Tocolytics for preterm premature rupture of membranes.

BACKGROUND: In women with preterm labor, tocolysis has not been shown to improve perinatal mortality; however, it is often given for 48 hours to allow for the corticosteroid effect for fetal maturation. In women with preterm premature rupture of membranes (PPROM), the use of tocolysis is still controversial. In theory, tocolysis may prolong pregnancy in women with PPROM, thereby allowing for the corticosteroid benefit and reducing the morbidity and mortality associated with prematurity. OBJECTIVES: To assess the potential benefits and harms of tocolysis in women with preterm premature rupture of membranes. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (6 April 2011), CENTRAL (The Cochrane Library 2011, Issue 1), MEDLINE (1966 to 6 April 2011) and EMBASE (1974 to 6 April 2011). SELECTION CRITERIA: We included pregnant women with singleton pregnancies and PPROM (23 weeks to 36 weeks and six days). We included any tocolytic therapy compared to no tocolytic, placebo, or another tocolytic. DATA COLLECTION AND ANALYSIS: All review authors assessed the studies for inclusion. We extracted and quality assessed data. MAIN RESULTS: We included eight studies with a total of 408 women. Seven of the studies compared tocolysis to no tocolysis. One study compared nifedipine to terbutaline. Compared to no tocolysis, tocolysis was not associated with a significant effect on perinatal mortality in women with PPROM (risk ratio (RR) 1.67; 95% confidence interval (CI) 0.85 to 3.29). Tocolysis was associated with longer latency (mean difference (MD) 73.12 hours; 95% CI 20.21 to 126.03; three trials of 198 women) and fewer births within 48 hours (average RR 0.55; 95% CI 0.32 to 0.95; six trials of 354 women; random-effects, T(2) = 0.18, I(2) = 43%) compared to no tocolysis. However, tocolysis was associated with increased five-minute Apgar of less than seven (RR 6.05; 95% CI 1.65 to 22.23; two trials of 160 women) and increased need for ventilation of the neonate (RR 2.46; 95% CI 1.14 to 5.34; one trial of 81 women). In the subgroup analysis comparing betamimetic to no betamimetics, tocolysis was associated with increased latency and borderline significance for chorioamnionitis. Prophylactic tocolysis with PPROM was associated with increased overall latency, without additional benefits for maternal/neonatal outcomes. For patients with PPROM before 34 weeks, there was a significantly increased risk of chorioamnionitis in women who received tocolysis. However, neonatal outcomes were not significantly different. There were no significant differences in maternal/neonatal outcomes in subgroup analyses comparing cox inhibitor versus no tocolysis, calcium channel blocker versus betamimetic, antibiotic, corticosteroid or combined antibiotic/corticosteroid. AUTHORS' CONCLUSIONS: Our review suggests there is insufficient evidence to support tocolytic therapy for women with PPROM, as there was an increase in maternal chorioamnionitis without significant benefits to the infant. However, studies did not consistently administer latency antibiotics and corticosteroids, both of which are now considered standard of care.

Cervical length and prediction of preterm delivery.

PURPOSE OF REVIEW: To present a summary of the literature and most recent advances in the clinical use of cervical length for the prediction of preterm birth. RECENT FINDINGS: Cervical length is predictive of preterm birth in all populations studied, including asymptomatic women with prior cone biopsy, mullerian anomalies, or multiple dilation and evacuations. While cervical length remains the most predictive measurement, funneling may add to its predictive value in certain populations. In terms of interventions aimed at preventing preterm birth once a short cervical length has been identified in asymptomatic women, recent data from a meta-analysis of all trials published so far point to the benefit of ultrasound-indicated cerclage in women with both a prior preterm birth and a cervical length less than 25 mm. Other interventions for a short cervical length such as progesterone and indomethacin are promising, but deserve further study before clinical recommendations can be made. In women with symptomatic preterm labor, a recent trial has shown that knowledge of cervical length (and fetal fibronectin) may be beneficial both in terms of time to triage and reduction of preterm birth. SUMMARY: Transvaginal ultrasound cervical length used as a screening tool for prediction and prevention of preterm birth can significantly improve the health outcomes of pregnant patients and their babies.

Rapid diagnostic testing for HIV. Clinical implications.

There have been many advances in HIV counseling, testing, and referral over the past ten years. One of the most recent advances is the United States Food and Drug Administration's (FDA) approval of a rapid test. As a result of the availability of rapid diagnostic testing for HIV, practices regarding testing and counseling need to be updated, particularly in time-sensitive situations in which rapid results are crucial.

Rapid diagnostic testing for HIV. Clinical implications.

There have been many advances in HIV counseling, testing, and referral over the past ten years. One of the most recent advances is the United States Food and Drug Administration's (FDA) approval of a rapid test. As a result of the availability of rapid diagnostic testing for HIV, practices regarding testing and counseling need to be updated, particularly in time-sensitive situations in which rapid results are crucial.