Deirdre J. Murphy

Case-control study of antenatal and intrapartum risk factors for cerebral palsy in very preterm singleton babies

The increase in survival of very preterm babies during the 1980s was accompanied by a sharp increase in the rate of cerebral palsy in this group. The relation between antenatal and intrapartum factors and cerebral palsy in such babies has not been well defined. To identify adverse and protective antenatal and intrapartum factors we undertook a case-control study of 59 very preterm babies who developed cerebral palsy, identified from a population-based register, and 234 randomly selected controls. The frequency of cerebral palsy decreased with increasing gestational age and birthweight. Antenatal complications occurred in 215 (73%) of the women with preterm deliveries. Factors associated with an increased risk of cerebral palsy after adjustment for gestational age were chorioamnionitis (odds ratio 4.2 [95% CI 1.4-12.0]) prolonged rupture of membranes (2.3 [1.2-4.2]), and maternal infection (2.3 [1.2-4..5]). Pre-eclampsia was associated with a reduced risk of cerebral palsy (0.4 [0.2-0.9]), as was delivery without labour (0.3 [0.2-0.7]). There was no increased risk of cerebral palsy with intrauterine growth retardation (1.0 [0.9-1.1]). The effect of rigorous management of adverse antenatal factors on the frequency of cerebral palsy in very preterm babies should be tested in randomised controlled trials.

Early maternal and neonatal morbidity associated with operative delivery in second stage of labour: a cohort study

BACKGROUND A frequent dilemma for obstetricians is how to keep morbidity to a minimum when faced with arrested progress at full dilatation of the cervix. Our aim was to examine maternal and neonatal morbidity associated with vaginal instrumental delivery in theatre and caesarean section, at full dilatation. METHODS We did a prospective cohort study of 393 women, who had term, singleton, liveborn, cephalic pregnancies requiring operative delivery in theatre at full dilatation for 1 year. FINDINGS Factors increasing the likelihood of caesarean section included maternal body-mass index greater than 30 (adjusted odds ratio 2.4, 95% CI 1.2-4.9), neonatal birthweight greater than 4.0 kg (2.3, 1.3-3.8), and occipitoposterior position (2.5, 1.6-3.9). Women undergoing caesarean section were more likely to have a major haemorrhage (>1 L; 2.8, 1.1-7.6) and extended hospital stay (>/=6 days; 3.5, 1.6-7.6) than those with vaginal delivery. Babies delivered by caesarean section were more likely to require admission for intensive care (2.6, 1.2-6.0) but less likely to have trauma (0.4, 0.2-0.7) than babies delivered by forceps. Overall neonatal morbidity was low, but a few babies in each group had serious complications (serious trauma, eight vs three; sepsis, six vs 13; and jaundice, ten vs 12 after vaginal delivery and caesarean section, respectively). Major haemorrhage was less likely after delivery by a skilled obstetrician (0.5, 0.3-0.9). INTERPRETATION The data lend support to an aim to deliver women vaginally, unless there are clear signs of cephalopelvic disproportion, and underline the importance of skilled obstetricians supervising complex operative deliveries.

Methadone dose and neonatal abstinence syndrome: systematic review and meta-analysis

AIM To determine if there is a relationship between maternal methadone dose in pregnancy and the diagnosis or medical treatment of neonatal abstinence syndrome (NAS). METHODS PubMed, EMBASE, the Cochrane Library and PsychINFO were searched for studies reporting on methadone use in pregnancy and NAS (1966-2009). The relative risk (RR) of NAS was compared for methadone doses above versus below a range of cut-off points. Summary RRs and 95% confidence intervals (CI) were estimated using random effects meta-analysis. Sensitivity analyses explored the impact of limiting meta-analyses to prospective studies or studies using an objective scoring system to diagnose NAS. RESULTS A total of 67 studies met inclusion criteria for the systematic review; 29 were included in the meta-analysis. Any differences in the incidence of NAS in infants of women on higher compared with lower doses were statistically non-significant in analyses restricted to prospective studies or to those using an objective scoring system to diagnose NAS. CONCLUSIONS Severity of the neonatal abstinence syndrome does not appear to differ according to whether mothers are on high- or low-dose methadone maintenance therapy.

Poor glycated haemoglobin control and adverse pregnancy outcomes in type 1 and type 2 diabetes mellitus: systematic review of observational studies.

