Prophylactic oral betamimetics for reducing preterm birth in women with a twin pregnancy.

BACKGROUND: Twin pregnancies are associated with a high risk of neonatal mortality and morbidity due to an increased rate of preterm birth. Betamimetics can decrease contraction frequency or delay preterm birth in singleton pregnancies by 24 to 48 hours. The efficacy of oral betamimetics in women with a twin pregnancy is unproven. OBJECTIVES: To assess the effectiveness of prophylactic oral betamimetics for the prevention of preterm labour and birth for women with twin pregnancies. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group Trials Register (21 September 2015), MEDLINE (January 1966 to 31 July 2015), EMBASE (January 1985 to 31 July 2015) and reference lists of retrieved studies. SELECTION CRITERIA: Randomised controlled trials in twin pregnancies comparing oral betamimetics with placebo or any intervention with the specific aim of preventing preterm birth. Quasi-randomised controlled trials, cluster-randomised trials and cross-over trials were not eligible for inclusion. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. Two authors assessed the quality of the evidence using the GRADE approach. MAIN RESULTS: Overall, the quality of evidence is low for the primary outcomes. All of the included trials had small numbers of participants and few events. Preterm birth, the most important primary outcome, had wide confidence intervals crossing the line of no effect.Six trials (374 twin pregnancies) were included, but only five trials (344 twin pregnancies) contributed data. All trials compared oral betamimetics with placebo.Betamimetics reduced the incidence of preterm labour (two trials, 194 twin pregnancies, risk ratio (RR) 0.37; 95% confidence interval (CI) 0.17 to 0.78; low quality evidence). However, betamimetics did not reduce prelabour rupture of membranes (one trial, 144 twin pregnancies, RR 1.42; 95% CI 0.42 to 4.82; low quality evidence), preterm birth less than 37 weeks' gestation (four trials, 276 twin pregnancies, RR 0.85; 95% CI 0.65 to 1.10; low quality evidence), or less than 34 weeks' gestation (one trial, 144 twin pregnancies, RR 0.47; 95% CI 0.15 to 1.50; low quality evidence). Mean neonatal birthweight in the betamimetic group was significantly higher than in the placebo group (three trials, 478 neonates, mean difference 111.22 g; 95% CI 22.21 to 200.24). Nevertheless, there was no evidence of an effect of betamimetics in reduction of low birthweight (two trials, 366 neonates, average RR 1.19; 95% CI 0.77 to 1.85, random-effects), or small-for-gestational age neonates (two trials, 178 neonates, average RR 0.90; 95% CI 0.41 to 1.99, random-effects). Two trials showed that betamimetics significantly reduced the incidence of respiratory distress syndrome (388 neonates, RR 0.30; 95% CI 0.12 to 0.77), but the difference was not significant when the analysis was adjusted to account for the non-independence of twins (194 twins, RR 0.35; 95% CI 0.11 to 1.16). Three trials showed no evidence of an effect of betamimetics in reducing neonatal mortality, either with the unadjusted analysis, assuming twins are completely independent of each other (452 neonates, average RR 0.90; 95% CI 0.15 to 5.37, random-effects), or in the adjusted analysis, assuming non-independence of twins (226 twins, average RR 0.74; 95% CI 0.23 to 2.38, random-effects). A maternal death was reported in one trial without a significant difference between the groups (144 women, RR 2.84; 95% CI 0.12 to 68.57). AUTHORS' CONCLUSIONS: There is insufficient evidence to support or refute the use of prophylactic oral betamimetics for preventing preterm birth in women with a twin pregnancy.

Pneumococcal vaccination during pregnancy for preventing infant infection.

