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Biomedical subjects

S A Walkinshaw

Publications and source records attributed to S A Walkinshaw.

At least 19 recordsLinked to original sources
PubMed2003

Treatments for gestational diabetes and impaired glucose tolerance in pregnancy.

BACKGROUND: Gestational diabetes and impaired glucose tolerance (IGT) in pregnancy affects between 3 and 6% of all pregnancies and both have been associated with pregnancy complications. A lack of conclusive evidence has led clinicians to equate the risk of adverse perinatal outcome with pre-existing diabetes. Consequently, women are often intensively managed with increased obstetric monitoring, dietary regulation, and in some cases insulin therapy. However, there has been no sound evidence base to support intensive treatment. The key issue for clinicians and consumers is whether treatment of gestational diabetes and IGT will improve perinatal outcome. OBJECTIVES: The objective of this review was to compare alternative policies of care for women with gestational diabetes and IGT in pregnancy. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register (12 September 2002) and the bibliographies of relevant papers. The Cochrane Central Register of Controlled Trials was also searched (The Cochrane Library, Issue 3, 2002). SELECTION CRITERIA: Randomised controlled trials comparing alternative management strategies for women with gestational diabetes and IGT in pregnancy. DATA COLLECTION AND ANALYSIS: Quality was assessed according to the criteria defined by the Cochrane Reviewers' Handbook. Data were extracted and checked independently by two reviewers. Any disagreements were resolved through discussion with the third reviewer. MAIN RESULTS: Three studies with a total of 223 women were included. All three included studies involved women with IGT. No trials reporting treatments for gestational diabetes met the criteria. There are insufficient data for any reliable conclusions about the effect of treatments for IGT on perinatal outcome. The difference in abdominal operative delivery rates is not statistically significant (relative risk (RR) 0.86, 95% confidence interval 0.51 to 1.45) and the effect on special care baby unit admission is also not significant (RR 0.49, 95% confidence interval (CI) 0.19 to 1.24). Reduction in birthweight greater than 90th centile (RR 0.55, 95% CI 0.19 to 1.61) was not found to be significant. This review suggests that an interventionist policy of treatment may be associated with a reduced risk of neonatal hypoglycaemia (RR 0.25, 95% CI 0.07 to 0.86). No other statistically significant differences were detected. A number of outcomes are only reported by one study resulting in a small sample and wide confidence intervals. REVIEWER'S CONCLUSIONS: There are insufficient data for any reliable conclusions about the effects of treatments for impaired glucose tolerance on perinatal outcome.

Blood Glucose↗
PubMed2003

Term Breech Trial.

Explore the source record for details and available documents.

Breech Presentation↗
PubMed2001

Extracranial vascular malformation: value of antenatal and postnatal MRI in management.

We report a case where fetal MRI using a low-field-strength magnet (0.5 T) accurately confirmed a large extracranial vascular malformation, which was suspected on antenatal US. Fetal MRI enabled better counselling of the parents and allowed suitable plans to be made regarding method of delivery and early management of the neonate. To our knowledge this is the first case of an extracranial vascular malformation imaged using fetal MRI.

Arteriovenous Malformations↗
PubMed2001

Reducing postnatal pain from perineal tears by using lignocaine gel: a double-blind randomized trial.

BACKGROUND: Perineal pain is one of the most common causes of maternal morbidity in the early puerperium. Several randomized trials have shown that topical application of local anesthetics is effective in reducing postepisiotomy pain, but no randomized study has assessed the efficacy of local anesthetics for other perineal trauma. This study investigated if topically applied 2 percent lignocaine gel was an effective treatment for this group of women. METHODS: A double-blind placebo controlled trial was conducted in a regional teaching hospital in the northwest of England. One hundred and forty-nine women who had sustained a first- or second-degree tear were allocated by sealed envelopes to the lignocaine gel or placebo group. The primary outcome was self-reported pain at 24 hours postdelivery as measured on a numerical rating scale (pain score). Secondary outcomes included pain scores at 48 hours, the need for oral analgesia, and maternal satisfaction. Based on a pilot study, we calculated that 128 women were required to detect a 25 percent difference in pain scores between the two groups with 80 percent power (alpha = 0.05). The pain scores of women in each trial arm were compared using the unpaired t test and 95 percent confidence intervals. RESULTS: Women using lignocaine gel had lower average pain scores, although this only reached statistical significance at 48 hours after delivery (p = 0.023). In general, women liked using the study gel. No difference was found in consumption of oral analgesia. CONCLUSIONS: This study suggested that lignocaine gel may be effective on the second postnatal day. Further research is required to assess the optimum timing of this intervention and the population that would most benefit from its use.

