Andrew Child

Is C‐reactive protein really useful in preterm premature rupture of the membranes?

Summary. In a prospective blind study 380 daily serum samples from 55 women with preterm premature rupture of the membranes were analysed for C‐reactive protein (CRP). Although the last CRP before delivery was higher in patients with histological chorioamnionitis (P= 0.007), considerable overlap between infected and non‐infected pregnancies occurred, precluding the use of CRP as a diagnostic test if published normal levels were used. When upper limits were set at 30, 35, or 40 mg/1, the last CRP before delivery proved 90, 95 and 100% specific and 88, 92 and 100% positively predictive of infection in singleton pregnancies. Such high specificities are needed to prevent inappropriate intervention based on false positive results. We therefore propose upper limits for single estimations of 30, 35, or 40 mg/1 depending on the relative risks of preterm delivery versus infection at various gestational ages. In addition, consecutive values <20 mg/1 appeared highly predictive of infection.

A randomised comparison of hydralazine and mini-bolus diazoxide for hypertensive emergencies in pregnancy: The PIVOT trial

Aims:  Diazoxide is one of few available agents for treatment of hypertensive emergencies in pregnancy. From previous studies, there is a question concerning safety after moderate‐dose administration caused episodes of hypotension. Rapid control of severe hypertension is necessary to reduce maternal morbidity, for example, stroke and placental abruption. This study was designed to compare the efficacy of mini‐bolus diazoxide with intravenous (i.v.) hydralazine.

Transforming growth factor-ß1 does not relate to hypertension in pre-eclampsia

1. Pre‐eclampsia is a human disease of pregnancy characterized by high blood pressure, proteinuria and end‐organ damage, if severe. Pre‐eclampsia is thought to be related to changes in early placental development, with the formation of a shallower than normal placental bed.

Postpartum diagnosis of a maternal diaphragmatic hernia

The diagnosis is often delayed beeause the presenting symptoms af nausea. vomiting and mild abdominal pain are commonly Seen in the normal antenatal or postpartum woman.] The condition is associated with signiflcant fetal and maternal morbidity and mortality. A case of a left-sided diaphragmatic hernia presenting acutely four days postpartum is described. To the authors’ knowledge this is the first case to be reported in the Australian literature. 13.14.15.16.17

Time poor : rushing decreases the accuracy and reliability of blood pressure measurement technique in pregnancy

Background: In pregnancy, absolute blood pressure (BP) limits define preeclampsia. Therefore, BP in pregnancy should be measured accurately and in accordance with accepted guidelines. Accuracy of BP readings determined by rate of cuff deflation was analyzed. This study also investigated the compliance of clinical staff at Royal Prince Alfred Hospital, Australia, to guidelines for BP measurement. Methods: The study was an observational trial of 98 normotensive antenatal or recently postnatal patients. Two BP readings were taken, each with fast (>5 mm Hg/sec) and slow (≤2 mm Hg/sec) descent of mercury and compared by Bland-Altman analysis. Also, BP techniques used by junior doctors, specialist obstetricians, and midwives were compared using a 9-point scale. Findings: Australian national guidelines recommend slow descent of mercury. Fast descent underestimated the systolic BP by 9 mm Hg (95% confidence interval [CI], −23 to +5 mm Hg) (p < 0.001). Fast descent measured the diastolic BP within 2 mm Hg (95% CI, −10 to +14 mm Hg) (not different, p = 0.151). Accuracy of fast cuff deflation was 28% for systolic BP and 50% for diastolic BP for <5 mm Hg, and respectively, 64% and 68% for <10 mm Hg, 84% and 80% for <15 mm Hg and 91% and 87% for <20 mm Hg. Compliance with guidelines was greatest for specialists and midwives (p = 0.001) and their most commonly missed feature (76% to100%) was slow cuff deflation. Interpretation: Rapid cuff deflation underestimates the systolic BP compared to accepted guidelines (≤2 mm Hg/sec). Medical and midwifery staff may not follow accepted guidelines for BP measurement, particularly with regard to rate of cuff deflation. Potential misdiagnosis and under-treatment of patients with hypertension may compromise pregnancy outcomes.

EFFECT OF ANTIHYPERTENSIVE DRUGS ON NEONATAL BLOOD PRESSURE

1. This study evaluates the perinatal outcome of infants born to ninety‐five mothers with hypertension in pregnancy whose blood pressure was treated in a double blind trial comparing clonidine hydrochloride (C) and α‐methyldopa (A).

Recovery after Childbirth: A Preliminary Prospective Study

This prospective study examined the time for 93 women to cease to feel discomfort in their perineal areas after the births of their first babies. Sixty-two of the women had experienced a spontaneous delivery that did not require forceps assistance. In 58 patients, an episiotomy was performed. Of the 35 women in whom an episiotomy was not performed, 24 women required sutures and only four women did not suffer any perineal damage. The median time for perineal comfort in general (including walking and sitting) was one month (range, zero to six months); 20% of women took more than two months to achieve general perineal comfort. For comfort during sexual intercourse, the median time was three months (range, one to more than 12 months); 20% of women took longer than six months to achieve comfort during sexual intercourse. Factors that were associated with discomfort for longer than the median time were delivery by forceps; spontaneous vaginal (not perineal) tears; and, in the three to four days after the birth, oedema and the breakdown of muscle or skin sutures. There was no significant difference in these times between patients who did not undergo an episiotomy and those who underwent an episiotomy without a forceps delivery.

Is C-reactive protein really useful in preterm premature rupture of the membranes?

In a prospective blind study 380 daily serum samples from 55 women with preterm premature rupture of the membranes were analysed for C-reactive protein (CRP). Although the last CRP before delivery was higher in patients with histological chorioamnionitis (P = 0.007), considerable overlap between infected and non-infected pregnancies occurred, precluding the use of CRP as a diagnostic test if published normal levels were used. When upper limits were set at 30, 35, or 40 mg/l, the last CRP before delivery proved 90, 95 and 100% specific and 88, 92 and 100% positively predictive of infection in singleton pregnancies. Such high specificities are needed to prevent inappropriate intervention based on false positive results. We therefore propose upper limits for single estimations of 30, 35, or 40 mg/l depending on the relative risks of preterm delivery versus infection at various gestational ages. In addition, consecutive values greater than 20 mg/l appeared highly predictive of infection.