BACKGROUND: Approximately 450,000 children worldwide die of pneumococcal infections each year. The development of bacterial resistance to antimicrobials adds to the difficulty of treatment of diseases and emphasizes the need for a preventive approach. Newborn vaccination schedules could substantially reduce the impact of pneumococcal disease in immunized children, but do not have an effect on the morbidity and mortality of infants less than three months of age. Pneumococcal vaccination during pregnancy may be a way of preventing pneumococcal disease during the first months of life before the pneumococcal vaccine administered to the infant starts to produce protection. OBJECTIVES: To assess the effect of pneumococcal vaccination during pregnancy for preventing infant infection. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 July 2014) and reference lists of retrieved studies. SELECTION CRITERIA: Randomized controlled trials in pregnant women comparing pneumococcal vaccine with placebo or doing nothing, or with another vaccine to prevent infant infections. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We contacted study authors for additional information. MAIN RESULTS: Seven trials were included, but only six trials (919 participants) contributed data. There was no evidence that pneumococcal vaccination during pregnancy reduces the risk of neonatal infection (risk ratio (RR) 0.66; 95% confidence interval (CI) 0.30 to 1.46; two trials, 241 pregnancies, low quality evidence). Although the data suggest an effect in reducing pneumococcal colonization in infants by 16 months of age (average RR 0.33; 95% CI 0.11 to 0.98; one trial, 56 pregnancies), there was no evidence of this effect in infants at two to three months of age (average RR 1.13; 95% CI 0.46 to 2.78; two trials, 146 pregnancies, low quality evidence) or by six to seven months of age (average RR 0.67, 95% CI 0.22 to 2.08; two trials, 148 pregnancies, low quality evidence). None of the trials included in this review reported neonatal death as a result of pneumococcal infection.Neonatal antibody levels were reported as geometric mean and 95% CI. There were inconsistent results between studies. Two studies showed significantly higher immunoglobulin G (IgG) levels in cord blood in the pneumococcal vaccine group when compared with the control group for all serotypes. In contrast, another trial showed no difference in neonatal antibody levels between the pneumococcal vaccine group and the control group.Maternal antibody levels were also reported as geometric mean and 95% CI. One study showed significantly higher IgG levels in maternal serum in women immunized with pneumococcal vaccine when compared with control vaccine regardless of any serotypes. Another study showed significantly higher maternal antibody levels only for serotype 14, but no evidence of an effect for other serotypes.The percentage of women with seroprotection was measured in one trial at delivery and at 12 months post-delivery. At delivery, results favored the intervention group for serotype 6 (RR 1.49, 95% CI 1.31 to 1.69), serotype 14 (RR 1.40, 95% CI 1.25 to 1.56) and serotype 19 (RR 2.29, 95% CI 1.89 to 2.76). There were no group differences seen at 12 months post-delivery for serotypes 6 or 14 (RR 1.06, 95% CI 1.00 to 1.12 and RR 1.06, 95% CI 0.98 to 1.15, respectively), but results favored the intervention group for serotype 19 (RR 1.59, 95% CI 1.37 to 1.85).No significant difference for tenderness at the injection site between women who received pneumococcal vaccine and those who received control vaccine (average RR 3.20; 95% CI 0.32 to 31.54; two trials, 130 women).The overall quality of evidence is low for primary outcomes. Most outcomes had wide confidence intervals crossing the line of no effect, and most of the included trials had small numbers of participants and few events which led to downgrading evidence for imprecision of findings. AUTHORS' CONCLUSIONS: There is insufficient evidence to assess whether pneumococcal vaccination during pregnancy could reduce infant infections.

Attitude and preference of Thai pregnant women towards mode of delivery.

OBJECTIVE: To explore the attitudes and wishes of Thai pregnant women regarding modes of delivery. MATERIAL AND METHOD: Four hundred fifteen pregnant women attending the Vajira Hospital antenatal clinic were included in the present study. Data was assembled from the voluntarily self-completion questionnaires completed by the eligible women. RESULTS: Only 3.1% of the participants could give entirely correct answers in the knowledge module. Most of the respondents (87.5%) preferred vaginal delivery. The most popular reason for the preference for vaginal delivery was desire for a natural process. Fear of labor pain was the most frequent reason of the women who preferred cesarean section. The strongest predictor for patients' preference for cesarean delivery was a prior cesarean section (RR 11.1, 95% CI 4.7 to 26). Thirty-two percent of the participants felt that cesarean delivery on maternal request was their right and they desired to take part in the decision-making for their mode of delivery. Of those women who stated that cesarean section on demand was their right, the majority (77.3%) still preferred vaginal delivery. CONCLUSION: Although the proportion of Thai pregnant women who wished to have a cesarean delivery was higher than that of women from other countries, the majority of study participants preferred vaginal delivery.

Prophylactic oral betamimetics for reducing preterm birth in women with a twin pregnancy.