Administration, Topical↗
PubMed2001

Computerised antenatal fetal heart rate recordings between 24 and 28 weeks of gestation.

OBJECTIVE: To assess computerised fetal heart rate recordings between 24 and 28 weeks of gestation for gestation related differences. DESIGN: Prospective, cross sectional observational study. SETTING: Liverpool Women's Hospital. POPULATION: 112 women: 28 at 27 weeks, 30 at 26 weeks, 27 at 25 weeks and 27 at 24 weeks of gestation, respectively. METHODS: Fetal heart recordings of 60 minutes duration were performed once in each pregnancy using the System 8000 fetal heart rate programme (System 8000, Oxford Sonicaid Ltd, Chichester, UK). For each gestational age, records were analysed for short term variation, basal heart rate, accelerations and time spent in high episodes. RESULTS: The mean short term variation increased with gestation (P = 0.05). No record had a short term variation <4 msecs. There was no relationship between heart rate and increasing gestation. The mean number of accelerations per record increased with increasing gestation (P < 0.01). 20% of recordings showed no accelerations > 15 bpm. The mean duration spent in episodes of high variation increased with gestation (P = 0.05). 13% of recordings showed no time spent in high episodes. All fetuses had normal outcomes at delivery. CONCLUSIONS: Absence of episodes of high variation or absence of accelerations is not an abnormal finding at lower gestations. The standard threshold of 4 msecs for short term variation appears to remain valid at lower gestations. These differences should be considered when using computerised CTG analysis at early gestations.

Adolescent↗
PubMed2000

Prenatal detection of trisomy 21: combined experience of two British hospitals.

A retrospective study was performed to determine the detection rate of trisomy 21 in two British hospitals using a combination of: (1) second trimester serum screening with maternal age, alphaFP and hCG; (2) karyotyping for raised maternal age and high background risk of aneuploidy; and (3) second trimester fetal anomaly ultrasonography at 18-22 week gestation. 36-410 women with a median age of 27 years were studied. Trisomy 21 detected by the combination of methods in both hospitals was compared with the actual number of pregnancies affected by trisomy 21, to determine the detection rate. Serum screening as the backbone of the service detected 31/48 (65%) trisomy 21 affected pregnancies. Karyotyping for maternal age and previous aneuploidy detected eight trisomy 21 affected pregnancies, and second trimester ultrasound a further six, giving a total detection rate of 45/56 (80%). Thus, the detection rate of trisomy 21 in our population is 65% by serum screening alone. This is similar to demonstration projects, but the addition of second trimester ultrasonography and karyotyping for maternal age and prior risk, contributes further to improve the overall sensitivity to 80%. The invasive procedure rate was 4.8% of all women.

Adult↗
PubMed2000

Dietary regulation for 'gestational diabetes'.

BACKGROUND: Impaired glucose metabolism in pregnancy may be associated with adverse pregnancy outcomes. Primary dietary therapy is used in the management of diabetes, including gestational diabetes. OBJECTIVES: The objective of this review was to assess the effects of primary dietary therapy in women identified as having gestational diabetes on fetal growth and neonatal outcomes. SEARCH STRATEGY: I searched the Cochrane Pregnancy and Childbirth Group trials register. SELECTION CRITERIA: Randomised trials of primary dietary therapy compared with no specific treatment in pregnant women with abnormal glucose tolerance test results. DATA COLLECTION AND ANALYSIS: Trial quality was assessed. MAIN RESULTS: Four studies involving 612 women were included. Trials were small and of variable quality. No differences were detected between primary dietary therapy and no primary dietary therapy for birthweight greater than 4000 grams (odds ratio 0.78, 95% confidence interval 0.45 to 1.35) or caesarean deliveries (odds ratio 0.97, 95% confidence interval 0.65 to 1.44). REVIEWER'S CONCLUSIONS: There is not enough evidence to evaluate the use of primary dietary therapy for women who show impaired glucose metabolism during pregnancy.