BackgroundGlycaemic control in women with diabetes is critical to satisfactory pregnancy outcome. A systematic review of two randomised trials concluded that there was no clear evidence of benefit from very tight versus tight glycaemic control for pregnant women with diabetes.MethodsA systematic review of observational studies addressing miscarriage, congenital malformations and perinatal mortality among pregnant women with type 1 and type 2 diabetes was carried out. Literature searches were performed in MEDLINE, EMBASE, CINAHL and Cochrane Library. Observational studies with data on glycated haemoglobin (HbA1c) levels categorised into poor and optimal control (as defined by the study investigators) were selected. Relative risks and odds ratios were calculated for HbA1c and pregnancy outcomes. Adjusted relative risk estimates per 1-percent decrease in HbA1c were calculated for studies which contained information on mean and standard deviations of HbA1c.ResultsThe review identified thirteen studies which compared poor versus optimal glycaemic control in relation to maternal, fetal and neonatal outcomes. Twelve of these studies reported the outcome of congenital malformations and showed an increased risk with poor glycaemic control, pooled odds ratio 3.44 (95%CI, 2.30 to 5.15). For four of the twelve studies, it was also possible to calculate a relative risk reduction of congenital malformation for each 1-percent decrease in HbA1c, these varied from 0.39 to 0.59. The risk of miscarriage was reported in four studies and was associated with poor glycaemic control, pooled odds ratio 3.23 (95%CI, 1.64 to 6.36). Increased perinatal mortality was also associated with poor glycaemic control, pooled odds ratio 3.03 (95%CI, 1.87 to 4.92) from four studies.ConclusionThis analysis quantifies the increase in adverse pregnancy outcomes in women with diabetes who have poor glycaemic control. Relating percentage risk reduction in HbA1c to relative risk of adverse pregnancy events may be useful in motivating women to achieve optimal control prior to conception.

Outcome of subsequent pregnancy three years after previous operative delivery in the second stage of labour: cohort study

Objective To evaluate the reproductive outcome and the mode of delivery in subsequent pregnancies after instrumental vaginal delivery in theatre or caesarean section at full dilatation. Design Prospective cohort study. Setting Two urban hospitals with a combined total of 10 000 deliveries a year. Participants A cohort of 393 women with term, singleton, cephalic pregnancies who needed operative delivery in theatre during the second stage of labour from February 1999 to February 2000. Postal questionnaires were received from 283 women (72%) at three years after the initial delivery. Main outcome measure Mode of delivery in the subsequent pregnancy. Results 140 women (49%) achieved a further pregnancy at three years. 91/283 (32%) women wished to avoid a further pregnancy. Women were more likely to aim for vaginal delivery (87% (47/54) v 33% (18/54); adjusted odds ratio 15.55 (95% confidence interval 5.25 to 46.04)) and more likely to have a vaginal delivery (78% (42/54) v 31% (17/54); 9.50 (3.48 to 25.97)) if they had had a previous instrumental vaginal delivery rather than a caesarean section. There was a high rate of vaginal delivery after caesarean section among women who attempted vaginal delivery 17/18 (94%). In both groups, fear of childbirth was a frequently reported reason for avoiding a further pregnancy (51% after instrumental vaginal delivery, 42% after caesarean section; 1.75 (0.58 to 5.25)). Conclusion Instrumental vaginal delivery offers advantages over caesarean section for future delivery outcomes. The psychological impact of operative delivery requires urgent attention.

Cohort study of operative delivery in the second stage of labour and standard of obstetric care

Objective To assess the maternal and neonatal morbidity following operative delivery in the second stage of labour in relation to the standard of obstetric care.

