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Z Alfirevic

Publications and source records attributed to Z Alfirevic.

At least 19 recordsLinked to original sources
PubMed2007

Targeted therapy for threatened preterm labor based on sonographic measurement of the cervical length: a randomized controlled trial.

OBJECTIVE: False positive diagnosis of preterm labor is common. As a consequence, medications including corticosteroids to promote fetal lung maturity and tocolysis are prescribed unnecessarily. We tested the hypothesis that management of threatened preterm labor based on measurement of cervical length by ultrasonography can reduce the number of women who receive inappropriate treatment. METHODS: Forty-one women with threatened preterm labor for whom a clinical decision was made to prescribe antenatal corticosteroids and tocolysis were randomized to have their cervical length measured by transvaginal ultrasound (n=21) or to receive therapy as planned (n=20). Fourteen women in the ultrasound group had a cervix longer than 15 mm and the therapy was withheld, while the other seven with a short cervix were managed in the same way as the control group. RESULTS: Three women (14%) in the ultrasound group were treated inappropriately with antenatal corticosteroids because they remained undelivered for more than a week. This compared favorably with the control group where 18 out of 20 (90%) received corticosteroids unnecessarily (relative risk (RR) 0.16; 95% confidence interval (CI), 0.05-0.39). Tocolysis was given to only seven women (33.3%) in the ultrasound group compared with 20 (100%) in the control group (RR 0.3; 95% CI, 0.15-0.54). There were no babies in either group who were born prematurely without being given a full course of antenatal corticosteroid therapy. CONCLUSION: Women with threatened preterm labor and cervical length more than 15 mm should not receive tocolysis. The issue of the safety of withholding corticosteroid therapy in this clinical scenario warrants further study.

Adrenal Cortex Hormones↗
PubMed2006

Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour.

BACKGROUND: Cardiotocography (sometimes known as electronic fetal monitoring), records changes in the fetal heart rate and their temporal relationship to uterine contractions. The aim is to identify babies who may be short of oxygen (hypoxic), so additional assessments of fetal well-being may be used, or the baby delivered by caesarean section or instrumental vaginal birth. OBJECTIVES: To evaluate the effectiveness of continuous cardiotocography during labour. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group Trials Register (March 2006), CENTRAL (The Cochrane Library 2005, Issue 4), MEDLINE (1966 to December 2005), EMBASE (1974 to December 2005), Dissertation Abstracts (1980 to December 2005) and the National Research Register (December 2005). SELECTION CRITERIA: Randomised and quasi-randomised controlled trials involving a comparison of continuous cardiotocography (with and without fetal blood sampling) with (a) no fetal monitoring, (b) intermittent auscultation (c) intermittent cardiotocography. DATA COLLECTION AND ANALYSIS: Two authors independently assessed eligibility, quality and extracted data. MAIN RESULTS: Twelve trials were included (over 37,000 women); only two were high quality. Compared to intermittent auscultation, continuous cardiotocography showed no significant difference in overall perinatal death rate (relative risk (RR) 0.85, 95% confidence interval (CI) 0.59 to 1.23, n = 33,513, 11 trials), but was associated with a halving of neonatal seizures (RR 0.50, 95% CI 0.31 to 0.80, n = 32,386, nine trials) although no significant difference was detected in cerebral palsy (RR 1.74, 95% CI 0.97 to 3.11, n = 13,252, two trials). There was a significant increase in caesarean sections associated with continuous cardiotocography (RR 1.66, 95% CI 1.30 to 2.13, n =18,761, 10 trials). Women were also more likely to have an instrumental vaginal birth (RR 1.16, 95% CI 1.01 to 1.32, n = 18,151, nine trials). Data for subgroups of low-risk, high-risk, preterm pregnancies and high quality trials were consistent with overall results. Access to fetal blood sampling did not appear to influence the difference in neonatal seizures nor any other prespecified outcome. AUTHORS' CONCLUSIONS: Continuous cardiotocography during labour is associated with a reduction in neonatal seizures, but no significant differences in cerebral palsy, infant mortality or other standard measures of neonatal well-being. However, continuous cardiotocography was associated with an increase in caesarean sections and instrumental vaginal births. The real challenge is how best to convey this uncertainty to women to enable them to make an informed choice without compromising the normality of labour.