Diabetes, Gestational↗
PubMed2000

Very tight versus tight control for diabetes in pregnancy.

BACKGROUND: Pregnancies complicated by pre-existing insulin dependent diabetes are high risk for a number of poor pregnancy and neonatal outcomes. OBJECTIVES: The objective of this review was to assess the effects of very tight glycaemic control in established insulin dependence. SEARCH STRATEGY: The Cochrane Pregnancy and Childbirth Group trials register was searched. SELECTION CRITERIA: Randomised trials comparing very tight with tight control of diabetes in pregnancy. DATA COLLECTION AND ANALYSIS: One reviewer assessed trial quality and extracted data. MAIN RESULTS: Two trials involving 182 women were involved. The two trials were difficult to compare. Maternal hypoglycaemia was more common among women whose diabetic control was very tight compared to tight control (odds ratio 25.96, 95% confidence interval 4.91 to 137.26) based on one trial. There was no difference detected in perinatal outcome between the groups. REVIEWER'S CONCLUSIONS: There appears to be no clear evidence of benefit from very tight glycaemic control for pregnant diabetic women. Since very strict control may have a substantial impact on lifestyle, this suggests caution in advising such a degree of control.

Blood Glucose↗
PubMed1999

A prospective study of women's views of factors contributing to a positive birth experience.

OBJECTIVE: To explore the aspects of a woman's childbirth experience which she perceived as being important. DESIGN: As part of a large randomised trial, which assessed the timing of intervention in prolonged labour, women's views were explored using a specifically-designed questionnaire. The questionnaire, which was administered on the second postnatal day, incorporated a rating scale followed by an open question. The responses to the open question are presented in this paper. SETTING: Regional teaching hospital in the north west of England. SAMPLE: 615 primigravid women received a copy of the questionnaire. Of the 519 women who returned the questionnaire, 412 women answered the relevant section, the findings of which are presented in this paper. ANALYSIS: The responses to the open-ended question were analysed by the generation of themes from the most frequently occurring responses. MAIN FINDINGS: The main themes which emerged were support, information, intervention, decision making, control, pain relief and trial participation. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Most women are able to identify important contributors to a positive intrapartum experience. Midwives have an important role in identifying these contributors and supporting women to fulfil their individual needs.

Adult↗
PubMed1999

Managing labor using partograms with different action lines: a prospective study of women's views.

BACKGROUND: The precise timing of medical intervention for women in prolonged labor is the subject of considerable debate. The partogram action line is a tool to assist practitioners in the correct diagnosis of prolonged labor. Despite its widespread use, the precise timing of the action line has not been rigorously studied, and women's views have rarely been sought. The aim of this study was to assess the effect on maternal satisfaction of managing labor using partograms with action lines drawn at 2, 3, or 4 hours to the right of the alert line. METHODS: As part of a large pilot randomized controlled trial, women's views were explored using a specifically designed questionnaire that was completed by 615 primiparas 2 days after giving birth. The quantifiable data were analyzed by comparing means using ANOVA followed by the Scheffe test. RESULTS: Women in the 2-hour arm were significantly more satisfied than those in the other two arms (p < 0.001), despite having the most obstetric intervention. CONCLUSIONS: For women in prolonged labor, obstetric intervention can be an acceptable or even favorable option. Midwives and obstetricians need to provide labor management that takes into account the preferences of the women to whom they give care.

Adult↗
PubMed1998

Intraumbilical oxytocin for the management of retained placenta: a randomized controlled trial.