BACKGROUND: Twin pregnancies are associated with a high risk of neonatal mortality and morbidity due to an increased rate of preterm birth. Betamimetics can decrease contraction frequency or delay preterm birth in singleton pregnancies by 24 to 48 hours. The efficacy of oral betamimetics in women with a twin pregnancy is unproven. OBJECTIVES: To assess the effectiveness of prophylactic oral betamimetics for the prevention of preterm labour and birth for women with twin pregnancies. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group Trials Register (31 January 2012), the Central Register of Controlled Trials (The Cochrane Library 2012, Issue 2), MEDLINE (January 1966 to 1 February 2012) and EMBASE (January 1985 to 1 February 2012). SELECTION CRITERIA: Randomised controlled trials in twin pregnancies comparing oral betamimetics with placebo or any intervention with the specific aim of preventing preterm birth. Quasi-randomised controlled trials, cluster-randomised trials and cross-over trials were not included. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion and trial quality. Two review authors extracted data. Data were checked for accuracy. MAIN RESULTS: Six trials (374 twin pregnancies) were included, but only five trials (344 twin pregnancies) contributed data. All trials compared oral betamimetics with placebo.Betamimetics reduced the incidence of preterm labour (one trial, 50 twin pregnancies, risk ratio (RR) 0.40; 95% confidence interval (CI) 0.19 to 0.86). However, betamimetics did not reduce preterm birth less than 37 weeks' gestation (four trials, 276 twin pregnancies, RR 0.85; 95% CI 0.65 to 1.10) or less than 34 weeks' gestation (one trial, 144 twin pregnancies, RR 0.47; 95% CI 0.15 to 1.50). Mean neonatal birthweight in the betamimetic group was significantly higher than in the placebo group (three trials, 478 neonates, mean difference 111.22 g; 95% CI 22.2 to 200.2). Nevertheless, there was no evidence of an effect of betamimetics in reduction of low birthweight (two trials, 366 neonates, average RR 1.19; 95% CI 0.77 to 1.85, random-effects) or small-for-gestational age neonates (two trials, 178 neonates, RR 0.92; 95% CI 0.52 to 1.65). Two trials (388 neonates) showed that betamimetics significantly reduced the incidence of respiratory distress syndrome but the difference was not significant when the analysis was adjusted for correlation of babies from twins. Three trials (452 neonates) showed no evidence of an effect of betamimetics in reducing neonatal mortality (RR 0.80; 95% CI 0.35 to 1.82). AUTHORS' CONCLUSIONS: There is insufficient evidence to support or refute the use of prophylactic oral betamimetics for preventing preterm birth in women with a twin pregnancy.

Pneumococcal vaccination during pregnancy for preventing infant infection.

BACKGROUND: Each year at least one million children worldwide die of pneumococcal infections. The development of bacterial resistance to antimicrobials adds to the difficulty of treatment of diseases and emphasizes the need for a preventive approach. Newborn vaccination schedules could substantially reduce the impact of pneumococcal disease in immunized children, but does not have an effect on the morbidity and mortality of infants less than three months of age. Pneumococcal vaccination during pregnancy may be a way of preventing pneumococcal disease during the first months of life before the pneumococcal vaccine administered to the infant starts to produce protection. OBJECTIVES: To assess the effect of pneumococcal vaccination during pregnancy for preventing infant infection. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 December 2011) and reference lists of retrieved studies. SELECTION CRITERIA: Randomized controlled trials in pregnant women comparing pneumococcal vaccine with placebo or doing nothing or with another vaccine to prevent infant infections. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion, methodological quality and extracted data using a data collection form. Data were checked for accuracy. We contacted study authors for additional information. MAIN RESULTS: Seven trials were included, but only five trials (579 participants) contributed data. There was no evidence that pneumococcal vaccination during pregnancy reduces the risk of neonatal infection (risk ratio (RR) 0.66; 95% confidence interval (CI) 0.30 to 1.46; two trials, 241 pregnancies). Although the data suggest an effect in reducing pneumococcal colonization in infants by 16 months of age (RR 0.33; 95% CI 0.11 to 0.98; one trial, 56 pregnancies), there was no evidence of this effect in infants at two to three months of age (RR 1.13; 95% CI 0.46 to 2.78; two trials, 146 pregnancies) or by six to seven months of age (RR 0.66; 95% CI 0.20 to 2.17; two trials, 144 pregnancies). No significant difference for tenderness at the injection site between women who received pneumococcal vaccine and those who received control vaccine (RR 3.20; 95% CI 0.32 to 31.54; two trials, 130 women). AUTHORS' CONCLUSIONS: There is insufficient evidence to assess whether pneumococcal vaccination during pregnancy could reduce infant infections.

Risk factors for cesarean hysterectomy in tertiary center in Thailand: a case-control study.

