Ann-Sophie Page

Tocolysis may optimise outcomes in very preterm infants

The article by Zeitlin and colleagues reiterates the importance of prenatal interventions,1 in the form of timely transport to a level 3 unit and administration of antenatal …

Can the cerebroplacental ratio (CPR) predict intrapartum fetal compromise? A prospective observational study

Objective: To investigate the potential clinical use of serial fetal CPR measurements during the last month of pregnancy for the prediction of adverse perinatal outcome in unselected low-risk pregnancies. Methods: A multicenter prospective observational cohort study in 315 consecutively recruited low-risk pregnancies. All eligible pregnancies underwent serial sonographic evaluation of fetal weight and Doppler indices at two week intervals, from 36 weeks gestation until delivery. Data were converted into centiles correcting for gestational age. These data were not available for the obstetrical team and hence, could not influence management decisions. Primary outcomes were operative delivery for presumed fetal compromise and a composite neonatal outcome (arterial cord Ph 90th centile). Results: Three hundred fifteen women were recruited in this study. We ecxluded 32 pregnancies because of small for gestational age babies (SGA), leaving 293 women and 583 CPR values for data-analysis. There were 85 (27%) adverse neonatal outcomes and 29 patients (9%) underwent operative delivery for presumed fetal compromise. Both primary and secondary outcomes were not significant different between the different CPR groups. Furthermore, we examined if individual serial CPR measurements could predict adverse outcome and found no linear correlation between repeated measurements of CPR and adverse outcomes. Conclusion: Our study shows that routine serial screening by CPR measurements provides poor prediction for adverse perinatal outcome in uncomplicated pregnancies.

Association between antenatal corticosteroid administration-to-birth interval and outcomes of preterm neonates

We read with interest the article by Melamed et al. The main question of this research is to explore the optimal timing of administration of antenatal corticosteroids from 24 to 34 weeks of gestation to gain optimal neonatal therapeutic effects. The large sample size of this retrospective cohort study could provide new evidence for answering this question. Unfortunately, owing to limitations in the internal and external validity of this observational study, we believe it does not. The main limitation is that the relative difference in outcomes between the four study groups is minimal (21– 24%) and that only 31% of the cohort consists of patients with a gestational age less than 28 weeks. Although the choice of the composite primary endpoint seems clinically justified, it fails to reach clinical significance between treatments in the group of gestational age more than 28 weeks, even in this large retrospective design. For the entire cohort, 64 patients are to be treated correctly with antenatal corticosteroids to prevent one composite outcome in comparison with no antenatal corticosteroids at all, 53 in comparison with antenatal corticosteroids for less than 24 hours, and 111 in comparison with antenatal corticosteroids for longer than 7 days. The latter could suggest that a repeat course of antenatal corticosteroids is less effective in reducing nonrespiratory neonatal complications related to prematurity. In the cohort of participants at less than 28 weeks of gestation (the most vulnerable group), the odds ratio of the composite outcome is 2.48 (95% confidence interval 1.79–3.42). For participants at more than 28 weeks, the odds ratio is 1.77 (95% confidence interval 1.23–2.45). These ratios narrowly pass the zone of potential bias but do not reach the zone of potential interest for cohort studies. For now, the most important finding of the study is that 20% of patients did not get antenatal corticosteroids for any reason and that only 40% got an optimal treatment. We nevertheless think that a better designed study, preferably prospective, could confirm or refute the assumption that the optimal timing of antenatal corticosteroids administration is when delivery is expected to be within 7 days after administration. If confirmed, this hypothesis continues to challenge obstetricians to predict when preterm labor is going to result in preterm birth.

Importance of screening for gestational diabetes in late pregnancy

The study by Kurtbas et al. underlines the importance of screening for gestational diabetes mellitus (GDM) in late pregnancy (>24 weeks). We are conducting an analogous study in the Belgian population, and will be applying the new International Association of the Diabetes and Pregnancy Study Groups 2010 Guidelines. Our preliminary results indicate an even greater percentage of late detection of GDM (24% compared to 5.2% in the study by Kurtbas et al.), with an intake positive screen of 6%. We will register all possible risk factors in women found to be positive in late pregnancy, and hope to publish our results in this journal after summer 2012. As stated by the authors, the prevalence of GDM differs depending on the population screened and the methods of screening used. More studies of this kind (among different populations) are needed before we can offer an effective screening strategy for GDM with maximal sensitivity and an acceptable specificity.

Modified inside-out transobturator procedure: comment

Dear Editor, The study by de Leval et al. points to reassuring efficacy of the proposed modified technique with a shortened TVT-O tape [1]. However, concerning the effect on postoperative groin pain an important confounder has to be highlighted. The adjunct technique of no perforation of the obturator membrane by scissors and/or guide can contribute substantially to the findings of clinically significantly less postoperative groin pain. After all, this ‘no-touch technique’ can also be applied in the placement of the original TVT-O tape, as we have already been doing for 2 years. Due to different use of anaesthesia techniques it seems that groin pain at day 1 is the most accurate outcome to measure. As stated by the authors, a randomised trial with groin pain as primary outcome has to be awaited, preferentially with a comparison of the original versus the shortened TVT-O tape and using the same ‘no-touch technique’ for the placement of both tapes.