Charlene Thornton

Rates of obstetric intervention among low-risk women giving birth in private and public hospitals in NSW: a population-based descriptive study

Objectives To compare the risk profile of women giving birth in private and public hospitals and the rate of obstetric intervention during birth compared with previous published rates from a decade ago. Design Population-based descriptive study. Setting New South Wales, Australia. Participants 691 738 women giving birth to a singleton baby during the period 2000 to 2008. Main outcome measures Risk profile of women giving birth in public and private hospitals, intervention rates and changes in these rates over the past decade. Results Among low-risk women rates of obstetric intervention were highest in private hospitals and lowest in public hospitals. Low-risk primiparous women giving birth in a private hospital compared to a public hospital had higher rates of induction (31% vs 23%); instrumental birth (29% vs 18%); caesarean section (27% vs 18%), epidural (53% vs 32%) and episiotomy (28% vs 12%) and lower normal vaginal birth rates (44% vs 64%). Low-risk multiparous women had higher rates of instrumental birth (7% vs 3%), caesarean section (27% vs 16%), epidural (35% vs 12%) and episiotomy (8% vs 2%) and lower normal vaginal birth rates (66% vs 81%). As interventions were introduced during labour, the rate of interventions in birth increased. Over the past decade these interventions have increased by 5% for women in public hospitals and by over 10% for women in private hospitals. Among low-risk primiparous women giving birth in private hospitals 15 per 100 women had a vaginal birth with no obstetric intervention compared to 35 per 100 women giving birth in a public hospital. Conclusions Low-risk primiparous women giving birth in private hospitals have more chance of a surgical birth than a normal vaginal birth and this phenomenon has increased markedly in the past decade.

The incidence of preeclampsia and eclampsia and associated maternal mortality in Australia from population-linked datasets: 2000-2008

OBJECTIVE To determine the incidence of preeclampsia and eclampsia and associated mortality in Australia between 2000 and 2008. STUDY DESIGN Analysis of statutorily collected datasets of singleton births in New South Wales using International Classification of Disease coding. Analyzed using cross tabulation, logistic regression, and means testing, where appropriate. RESULTS The overall incidence of preeclampsia was 3.3% with a decrease from 4.6% to 2.3%. The overall rate of eclampsia was 8.6/10,000 births or 2.6% of preeclampsia cases, with an increase from 2.3% to 4.2%. The relative risk of eclampsia in preeclamptic women in 2008 was 1.9 (95% confidence interval, 1.28-2.92) when compared with the year 2000. The relative risk of a woman with preeclampsia/eclampsia dying in the first 12 months following birth compared with normotensive women is 5.1 (95% confidence interval, 3.07-8.60). CONCLUSION Falling rates of preeclampsia have not equated to a decline in the incidence of eclampsia. An accurate rate of both preeclampsia and eclampsia is vital considering the considerable contribution that these diseases make to maternal mortality. The identification and treatment of eclampsia should remain a priority in the clinical setting.

Soluble Flt-1 as a diagnostic marker of pre-eclampsia

Backgound: Serum levels of soluble fms‐like tyrosine kinase (sFlt‐1) increase in pre‐eclampsia (PE).

The effect of acupuncture on post-cancer fatigue and well-being for women recovering from breast cancer: a pilot randomised controlled trial

Objective To determine the feasibility and acceptability of acupuncture in managing fatigue and well-being in breast cancer survivors. Methods A randomised controlled trial compared acupuncture was with sham acupuncture and wait list controls was performed in Sydney, Australia. A total of 30 women with fatigue following breast cancer treatment participated in the trial. Women received six sessions of acupuncture over 8 weeks. Outcomes related to an assessment of interest to participate in the trial and identification of appropriate recruitment strategies, appropriateness of eligibility criteria and compliance with treatment attendance. Clinical outcomes assessed fatigue and well-being. In-depth interviews were undertaken with seven women, who described their experience of acupuncture. Results Our study demonstrated feasibility with appropriate trial entry criteria, good acceptability and treatment compliance with the study interventions, and with the completion of outcome forms. There was a significant reduction in fatigue for women receiving acupuncture compared with control after 2 weeks mean difference (MD) 5.3, 95% CI 4.5 to 6.2, p=0.05, and a significant improvement in well-being at 6 weeks for acupuncture compared with the sham and wait list control, MD 2.7, 95% CI 2.1 to 3.2, p=0.006. Women described their experience of acupuncture positively, and interview data may also offer explanations for the improved outcomes of well-being, with women reporting an improvement in sleep, mood and relaxation. Conclusions Fatigue is a common symptom experienced by people recovering from treatment, and an appropriately powered trial to evaluate the effect of acupuncture is needed. Clinical Trial Registration Australian New Zealand Clinical Trials Registry, www.anzctr.org.au ACTRN12610000720011.

Antihypertensive drugs clonidine, diazoxide, hydralazine and furosemide regulate the production of cytokines by placentas and peripheral blood mononuclear cells in normal pregnancy.