Cardiotocography↗
PubMed2006

Oral misoprostol for induction of labour.

BACKGROUND: Misoprostol is a synthetic prostaglandin that can be given orally or vaginally. In most countries misoprostol has not been licensed for use in pregnancy, but its unlicensed use is common because misoprostol is cheap, stable at room temperature and effective in causing uterine contractions. Oral use of misoprostol may be convenient, but high doses could cause uterine hyperstimulation and uterine rupture which may be life-threatening for both mother and fetus. OBJECTIVES: To assess the effectiveness and safety of oral misoprostol used for labour induction in women with a viable fetus in the third trimester of pregnancy. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group Trials Register (January 2005). SELECTION CRITERIA: Randomised trials comparing oral misoprostol versus other methods, placebo or no treatment, given to women with a viable fetus for labour induction. DATA COLLECTION AND ANALYSIS: Three authors independently assessed trial quality and extracted data, using centrally-designed data sheets. MAIN RESULTS: Forty-one trials (8606 participants) were included. In four trials comparing oral misoprostol with placebo (474 participants), women using oral misoprostol were less likely to have long labours (relative risk (RR) 0.16, 95% confidence interval (CI) 0.05 to 0.49), needed less oxytocin (RR 0.32, 95% CI 0.24 to 0.43) and had a lower caesarean section rate (RR 0.62, 95% CI 0.40 to 0.96). In nine trials comparing oral misoprostol with vaginal dinoprostone (2627 participants), women given oral misoprostol were less likely to need a caesarean section, but this reduction reached statistical significance only in the subgroup with intact membranes (RR 0.78, 95% CI 0.66 to 0.94). Uterine hyperstimulation was more common after oral misoprostol (RR 1.63, 95% CI 1.09 to 2.44) although this was not associated with any adverse fetal events. Seven trials (1017 participants) compared oral misoprostol with intravenous oxytocin. The only difference between the groups was an increase in meconium-stained liquor in women with ruptured membranes following administration of oral misoprostol (RR 1.72, 95% 1.08 to 2.74). Sixteen trials (3645 participants) compared oral and vaginal misoprostol and found no difference in the primary outcomes. There was less uterine hyperstimulation without fetal heart rate changes in those given oral misoprostol (RR 0.37, 95% 0.23 to 0.59). Oral misoprsotol was associated with increased need for oxytocin augmentation (RR 1.28, 95% 1.11 to 1.48) and more meconium-stained liquor (RR 1.27, 1.01 to 1.60). AUTHORS' CONCLUSIONS: Oral misoprostol appears to be more effective than placebo and at least as effective as vaginal dinoprostone. However, there remain questions about its safety because of a relatively high rate of uterine hyperstimulation and the lack of appropriate dose ranging studies. In countries where misoprostol remains unlicenced for the induction of labour, many practitioners will prefer the legal protection of using a licenced product like dinoprostone. There is no evidence that misoprostol given orally is inferior to the vaginal route and has lower rates of hyperstimulation. If misoprostol is used orally, the dose should not exceed 50 mcg.

Administration, Oral↗
PubMed2005

The prevention of neonatal group B streptococcal disease: a report by a working group of the Medical Screening Society.

Streptococcus agalactiae, or Lancefield group B streptococcus (GBS), is the most frequent cause of serious bacterial sepsis, including neonatal meningitis, in UK neonates. Early-onset neonatal GBS infection, but not late-onset, can be prevented by screening to identify high-risk pregnancies and administering penicillin during delivery. A vaccine has been developed as an alternative means of prevention but it is awaiting a randomized trial before being available for general use. In this review we examine the published literature to assess the morbidity and mortality attributable to neonatal GBS infection, quantify the screening performance of the two alternative modes of screening (microbiological and risk factor based), review the evidence on the efficacy of the vaccine, and estimate the numbers of deaths and cases of serious disability that each strategy in turn might prevent in the UK, in order to assess the most effective means of prevention for the UK.

