delivery rate has become a commonly used measure intended to reflect the quality of obstetric care. At least 25% of all primary caesarean deliveries occur electively, i.e. to women who are not in labour. This study is intended to validate a previously published model designed to use ICD-9-CM codes to identify and categorise cases of elective primary caesarean delivery by their indication. ICD-9-CM codes were compared with diagnoses written in the medical record for all women without a prior caesarean who delivered in the same month in a single hospital to examine the accuracy of the codes for 12 potential elective primary caesarean indications derived by the published model: malpresentation; bleeding; genital herpes; severe hypertension; uterine scar; multiple gestation; macrosomia; unengaged fetus; maternal soft tissue conditions; other hypertensive conditions; prematurity; and chromosomal anomalies. Of 440 eligible women, a total of 26 (5.9%) had an elective primary caesarean by medical record review vs. [27] (6.1%) by administrative data. Using medical record data as the gold standard, the sensitivity, specificity, and accuracy of administrative data for the identification of elective primary caesarean delivery were 73.1%, 98.1%, and 96.6%, respectively. Administrative coding for all of the 12 conditions was highly specific, although wide variability existed in its sensitivity; its accuracy ranged between 83.9% and 100%. These results suggest that, despite widespread use of caesarean delivery rates obtained through administrative data, more experience is needed to determine which obstetric codes may be sufficiently specific, sensitive, or prevalent to serve a monitoring or surveillance function reflecting the quality of obstetrical care. The results support continued efforts to use administrative data to monitor elective primary caesarean delivery.     

Pregestational obesity,maternal morbidity and risk of caesarean delivery in a country in an advanced stage of obstetric transition

ObjectiveTo evaluate whether pregestational obesity is associated with the risk of caesarean section in pregnant women living in a country in an advanced stage of the obstetric transition.MethodsRetrospective cohort study. Data were collected from prenatal and hospital records. Pregestational obesity was defined as: body mass index, [weight(k)/height (m²)] ≥30, and caesarean sections were categorized as elective, emergency, or non-emergency/medically necessary. Biodemographic and sociodemographic characteristics, obstetric and perinatal pathologies, and maternal anthropometric variables were assessed. Chi-square and t-tests were used to compare qualitative and quantitative variables, respectively. Simple and adjusted generalized linear models were used to evaluate the association between pregestational obesity and caesarean delivery. Finally, population attributable risk was calculated. Data analysis was performed using STATA.v.14.0.Participants2309 pregnant women with a singleton pregnancy who gave birth at a public hospital in the Metropolitan Region of Santiago, Chile in 2015.ResultsThe prevalence of pregestational obesity was 21.4%, and the incidence of caesarean deliveries was 34.8% (33% of which corresponded to elective, 46% to emergency, and 21% to non-emergency/medically necessary caesarean deliveries). Pregestational obesity increased the risk of caesarean delivery (aRR = 1.46; 95%CI. [1.19–1.79] as well as the risk of elective (aRR = 1.74; 95%CI. [1.23–2.45]) and emergency caesarean delivery (aRR = 1.44; 95%CI. [1.03–2.00]). The population attributable risk of pregestational obesity for caesarean section was 32%.ConclusionGiven the significant association between pregestational obesity and caesarean delivery, it is necessary to develop strategies to decrease obesity among women of childbearing age in order to decrease obstetric intervention.     

The delivery record: a help to make the right decision

The delivery record is a key document for risk assessment and proper decision making at the right time during delivery. If it is exhaustive or badly presented, health workers see it as an administrative constraint, not as a help. The authors recall some principles regarding its form and contents. Its different parts are reviewed: administrative data, medical history, antenatal care, admission clinical examination, partograph, delivery, newborn, recent post-partum and exit examinations. An example of a delivery record used in Nouakchott is presented.     

Reproductive risk factors of fetal asphyxia at delivery: a population based analysis

To investigate reproductive maternal risk factors of intrapartum fetal asphyxia, we analyzed 556 women with singleton pregnancies complicated by intrapartum fetal asphyxia who gave birth at Kuopio University Hospital from January 1990 to December 1998. The general obstetric population (N=21746) was selected as the reference group and logistic regression analysis was used to identify independent reproductive risk factors. The incidence of intrapartum fetal asphyxia was 2.5%. Placental abruption, primiparity, alcohol use during pregnancy, low birth weight, preeclampsia, male fetuses, and small-for-gestational age births were independent risk factors of intrapartum asphyxia, with adjusted relative risks of 3.74, 3.10, 1.75, 1.57, 1.49, 1.48 and 1.33, respectively. Most cases of intrapartum fetal asphyxia occur in low-risk pregnancies and, therefore, risk screening in antenatal care cannot accurately predict which women will eventually need emergency care for fetal asphyxia.     

Physician labour supply in Canada: a cohort analysis

This paper employs a cohort analysis to examine the relative importance of different factors in explaining changes in the number of hours spent in direct patient care by Canadian general/family practitioners (GPs) over the period 1982-2003. Cohorts are defined by year of graduation from medical school. The results for male GPs indicate that there is little age effect on hours of direct patient care, especially among physicians aged 35-55, there is no strong cohort effect on hours of direct patient care, but there is a secular decline in hours of direct patient care over the period. The results for female GPs indicate that female physicians on average work fewer hours than male physicians, there is a clear age effect on hours of direct patient care, there is no strong cohort effect, and there has been little secular change in average hours of direct patient care. The changing behaviour of male GPs accounted for a greater proportion of the overall decline in hours of direct patient care from the 1980s through the mid-1990 s than did the growing proportion of female GPs in the physician stock.     