Two decision aids for mode of delivery among women with previous caesarean section: randomised controlled trial

Objectives To determine the effects of two computer based decision aids on decisional conflict and mode of delivery among pregnant women with a previous caesarean section. Design Randomised trial, conducted from May 2004 to August 2006. Setting Four maternity units in south west England, and Scotland. Participants 742 pregnant women with one previous lower segment caesarean section and delivery expected at ≥37 weeks. Non-English speakers were excluded. Interventions Usual care: standard care given by obstetric and midwifery staff. Information programme: women navigated through descriptions and probabilities of clinical outcomes for mother and baby associated with planned vaginal birth, elective caesarean section, and emergency caesarean section. Decision analysis: mode of delivery was recommended based on utility assessments performed by the woman combined with probabilities of clinical outcomes within a concealed decision tree. Both interventions were delivered via a laptop computer after brief instructions from a researcher. Main outcome measures Total score on decisional conflict scale, and mode of delivery. Results Women in the information programme (adjusted difference −6.2, 95% confidence interval −8.7 to −3.7) and the decision analysis (−4.0, −6.5 to −1.5) groups had reduced decisional conflict compared with women in the usual care group. The rate of vaginal birth was higher for women in the decision analysis group compared with the usual care group (37% v 30%, adjusted odds ratio 1.42, 0.94 to 2.14), but the rates were similar in the information programme and usual care groups. Conclusions Decision aids can help women who have had a previous caesarean section to decide on mode of delivery in a subsequent pregnancy. The decision analysis approach might substantially affect national rates of caesarean section. Trial Registration Current Controlled Trials ISRCTN84367722.

MORTALITY AND MORBIDITY ASSOCIATED WITH EARLY-ONSET PREECLAMPSIA

Objective To examine the management of early-onset preeclampsia and its maternal and fetal morbidity and mortality.Design Retrospective cohort study of 49,812 births at a university teaching hospital between June 1986 and March 1997. Seventy-one women were identified with a diagnosis of preeclampsia with an onset at less than 30 completed weeks of gestation.Results The incidence of very preterm preeclampsia was 1 in 682 total births. The mean diagnosis to delivery interval (range) was 14 days (0–49 days). There were no maternal deaths. Fifteen women (21%) had developed HELLP/ELLP syndrome, 9 (13%) had renal failure, 1 (1.4%) had eclampsia, and 11 (15%) had an abruption. Five women (7%) had a termination of pregnancy, 57 (80%) were delivered by cesarean section, and 4 (5%) required a classical incision. There were 12 intrauterine deaths (16%), 9 neonatal deaths (12%), and 52 neonatal survivors (72%). Two of the survivors were known to have neurological impairment at the 2-year follow-up.Conclusions A conservative approach to the management of early-onset preeclampsia results in a good obstetric outcome for the majority of fetuses, but this must be balanced against the significant risk of morbidity to the mothers.

A randomised controlled trial of routine versus restrictive use of episiotomy at operative vaginal delivery: a multicentre pilot study.

Objective  To compare the maternal and neonatal outcomes of operative vaginal delivery in relation to the use of episiotomy.

Pre-eclampsia and the later development of type 2 diabetes in mothers and their children: an intergenerational study from the Walker cohort.

Aims/hypothesisStudies have shown a relationship between pre-eclampsia and later coronary artery disease. This study investigated whether there is a relationship between pre-eclampsia and the development of type 2 diabetes in mothers and their babies and how this is affected by infant birthweight.Subjects and methodsThis was an intergenerational cohort study. The study population comprised 7,187 mothers who gave birth and 8,648 babies who were born in Dundee, Scotland between 1952 and 1958. Their later diabetic status was defined from 1980 to 2003 by linkage to population-based datasets.ResultsThere were 810 (11.3%) mothers with pre-eclampsia and 745 (10.4%) who subsequently developed type 2 diabetes. Logistic regression showed an increased risk of developing type 2 diabetes for mothers with pre-eclampsia, unadjusted odds ratio (OR) 1.37 (95% CI 1.10–1.71), p = 0.005. This relationship persisted after adjustment for infant birthweight, OR 1.40 (95% CI 1.12–1.75), p = 0.003. Of the babies born between 1952 and 1958, 221 (2.6%) had developed type 2 diabetes, 137 of them male (2.9% of male subjects in study population) and 84 female (2.2% of female subjects). The relationship between pre-eclampsia in the mother and the risk of type 2 diabetes in the offspring did not reach statistical significance, OR 1.38 (95% CI 0.90–2.10). Babies with birthweight in the lowest quintile (adjusted for sex, gestation and birth order) had an increased risk of developing type 2 diabetes, OR for lowest quintile vs highest quintile 1.84 (95% CI 1.24–2.72), p = 0.002.Conclusions/interpretationPre-eclampsia is associated with increased risk of developing type 2 diabetes in the mother, but birthweight is a more important determinant of future risk for the offspring.