OBJECTIVE: To evaluate the ability of intraumbilical oxytocin injection as a treatment for retained placenta after vaginal delivery to reduce the incidence of manual removal and postpartum hemorrhage. METHODS: A randomized controlled trial was set up in a university and a district general hospital. We recruited 81 women with singleton pregnancies who underwent vaginal delivery and who failed to deliver the placenta after 20 minutes of active management of the third stage of labor. Study subjects were randomized to receive either 1) an intraumbilical injection of oxytocin (20 IU in 20 mL of saline); 2) an intraumbilical injection of saline (20 mL); or 3) no treatment. Outcome measures were expulsion of the placenta within 45 minutes of delivery, need for manual removal of the placenta under anesthesia, and postpartum hemorrhage (defined as a blood loss greater than 500 mL). RESULTS: Women given an intraumbilical injection of oxytocin had a significant increase in spontaneous expulsion of the placenta within 45 minutes of delivery and fewer manual removals of the placenta, compared with women without treatment (odds ratio [OR] 11.6, 99% confidence interval [CI] 1.4, 272.8; and OR 7.4, 99% CI 1.1, 86.5; respectively). When women given intraumbilical oxytocin were compared with women given only intraumbilical saline, the difference was not statistically significant (OR 6.6, 99% CI 0.9, 77.2 for spontaneous expulsion of the placenta; and OR 4.7, 99% CI 0.8, 39.5 for manual removal). There was no significant difference in the incidence of spontaneous expulsion and manual removal of the placenta between women given intraumbilical saline injection and women without treatment (OR 1.8, 99% CI 0.1, 53.9; and OR 1.6, 99% CI 0.1, 22.4; respectively). CONCLUSION: The results of our study suggest a clinically important beneficial effect of intraumbilical oxytocin injection in the management of retained placenta.

Adult↗
PubMed1998

Can midwives reduce postpartum psychological morbidity? A randomized trial.

BACKGROUND: Women who are traumatized after childbirth find that listening, support, counseling, understanding, and explanation are the most useful treatments. However, little evidence is available from randomized trials of the relative efficacy of these treatments as a positive postnatal intervention. This study purpose was to examine if postnatal "debriefing" by midwives can reduce psychological morbidity after childbirth. METHOD: A randomized trial was conducted in a regional teaching hospital in northwest England. One hundred and twenty postnatal primigravidas were allocated by sealed envelopes to receive the debriefing intervention (n = 56) or not (n = 58). The main outcome measure was the Hospital Anxiety and Depression (HAD) scale administered by postal questionnaire 3 weeks after delivery. The proportion of women in each group with anxiety and depression scores of more than 10 points were compared, using odds ratios and 95% confidence intervals. RESULTS: Women who received the intervention were less likely to have high anxiety and depression scores after delivery when compared with the control group. CONCLUSIONS: The support, counseling, understanding, and explanation given to women by midwives in the postnatal period provides benefits to psychological well-being. Maternity units have a responsibility to develop a service that offers all women the option of attending a session to discuss their labor.

Adult↗
PubMed1998

Computerised analysis of fetal heart rate recordings in patients with diabetes mellitus: the Dawes-Redman criteria may not be valid indicators of fetal well-being.

Computerised cardiotocograph analysis has been used in our medical antenatal clinic for women with insulin dependent diabetes mellitus for five years. We had observed that many of the patients failed the computer criteria and wished to examine this finding in more detail. All cardiotocographs from 40 pregnant women with insulin dependent diabetes mellitus who delivered between 1992 and 1995 were reviewed. The number of traces failing the criteria were calculated. Outcome was compared between patients with a normal trace and those with an abnormal trace. 233 recordings were examined. 30.5% of antenatal CTGs failed the criteria because of absent high episodes of variation (a parameter which is a specific marker of fetal well-being). After excluding repeat traces on all patients a sample of 26 traces was examined. 34.6% of these had failed because of absent high episodes of variation. Both these figures are significantly higher than the published normal values. There was no apparent difference in neonatal outcome between women whose trace had failed (9) and those with a normal trace (17). We suggest that the normal values of criteria used to analyse computerised CTGs may not be valid when applied to fetuses of women with diabetes mellitus.

Cardiotocography↗
PubMed1998

The fetal outcome in pregnancies with isolated reduced amniotic fluid volume in the third trimester.