Background Antihypertensive drugs such as clonidine, diazoxide, hydralazine and furosemide are used in the hypertensive disorders of pregnancy to control blood pressure, but it is not clear if they modulate the production of placental or circulating cytokines. Objective To examine the effect of pharmaceutical doses of well known antihypertensive drugs used for blood pressure control on the production of the cytokines interleukin (IL)-6, IL-10 and tumour necrosis factor (TNF)-α in placental tissue and peripheral blood mononuclear cells (PBMCs) in normal pregnancy. Design Placental biopsies were taken from the decidual surface of placentas after delivery of normal pregnancies (n = 6) and PBMCs were separated from the whole blood of normal term pregnant women (n = 7). Both villous explants and PBMCs were cultured with increasing concentrations of antihypertensive drugs. The dose effect of drugs on the production of placental and circulating cytokines (IL-6, IL-10 and TNF-α) were examined by enzyme-linked immunosorbent assay. Results Placental production of IL-10 was not affected by clonidine, but decreased significantly after incubation of the tissue with diazoxide, hydralazine or furosemide. Production of IL-10 by PBMCs increased significantly: by from 3.4 ± 2.7% [16.3 pg/ml (range 6.1–21.5 pg/ml)] to 24.5 ± 3.3% [30.4 pg/ml (range 16.9–34.8 pg/ml)] with increasing concentrations of clonidine (0.08–1.3 μg/ml), and by 8.8 ± 3.5% [4.1 pg/ml (range 3.0–17.8 pg/ml)] and 17.2 ± 1.9% [22.6 pg/ml (range 13.2–23.2 pg/ml)] with lower doses of hydralazine (6.3 and 12.5 μg/ml) (all P values < 0.05). There was a stepwise reduction in production of TNF-α and IL-6 with increasing doses of diazoxide, hydralazine and furosemide by placentas and PBMCs from these women with normal pregnancies. Conclusion Our data suggest that the antihypertensive drugs clonidine and hydralazine can stimulate production of the circulating anti-inflammatory cytokine IL-10, whereas furosemide and diazoxide inhibit the production of this cytokine and the proinflammatory cytokines TNF-α and IL-6 by placentas and PBMCs.

Acute Pulmonary Oedema as a Complication of Hypertension During Pregnancy

Objective. To determine rates of and potential causative factors for acute pulmonary oedema (APO) in hypertensive women. Methods. Statistical analysis, including logistic regression, was applied to the individual patient data (IPD) of all hypertensive women who delivered in 2005 at two comparable units. Results. Of 880 cases analysed, there were no women with APO in unit one and 19 women in unit two. The women with APO received larger quantities of intravenous fluids, delivered at earlier gestations, via Caesarean section, following failed induction of labour and had a longer hospital stay. Conclusion. The development of APO in women with hypertension during pregnancy is associated with high levels of intravenous fluid administration.

Role of proteinuria in defining pre-eclampsia: clinical outcomes for women and babies.

1. The presence of proteinuria is not essential to the diagnosis of pre‐eclampsia under many diagnostic consensus statements. The aim of the present study was to assess maternal and perinatal outcomes after proteinuric pre‐eclampsia compared with other non‐proteinuric disease presentations.

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.

Birthplace in New South Wales, Australia: an analysis of perinatal outcomes using routinely collected data

BackgroundThe outcomes for women who give birth in hospital compared with at home are the subject of ongoing debate. We aimed to determine whether a retrospective linked data study using routinely collected data was a viable means to compare perinatal and maternal outcomes and interventions in labour by planned place of birth at the onset of labour in one Australian state.MethodsA population-based cohort study was undertaken using routinely collected linked data from the New South Wales Perinatal Data Collection, Admitted Patient Data Collection, Register of Congenital Conditions, Registry of Birth Deaths and Marriages and the Australian Bureau of Statistics. Eight years of data provided a sample size of 258,161 full-term women and their infants. The primary outcome was a composite outcome of neonatal mortality and morbidity as used in the Birthplace in England study.ResultsWomen who planned to give birth in a birth centre or at home were significantly more likely to have a normal labour and birth compared with women in the labour ward group. There were no statistically significant differences in stillbirth and early neonatal deaths between the three groups, although we had insufficient statistical power to test reliably for these differences.ConclusionThis study provides information to assist the development and evaluation of different places of birth across Australia. It is feasible to examine perinatal and maternal outcomes by planned place of birth using routinely collected linked data, although very large data sets will be required to measure rare outcomes associated with place of birth in a low risk population, especially in countries like Australia where homebirth rates are low.

Trends and risk factors for severe perineal trauma during childbirth in New South Wales between 2000 and 2008: a population-based data study

Objectives To determine trends and risk factors for severe perineal trauma between 2000 and 2008. Design This was a population-based data study. Setting New South Wales, Australia. Participants 510 006 women giving birth to a singleton baby during the period 2000–2008. Main outcome measures Rates of severe perineal trauma between 2000 and 2008 and associated demographic, fetal, antenatal, labour and delivery events and factors. Results There was an increase in the overall rate of severe perineal trauma from 2000 to 2008 from 1.4% to 1.9% (36% increase). Compared with women who were intact or had minor perineal trauma (first-degree tear, vaginal graze/tear), women who were primiparous (adjusted OR (AOR) 1.8 CI (1.65 to 1.95), were born in China or Vietnam (AOR 1.1 CI (1.09 to 1.23), gave birth in a private hospital (AOR 1.1 CI (1.03 to 1.20), had an instrumental birth (AOR 1.8 CI (1.65 to 1.95) and male baby (AOR 1.3 CI (1.27 to 1.34) all had a significantly higher risk of severe perineal trauma. Only giving birth to a male baby, adjusted for birth weight (AOR 1.5 CI (1.44 to 1.58), remained significant, when women with severe perineal trauma were compared with all other women not experiencing severe perineal trauma. This association increased over the study period. Conclusions To our knowledge, this is the first time that having a male baby has been found to exert such a strong independent risk for severe perineal trauma and the increasing significance of this in recent years needs further exploration.