AIM: To identify the risk factors for cesarean hysterectomy in a tertiary center in Bangkok, Thailand. METHODS: A case-control study was conducted by reviewing the medical records of pregnant women delivered at BMA Medical College and Vajira Hospital between 1 January 2001 and 28 February 2007. The case refers to pregnant women who underwent hysterectomy immediately or within 24 h following cesarean delivery. Controls included pregnant women who received cesarean section during the same study period by a ratio of 1:5 (case : control). RESULTS: During the study period, cesarean hysterectomy complicated 30 deliveries out of 31 106 deliveries (0.96:1000). Independent risk factors for cesarean hysterectomy from a multivariate logistic regression analysis were placental adherence (odds ratio [OR] = 440, 95% confidence interval [CI] 28-7000), placenta previa (OR = 57, 95% CI 6.0-540) and uterine atony (OR = 37, 95% CI 7.5-190). Sixty-three percent (5/8) of placental adherence were associated with placenta previa. Of these five patients, four had a uterine scar from a prior cesarean section. The following outcomes were significantly higher in the cesarean hysterectomy group as compared to the controls: operative time, blood loss, hypovolemia, coagulopathy, transfusions, febrile morbidity, secondary surgery, and duration of hospitalization. CONCLUSION: Placental adherence, placenta previa and uterine atony were identified as significant risk factors for cesarean hysterectomy. Cesarean section due to placenta previa should be electively scheduled with well-prepared blood components. The obstetrician should provide counsel and obtain detailed informed consent with regard to the possibility of cesarean hysterectomy.

A 50-g glucose challenge test: is there any diagnostic cut-off?

OBJECTIVE: To evaluate the diagnostic performance of 50-g glucose challenge test for diagnosis of gestational diabetes. MATERIAL AND METHOD: A retrospective study was conducted by reviewing the medical records of pregnant women who had a 50-g glucose challenge test of 140 mg/dL or higher and followed by a 100-g glucose tolerance test. Results were categorized in 10 mg/dL increments. Gestational diabetes was diagnosed using National Diabetes Data Group criteria. RESULTS: The present study included 2,226 cases from universal screening of 11,084 pregnant women. The incidence of gestational diabetes was 3.2% (351/11,084). Only 1.6% (6/374) of patients with positive screening results of less than 145 mg/dL had gestational diabetes. All of the 6 women undiagnosed by this threshold were gestational diabetes class A1 and had at least one risk factor Of 1,875 women, seven cases (0.4%) would be over diagnosed as gestational diabetes if 100-g glucose tolerance test was not performed after a result of 50-g glucose challenge test of > or = 250 mg/dL (99.6% specificity, 85.8% negative predictive value, 12.3% sensitivity and 86.0% positive predictive value). CONCLUSION: A 50-g glucose challenge test may be used as a diagnostic test when the value is > or = 250 mg/dL. The present data suggested that the value of glucose screening of > or = 145 mg/dL can be used as a threshold for a positive test in the low risk women.

Prenatal vitamin K1 administration in epileptic women to prevent neonatal hemorrhage: is it effective?

OBJECTIVE: To summarize current knowledge on whether prenatal prophylactic vitamin K1 administration to epileptic women receiving enzyme-inducing antiepileptic drugs (AEDs) to prevent neonatal hemorrhage is effective. STUDY DESIGN: A computerized MEDLINE search was conducted using the terms antiepileptic drug, hemorrhagic disease of the newborn, pregnancy and vitamin K since 1966 to July 2004, limited only to human studies. English-language publications were selected based on their relevance to the clinical effectiveness of administration of oral vitamin K to epileptic women exposed to enzyme-inducing AEDs for prevention of hemorrhagic disease of the newborn (HDN). RESULTS: No randomized, controlled trial testing prenatal vitamin K1 administration for reducing the incidence or severity of neonatal hemorrhage was identified. This review summarizes the data from published observational studies. CONCLUSION: There is inadequate evidence to recommend the routine administration of prenatal vitamin K to epileptic women exposed to enzyme-inducing AED therapy in order to prevent HDN.

Chromosomal abnormalities among 246 fetuses with pleural effusions detected on prenatal ultrasound examination: factors associated with an increased risk of aneuploidy.