Our aim was to assess the outcome of pregnancies where oligohydramnios, defined by a published gestational reference range for amniotic fluid index, was the only abnormal finding at third trimester scan, and all other ultrasound parameters including biometry were within normal limits at initial scan. A retrospective case-control study was performed at The Liverpool Maternity Hospital. 103 pregnancies with reduced amniotic fluid index in the third trimester and apparently normal fetal growth profile ultrasonographically were identified from ultrasound reports throughout 1993. Pregnancies in the third trimester with normal amniotic fluid index on index scan were also identified from these reports and 103 were matched for parity, gestational age at delivery, mode of onset of labour, presentation at labour and medical conditions. Exclusion criteria were ruptured membranes, fetal abnormalities, estimated fetal weight below the fifth centile at index scan and multiple pregnancies. The outcome criteria were birthweight, Apgar scores at delivery, induction and emergency delivery for fetal reasons and admission to Neonatal Intensive Care Unit. Statistical analysis was performed by Fisher's exact test and Gart's odds ratio. Compared with controls, pregnancies in the reduced liquor group had a higher number of babies below the 5th centile (odds ratio 5.2, 95% confidence interval 1.6 to 22), a higher risk of induction for fetal reasons (odds ratio 34.4, 95% confidence interval 5.35 to 1425.5) and admission to Neonatal Intensive Care Unit (odds ratio 9.77, 95% confidence interval 1.3 to 432). Any observed difference in the need for emergency delivery due to fetal reasons was not clinically significant (odds ratio 2.16, 95% confidence interval 0.77 to 6.6) The definition used for oligohydramnios used in this study appears to identify a group of babies with a fourfold risk of low birthweight and a high risk of admission to the Neonatal Intensive Care Unit and induction of labour for fetal reasons. This would suggest that pregnancies with isolated oligohydramnios require some form of fetal monitoring and further prospective studies are required to determine the most appropriate method.

Apgar Score↗
PubMed1997

A randomised comparison between amniotic fluid index and maximum pool depth in the monitoring of post-term pregnancy.

OBJECTIVE: To compare the impact of two different ultrasound methods for assessing amniotic fluid volume on the incidence of obstetric interventions in post-term pregnancies. DESIGN: A prospective randomised controlled trial. SETTING: Liverpool Women's Hospital. PARTICIPANTS: Five hundred women with singleton, uncomplicated pregnancies with gestational age > or = 290 days. INTERVENTIONS: Random allocation to fetal monitoring by either: 1. amniotic fluid index and computerised cardiotocography, or 2. maximum pool depth and computerised cardiotocography. MAIN OUTCOME MEASURES: Primary: caesarean section. Secondary: the number of abnormal monitoring tests, induction of labour, intrapartum management and neonatal outcome. RESULTS: The number of abnormal amniotic fluid indices was significantly higher than the number of abnormal maximum pool depths (10% vs 2.4%; OR 4.51, 95% CI 1.82-11.21; P = 0.0008) which resulted in more inductions for abnormal post-term monitoring in the amniotic fluid index group (14.8% vs 8.4%; OR 1.89; 95% CI 1.07-3.33; P = 0.0362) and more intrapartum electronic fetal monitoring (94.4% vs 88.4%; OR 2.21; 95% CI 1.13-4.29; P = 0.0255). There were no other statistically significant differences in outcomes related to labour and delivery, but there was a trend towards more caesarean sections in the amniotic fluid index group (18.8% vs 13.2%), in particular caesarean sections for fetal distress (8% vs 4%). There were no perinatal deaths and no statistically significant differences in perinatal outcome between the two groups. CONCLUSIONS: Published reference ranges for amniotic fluid index overestimate the number of abnormal results in post-term pregnancies. Their use, when compared with maximum pool depth, is likely to increase the number of obstetric interventions with, as yet, an uncertain impact on perinatal mortality and morbidity. It is possible that antepartum fetal assessment in pregnancies where the risk of adverse perinatal outcome is very low may cause, rather than prevent morbidity.

Adult↗
PubMed1997

The clinical significance of fetal right heart enlargement with a structurally normal heart.

Isolated right heart enlargement of the fetus without cardiac structural abnormalities appears to be associated with growth retardation or abnormal perinatal outcome. We report the outcome of eight fetuses with subjective enlargement of the right heart. All cases were diagnosed antenatally from a standard four-chamber view on an ultrasound scan. All fetuses had otherwise normal cardiac anatomy. Seven out of the eight fetuses ultimately had outcomes which deviated from the norm. An isolated finding of fetal right heart enlargement warrants close antenatal fetal surveillance.

Female↗