Antibiotic Prophylaxis↗
PubMed2004

Thyrotropin-releasing hormone added to corticosteroids for women at risk of preterm birth for preventing neonatal respiratory disease.

BACKGROUND: Thyrotropin-releasing hormones (TRH) added to prenatal corticosteroids has been suggested as a way to further reduce breathing problems and neonatal lung disease in infants born preterm. OBJECTIVES: To assess the effect of giving prenatal TRH in addition to corticosteroids to women at risk of very preterm birth for the prevention of neonatal respiratory disease. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register (July 2003), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 3, 2003), MEDLINE (1965 to July 2003), EMBASE (1988 to July 2003), Current Contents (1997 to July 2003). SELECTION CRITERIA: Randomised controlled trials in women at sufficient risk of preterm birth to warrant the use of prenatal corticosteroids to promote lung maturity. TRH and corticosteroids were compared with corticosteroids with or without placebo. The main outcomes considered were fetal and infant mortality, infant morbidity, childhood development and maternal morbidity. DATA COLLECTION AND ANALYSIS: All assessments of trial eligibility, quality and data extractions were done by at least two authors independently. MAIN RESULTS: Over 4600 women were recruited into the 13 included trials. Five trials were rated of high quality. Overall, prenatal TRH, in addition to corticosteroids, did not reduce the risk of neonatal respiratory disease or chronic oxygen dependence, and did not improve any of the fetal, neonatal or childhood outcomes assessed by intention to treat analyses.Indeed, the data showed prenatal TRH to have adverse effects for women and their infants. All side-effects monitored were more likely to occur in women receiving TRH. In the infants, prenatal TRH increased the risk of needing ventilation (relative risk (RR) 1.16, 95% confidence interval (CI) 1.03 to 1.29, 3 trials, 1969 infants), having a low Apgar score at five minutes (RR 1.48, 95% CI 1.14 to 1.92, 3 trials, 1969 infants) and, for the two trials providing data, was associated with poorer outcomes at childhood follow up. Sensitivity analyses by trial quality, or subgroups with differing times from entry to birth, or different dose regimens of TRH, did not change these findings. REVIEWERS' CONCLUSIONS: Prenatal thyrotropin-releasing hormones, in addition to corticosteroids, given to women at risk of very preterm birth do not improve infant outcomes and can cause maternal side-effects.

Drug Therapy, Combination↗
PubMed2003

Treatment for primary postpartum haemorrhage.

BACKGROUND: Primary postpartum haemorrhage is one of the top five causes of maternal mortality in both developed and developing countries. OBJECTIVES: The objective of this review was to assess the effectiveness and safety of pharmacological and surgical interventions used for the treatment of primary postpartum haemorrhage. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's trials register (April 2002). SELECTION CRITERIA: Randomised or quasi-randomised controlled trials comparing pharmacological, surgical and radiological interventions for the treatment of primary postpartum haemorrhage. DATA COLLECTION AND ANALYSIS: Studies were assessed for eligibility and quality by reviewers independently. Data were extracted into pre-specified data sheets. Authors of the included study were contacted for more information. Analysis was by intention to treat. Results are presented as relative risk with 95% confidence intervals using the fixed effects model. MAIN RESULTS: One trial, comparing rectally administered misoprostol versus syntometrine combined with an oxytocin infusion, met the eligibility criteria and was included in the review. It was not large enough to evaluate the effects of rectal misoprostol on maternal mortality, serious maternal morbidity or hysterectomy rates in women with primary postpartum haemorrhage. Compared with a combination of intramuscular syntometrine injection and oxytocin infusion, rectal misoprostol administration showed a statistically significant reduction in the number of women who continued to bleed after the intervention and those who required medical co-interventions to control the bleeding (6% versus 34%) (relative risk 0.18, 95% confidence interval 0.04 to 0.67). However, there was no significant difference between the two groups regarding surgical interventions to control intractable haemorrhage including hysterectomy, internal iliac artery ligation and/or uterine packing. REVIEWER'S CONCLUSIONS: Rectal misoprostol in a dose of 800 micrograms could be a useful 'first line' drug for the treatment of primary postpartum haemorrhage. Further randomised controlled trials are required to identify the best drug combinations, route, and dose for the treatment of postpartum haemorrhage.