PURPOSE: To determine the prevalence of chromosomal abnormalities in fetuses with prenatally diagnosed pleural effusions and to identify factors associated with an increased risk of aneuploidy. METHODS: A retrospective analysis of the Genzyme Genetics database was performed for samples submitted from October 1994 to April 2003 with an indication of fetal pleural effusion. RESULTS: There were 246 samples in which pleural effusion was identified as an indication for prenatal chromosome analysis. Ninety-four were from fetuses with isolated pleural effusions and 152 had other abnormalities in addition to pleural effusion. The prevalence of chromosome abnormalities was 35.4% (95% confidence interval, 29.2-41.4%). Among the eight first trimester samples, the aneuploidy rate was 63%. Pleural effusion cases associated with additional sonographic findings had a significantly higher aneuploidy rate than the isolated pleural effusion cases (50% vs. 12%, P < 0.001). CONCLUSIONS: Chromosome analysis is warranted after the prenatal detection of a fetal pleural effusion. The risk of aneuploidy is greater with first trimester detection and is significantly increased in the presence of other associated anomalies.

Random urinary protein-to-creatinine ratio for prediction of significant proteinuria in women with preeclampsia.

OBJECTIVE: To evaluate the accuracy of random urinary protein-to-creatinine ratio for prediction of significant proteinuria in women with suspected preeclampsia. METHODS: A prospective study was conducted in hospitalized pregnant women with a suspicion of preeclampsia. Random mid-stream urine specimens were obtained for protein-to-creatinine ratio determination, and then participants were instructed to collect 24-h urine samples for protein measurement. With the criterion of 24-h proteinuria of at least 300 mg as a significant proteinuria, the sensitivity and specificity of a random urinary protein-to-creatinine ratio of > or = 0.19 for prediction of significant proteinuria were analyzed and a receiver operating characteristic curve was constructed to determine the optimal cutoff value. RESULTS: Forty-two patients completed the study. Sixty-nine percent of the study population had significant proteinuria. A cutoff of 0.19 demonstrated a sensitivity of 100% and a specificity of 53.8%. A ratio below 0.22 could rule out a significant proteinuria. The optimal cutoff value is 0.25 which yielded sensitivity, specificity and accuracy of 96.6%, 92.3% and 95.2% respectively. CONCLUSION: In hospitalized preeclamptic patients, the random urinary protein-to-creatinine ratio at a cutoff of > or = 0.25 revealed a highly accurate prediction of significant proteinuria and could be a more practical alternative for assessment of proteinuria.

Correlation of 4- and 24-hour urine protein in women with initially diagnosed hypertensive disorders in pregnancy.

OBJECTIVE: To determine whether 4-hour urine protein value correlates with 24-hour urine protein value in women with hypertensive disorders in pregnancy. STUDY DESIGN: Cross-sectional study was performed in 38 in-patient pregnant women who were initially diagnosed as having hypertensive disorders in pregnancy. Urine samples were collected within 24 hours in 2 successive periods: the first 4-hour and the next 20-hour urine, in separate containers. The urine volume, urine protein and creatinine concentrations were thus separately measured. The 4- and 24-hour urine proteins were calculated and the correlation between both groups was determined by simple linear regression analysis. RESULTS: A total of 38 patients were recruited into the study, 26 had mild preeclampsia, 5 had severe preeclampsia, and 7 had superimposed preeclampsia. The result of the 4-hour urine protein was found to correlate with those of the 24-hour urine protein for patients with hypertensive disorders in pregnancy (p < 0.001). CONCLUSION: Total protein values of 4-hour samples positively correlated with values of 24-hour samples of patients with hypertensive disorders in pregnancy. This might be modified and used for urine protein collection in outpatients to improve the compliance.

Correlation between random urinary protein-to-creatinine ratio and quantitation of 24-hour proteinuria in preeclampsia.

OBJECTIVE: To determine whether random urinary protein-to-creatinine ratio correlated with the quantitation of 24-hour proteinuria in cases of preeclampsia. DESIGN: Cross-sectional descriptive study. SUBJECTS: Pregnant patients hospitalized in the obstetric ward, King Chulalongkorn Memorial Hospital due to preeclampsia. METHOD: The random urine specimens were obtained from the eligible subjects for protein-to-creatinine ratio determination, the subjects were then instructed to collect 24-hour urine samples for protein measurement. RESULTS: Twenty-five pregnant patients completed the study. There was a strong correlation between the random urinary protein-to-creatinine ratio and the quantitation of 24-hour proteinuria (r = 0.929, p < 0.001). CONCLUSION: The presented data support a strong correlation between random urinary protein-to-creatinine ratio and quantitation of 24-hour proteinuria in hospitalized pregnant patients with preeclampsia.