Chantal Roy

An international trial of antioxidants in the prevention of preeclampsia (INTAPP).

OBJECTIVE We sought to investigate whether prenatal vitamin C and E supplementation reduces the incidence of gestational hypertension (GH) and its adverse conditions among high- and low-risk women. STUDY DESIGN In a multicenter randomized controlled trial, women were stratified by the risk status and assigned to daily treatment (1 g vitamin C and 400 IU vitamin E) or placebo. The primary outcome was GH and its adverse conditions. RESULTS Of the 2647 women randomized, 2363 were included in the analysis. There was no difference in the risk of GH and its adverse conditions between groups (relative risk, 0.99; 95% confidence interval, 0.78-1.26). However, vitamins C and E increased the risk of fetal loss or perinatal death (nonprespecified) as well as preterm prelabor rupture of membranes. CONCLUSION Vitamin C and E supplementation did not reduce the rate of preeclampsia or GH, but increased the risk of fetal loss or perinatal death and preterm prelabor rupture of membranes.

Intrapartum amnioinfusion for meconium-stained amniotic fluid: a systematic review of randomised controlled trials.

This interesting article by Xu et al. stimulates us to put forward some basic questions regarding terminology and outcome measures related to efficacy of intrapartum amnioinfusion for meconium-stained amniotic fluid (MSAF). In this systematic review the studies were stratified according to the level of peripartum surveillance (standard versus limited). Although the authors attempted this stratification based on availability versus nonavailability of fetal monitoring in reality two studies included under the category of limited peripartum surveillance were from the settings where electronic fetal monitoring (EFM) was not routinely available. Is EFM an essential component of standard care and its absence indicates limited intrapartum/peripartum surveillance? Is it the sole differentiating point irrespective of the facilities for fetal scalp blood pH? Or has the availability of different levels of neonatal care also been included in this stratification? As lack of EFM or specialised neonatal services or both can compromise perinatal care in MSAF it may be logical to include both factors in this stratification. Use of appropriate uniform and explicit definition of nomenclature is vital for planning of future studies and analysis. Discordant effects of amnioinfusion on meconium aspiration syndrome (MAS) between centres with standard and limited peripartum surveillance is a significant observation. The plausible explanation as the authors suggested is prevention of severe perinatal asphyxia an important contributing factor for MAS by routine use of continuous EFM in the standard surveillance settings. While concurring with this hypothesis it is pertinent to note that perinatal asphyxia can be a cause as well as an effect of MAS. Dismantling cause and effect phenomenon in clinical scenarios can be a daunting task if not impossible in some cases. Stratification of data according to gestational age birthweight and presence or absence of intrauterine growth restriction (IUGR) may provide some clue in this area as IUGR is a common risk factor for both perinatal asphyxia and MAS. Increased perinatal morbidity and mortality is a major concern of MSAF and case fatality rate of MAS has been reported to be high ranging from 5 to 40%. Unfortunately the review is noticeably silent on the issue of perinatal mortality which has been included as a composite primary outcome measure in the international randomised controlled trial. It is understandable that perinatal mortality is low in settings with adequate perinatal care and the sample size required for such assessment could be prohibitably large in the context of the developed nations. That should not deter the reviewers to comment on this important issue related to hard outcome of intrapartum amnioinfusion. In several centres of the developing countries intrapartum amnioinfusion has been used in MSAF and meta-analysis of data from those centres with no concomitant use of EFM showed substantial reduction of perinatal mortality with the use of amnioinfusion (relative risk 0.25; 95%CI 0.13-0.45). Although much of these data came from nonrandomised trials consistency of the results across the seven studies included in this recent meta-analysis is important. At the very least these findings re-enforce the conclusions of Xu et al. - the need for high-quality studies and preferably an adequately powered multicentre randomised trial from under-resourced settings as it was conducted earlier in the settings with standard peripartum surveillance. Otherwise a potentially beneficial perinatal intervention may be consigned into oblivion. In conclusion Xu et al. must be congratulated for this in-depth timely review. (full text)