Administration, Rectal↗
PubMed2003

Amniocentesis and chorionic villus sampling for prenatal diagnosis.

BACKGROUND: A major disadvantage of second trimester amniocentesis is that the result is usually available only after 18 weeks' gestation. Chorionic villus sampling (CVS) and early amniocentesis can be done between 9 and 14 weeks and offer an earlier alternative. OBJECTIVES: The objective was to assess comparative safety and accuracy of second trimester amniocentesis, early amniocentesis, transcervical and transabdominal CVS. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register (March 2003) and the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2002). SELECTION CRITERIA: All randomised trials comparing amniocentesis and CVS. DATA COLLECTION AND ANALYSIS: Two reviewers assessed eligibility and trial quality and performed data extraction. We analysed the data using RevMan software. MAIN RESULTS: A total of 14 randomised studies have been included. In a low risk population with a background pregnancy loss of around 2%, a second trimester amniocentesis will increase this risk by another 1%. This difference did not reach statistical significance, but the increase in spontaneous miscarriages following second trimester amniocentesis compared with controls (no amniocentesis) did (2.1% versus 1.3%; relative risk (RR) 1.02 to 2.52). Early amniocentesis is not a safe early alternative to second trimester amniocentesis because of increased pregnancy loss (7.6% versus 5.9%; RR 1.29, 95% CI 1.03 to 1.61) and higher incidence of talipes compared to CVS (1.8% versus 0.2%; RR 6.43, 95% CI 1.68 to 24.64).Compared with second trimester amniocentesis, transcervical CVS carries a significantly higher risk of pregnancy loss (14.5% versus 11%; RR 1.40, 95% CI 1.09 to 1.81) and spontaneous miscarriage (12.9% versus 9.4%; RR 1.50, 95% CI 1.07 to 2.11). One study compared transabdominal CVS with second trimester amniocentesis and found no significant difference in the total pregnancy loss between the two procedures (6.3% versus 7%). Transcervical CVS is more technically demanding than transabdominal CVS with more failures to obtain sample and more multiple insertions. REVIEWER'S CONCLUSIONS: Second trimester amniocentesis is safer than transcervical CVS and early amniocentesis. If earlier diagnosis is required, transabdominal CVS is preferable to early amniocentesis or transcervical CVS. In circumstances where transabdominal CVS may be technically difficult the preferred options are transcervical CVS in the first trimester or second trimester amniocentesis.

Amniocentesis↗
PubMed2003

Cervical stitch (cerclage) for preventing pregnancy loss in women.