Intraoperative placement of the Copper T-380 intrauterine devices in women undergoing elective cesarean delivery: a pilot study

Background

The purpose of this pilot project was to test the feasibility of a technique designed to place a copper intrauterine device (IUD) through the hysterotomy incision of an elective cesarean delivery to minimize possible contamination and to guarantee that tailstrings were visible in the vagina for easy removal should complications occur.

Study Design

Women were monitored in the hospital for signs of infection or excessive blood loss. At the time of hospital discharge and at 2 and 6 weeks postpartum, they were examined to determine the status of the tailstrings. The position of the IUD was assessed by ultrasound at week 6.

Results

All seven of the subjects had successful placement. The sutures tied to the IUD strings were visible on vaginal examination in each case. The original tailstrings were visible in the vagina at 6 weeks and each IUD was fundally positioned.

Conclusion

Successful intraoperative placement of Copper T-380A IUDs through incision at the time of cesarean birth is possible.     

Reducing the risk: impact of a new curriculum on sexual risk-taking.

Reducing the Risk is a new sexuality education curriculum, based on social learning theory, social inoculation theory and cognitive-behavioral theory and employing explicit norms against unprotected sexual intercourse. In a quasi-experimental evaluation, this curriculum was implemented at 13 California high schools; 758 high school students assigned to treatment and control groups were surveyed before their exposure to the curriculum, immediately afterwards, six months later, and 18 months later. Among all participants, the program significantly increased participants' knowledge and parent-child communication about abstinence and contraception. Among students who had not initiated intercourse prior to the pretest, the curriculum significantly reduced the likelihood that they would have had intercourse by 18 months later. Reducing the Risk did not significantly affect frequency of sexual intercourse or use of birth control among sexually experienced students. Among all lower risk youths and among all students who had not initiated intercourse prior to their exposure to the curriculum, the curriculum appears to have significantly reduced unprotected intercourse, either by delaying the onset of intercourse, either by delaying the onset of intercourse or by increasing the use of contraceptives. Among the students not sexually active before participation in the program, effects seem to have extended across a variety of subgroups, including both whites and Latinos and lower risk and higher risk youths, but were particularly strong among lower risk youths and females.     

Reducing the risk of Legionnaires' disease

Many common aquatic bacteria like Legionella pneumophila are able to colonize man-made water systems. Poorly maintained systems or those that are seldom used provide ideal sites for growth and often also provide the means for aerosolizing the organism. Compounds leached from construction materials and the by-products of other organisms can be used as food by the Legionellaceae and can thus aid their growth. Keeping water systems clean and well serviced, keeping hot water at or above, and cold water below, recommended temperatures and additionally in cooling towers maintaining the required levels of biocide, will reduce or prevent the growth of legionellas. To be certain that the control measures are successful microbiological and chemical monitoring should be done. The results of this and the maintenance work undertaken should be kept in a log so that failures in treatment can be quickly seen and remedial action taken before any risk of infection arises. Adhering to these simple guidelines will go a long way to removing the risk of infection and will also provide systems that are more efficient and thus cheaper to run.     

Clinical decision support: managing quality in integrated delivery systems

Delivery of health care services under financial risk requires clinical decision support to ensure good and improving quality at efficient costs. This article reports our first five years of experience in developing clinical decision support methods at the University of Pennsylvania and Care Management Science Corporation.     

Reducing the risk of cardiovascular disease

In 1972 the Stanford Heart Disease Prevention Program launched a three-community field study. A multimedia campaign was conducted for two years in two California communities (Watsonville and Gilroy), in one of which (Watsonville) it was supplemented by an intensive-instruction program with high-risk subjects. A third community (Tracy) was used as a control. The campaigns were designed to increase participants' knowledge of the risk factors for cardiovascular disease, to change such risk-producing behavior as cigarette smoking, and to decrease the participants' dietary intake of calories, salt, sugar, saturated fat, and cholesterol. Results of a sample survey indicate that substantial gains in knowledge, in behavioral modification, and in the estimated risk of cardiovascular disease can be produced by both methods of intervention. The intensive-instruction program, when combined with the mass-medica campaign, emerged as the most effective for those participants who were initially evaluated to be at high risk. The results after two years of intervention are reported for effects on knowledge and behavioral change for the total participant samples and for the high-risk subsamples in each of the three communities.Dr. Maccoby is Janet M. Peck Professor of International Communication and Director of the Institute for Communication Research, Stanford University, Stanford, California 94305; he is also Co-Director of the Stanford Heart Disease Prevention Program. Dr. Farquhar is Professor of Medicine, Stanford University, and Director, Stanford Heart Disease Prevention Program. Dr. Wood is Adjunct Professor of Medicine, Stanford University, and Deputy Director, Stanford Heart Disease Prevention Program. Ms. Alexander is Media Director, Stanford Heart Disease Prevention Program. This research was supported by grant HL-14174 to the Stanford Specialized Center for Research in Arteriosclerosis and contract NIH-71-2161-L to the Stanford Lipid Research Clinic from the National Heart, Lung, and Blood Institute.     

Labour turnover in the British National Health Service: a local labour market analysis

This study uses regression analyses to examine the relationship between staff turnover in the British National Health Service (NHS) and a range of labour market, job and worker characteristics. Data relating to nine staff groups in up to 103 District Health Authority areas, and covering over 300,000 employees, form the basis for the analysis. In the regression analysis, two variables consistently emerge as significantly related to turnover across a range of staff groups: the size of the private nursing homes, and the pay of the staff group relative to the local average for comparable workers. The results suggest that staff groups of different skill levels each have distinct labour markets, and this needs to be recognised in the future design of human resources management policies.