BACKGROUND: A cervical stitch has been used to prevent preterm deliveries in women with previous second trimester pregnancy losses, or other risk factors such as short cervix on digital or ultrasound examination. OBJECTIVES: To assess effectiveness and safety of prophylactic cerclage (before the cervix has dilated), emergency cerclage (where cervices have started to shorten and dilate) and then labour halted, and to determine whether a particular technique of stitch insertion is better than others. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group specialised register (July 2002). We handsearched congress proceedings of International and European society meetings of feto-maternal medicine, recurrent miscarriage and reproductive medicine. We contacted researchers in the field. SELECTION CRITERIA: All randomised trials comparing cervical cerclage with expectant management or no cerclage during pregnancy and trials comparing one technique with another or with other interventions were included. Quasi randomised trials were excluded. DATA COLLECTION AND ANALYSIS: Two reviewers independently used prepared data extraction forms. Any discrepancy was resolved by discussion or by a third reviewer. Further clarification was sought from trial authors when required. Results were reported as relative risks using fixed or random effects model. MAIN RESULTS: Six trials with a total of 2175 women were analysed. Prophylactic cerclage was compared with no cerclage in four trials. There was no overall reduction in pregnancy loss and preterm delivery rates, although a small reduction in births under 33 weeks' gestation was seen in the largest trial (relative risks 0.75, 95% confidence interval 0.58 to 0.98). Cervical cerclage was associated with mild pyrexia, increased use of tocolytic therapy and hospital admissions but no serious morbidity. Two trials examined the role of therapeutic cerclage when ultrasound examination revealed short cervix. Pooled results failed to show a reduction in total pregnancy loss, early pregnancy loss or preterm delivery before 28 and 34 weeks in women assigned to cervical cerclage. REVIEWER'S CONCLUSIONS: The use of a cervical stitch should not be offered to women at low or medium risk of mid trimester loss, regardless of cervical length by ultrasound. The role of cervical cerclage for women who have short cervix on ultrasound remains uncertain as the numbers of randomised women are too few to draw firm conclusions. There is no information available as to the effect of cervical cerclage or its alternatives on the family unit and long term outcome.

Cerclage, Cervical↗
PubMed2002

Important clinical outcomes in urogynecology: views of patients, nurses and medical staff.

We attempted to grade treatment outcomes in female urinary incontinence by the perceived importance of these outcomes for patients, nursing staff and medical staff. One hundred millimeter visual analog scales (VAS) quantifying the relative importance of five clinical outcomes were sent to 100 patients, 50 nursing staff and 135 medical staff involved in continence care and median VAS scores for each outcome were compared between groups. Subjective improvement and improvement in quality of life were rated most highly. Median scores for subjective cure were 93 (76-99) for nurses, 93 (11-100) for patients and 91 (50-100) for ICS (UK) members. Median quality of life improvement scores were 92 (67-100), 93 (3-100) and 93 (74-100), respectively (not significant). There was a striking concordance of opinion regarding the importance of subjective improvement and improvement in quality of life. We suggest that these should become primary outcome measures in all future clinical trials and audits of incontinence treatments.

Attitude of Health Personnel↗
PubMed2001

Postnatal screening for thrombophilia in women with severe pregnancy complications.

OBJECTIVE: To examine the prevalence of maternal thrombophilia in women with severe preeclampsia/eclampsia, placental abruption, fetal growth restriction, and unexplained stillbirth. METHODS: We studied 102 women who had pregnancy complications and 44 healthy women with uncomplicated pregnancies. All women were tested 10 weeks postpartum for mutations of factor V Leiden, methylenetetrahydrofolate reductase (MTHFR) C677T, and G20210A prothrombin gene; deficiencies of protein C, protein S, and antithrombin III; and the presence of lupus anticoagulant and anticardiolipin antibodies. We aimed to recruit 100 cases and 300 controls to detect a 10% difference in thrombophilia between the groups. However, we were able to recruit only 44 controls. RESULTS: Abnormal thrombophilia screen was found in 54 women with pregnancy complications (53%) and in 17 women (39%) with normal pregnancies (odds ratio [OR] 1.8; 95% confidence interval [CI] 0.87, 3.67). Mutations encoding for factor V Leiden, G20210A prothrombin gene, and MTHFR C677T (homozygous) were identified in 18% of women with complications compared with 16% of controls (OR 1.1; 95% CI 0.44, 2.94). Activated protein C resistance, not due to factor V Leiden mutation, was the most common thrombophilic defect, found in 26% of women with pregnancy complications compared with 18% of controls (OR 1.5; 95% CI 0.63, 3.73). Twenty women with complications (20%) had multiple thrombophilic defects compared with four controls (9%) (OR 2.4; 95% CI 0.78, 7.61). CONCLUSION: In our cohort of women with pregnancy complications, maternal thrombophilia was less common than previously thought, and multiple thrombophilias were not a major additional risk factor.

Adolescent↗
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↗