Harry Gee

Aspirin for prevention of preeclampsia in women with historical risk factors: a systematic review.

OBJECTIVE To examine the effectiveness of aspirin in preventing perinatal death and preeclampsia in women with predisposing historical risk factors, such as previous history of preeclampsia, chronic hypertension, diabetes, and renal disease. DATA SOURCES: Searches were conducted in MEDLINE, EMBASE, Cochrane Library, National Research Register, SCISEARCH, and ISI Conference Proceedings without any language restriction, using the following medical subject headings and text words: “aspirin,” “antiplatelet*,” “salicyl*,” “acetylsalicyl*,” “platelet aggregation inhibitors,” “pre-eclamp*,” “preeclamp*,” and “hypertens*.” METHODS OF STUDY SELECTION: We included all randomized trials that evaluated the effectiveness of aspirin compared with placebo or no treatment in women with predisposing historical risk factors and reported clinically relevant perinatal or maternal outcomes. Study selection, quality appraisal, and data extractions were performed independently and in duplicate. TABULATION, INTEGRATION, AND RESULTS: We identified 14 relevant trials, including a total of 12,416 women. Meta-analysis showed a significant benefit of aspirin therapy in reducing perinatal death (odds ratio [OR] 0.79, 95% confidence interval [CI] 0.64, 0.96) and preeclampsia (OR 0.86, 95% CI 0.76, 0.96). Aspirin was also associated with a reduction in rates of spontaneous preterm birth (OR 0.86, 95% CI 0.79, 0.94), and an increase of 215 g in mean birth weight (weighted mean difference 215, 95% CI 90, 341). There was no increase in the risk of placental abruption with aspirin (OR 0.98, 95% CI 0.79, 1.21). Funnel plot analysis indicated that publication and related biases were unlikely (Egger test, P = .84). CONCLUSION Aspirin reduces the risk of perinatal death and preeclampsia in women with historical risk factors. Given the importance of these outcomes and the safety and low cost of aspirin, aspirin therapy should be considered in women with historical risk factors.

Planned vaginal delivery versus elective caesarean section: a study of 705 singleton term breech presentations

Objective To compare neonatal mortality and neonatal and maternal morbidity in planned vaginal delivery versus elective caesarean section for breech presentation at term. To identify factors associated with the risk of caesarean section during labour.

Effectiveness of nifedipine versus atosiban for tocolysis in preterm labour: a meta-analysis with an indirect comparison of randomised trials

Objective To explore the effectiveness of nifedipine compared with atosiban for tocolysis in preterm labour.

Aspirin for the prevention of preeclampsia in women with abnormal uterine artery doppler: a meta-analysis

OBJECTIVE To determine the effectiveness of aspirin to prevent preeclampsia in women identified as high risk for preeclampsia by an abnormal second‐trimester uterine artery Doppler examination. DATA SOURCES Searches were conducted in MEDLINE, Embase, the Cochrane Controlled Trials Register, and Science Citation Index for randomized trials published from 1966 to 2000, using the following medical subject headings and key words: “aspirin,” “antiplatelet*,” “salicyl*,” “acetylsalicyl*,” “platelet aggregation inhibitors,” “ultrasonography,” “ultraso*,” and “Doppler.” STUDY SELECTION We included all randomized trials that evaluated the effectiveness of aspirin compared with placebo or no treatment in women with an abnormal uterine artery Doppler and that reported clinically relevant perinatal and maternal outcomes. Study selection, quality assessment, and data extraction were performed in duplicate. TABULATION, INTEGRATION, AND RESULTS There were five relevant trials. Pooling of results from these trials showed a significant benefit of aspirin in reducing preeclampsia (odds ratio [OR] 0.55, 95% confidence interval [CI] 0.32, 0.95). The baseline risk of preeclampsia in women with abnormal uterine artery Doppler was 16%, and the number of women needed to be treated with aspirin to prevent one case of preeclampsia was 16 (95% CI 8, 316). Women on aspirin had babies who were on average 82 g heavier than controls, but this result did not reach statistical significance (weighted mean difference 81.5, 95% CI 40.27, 203.27). CONCLUSION Uterine artery Doppler assessment identifies high‐risk women in whom aspirin therapy results in a significant reduction in preeclampsia.

Management of severe, early pre-eclampsia: is conservative management justified?

Abstract A retrospective analysis was performed to assess the fetal and maternal benefits of allowing women presenting with severe pre-eclampsia between 24 and 32 weeks to continue their pregnancy following treatment of their hypertension. Cases presenting in Oxford (conservative management) and in Birmingham (stabilisation and early intervention) were compared. Patients were considered to require treatment when their systolic blood pressure was ≥ 170 mmHg systolic or ≥ 110 mmHg diastolic, associated with at least 1+ proteinuria and hyperuricaemia. We compared gestation at delivery, birth weight and neonatal complications for each group, and any maternal morbidity. There were 28 patients in each group. Gestational age at delivery was significantly less in the group managed by early intervention. Those women managed conservatively gained a mean of 9.5 days (range 2–26 days; P P P P = 0.0001). All of the women in the group managed by early intervention recovered with no severe complications. However, those women managed conservatively had a higher incidence of HELLP (2 cases) and ELLP syndrome (2 cases), 1 case requiring temporary renal dialysis. Previous studies have not indicated an increase in maternal morbidity from such management, and this finding serves to highlight the potential dangers of the conservative management of pre-eclampsia.

The prevention of preterm delivery—can we afford to continue to ignore the cervix?

The search for safer retinoid drugs continues. Acitretin, a drug of comparable efficacy but much more rapidly excreted than etretinate, looked promising until it was found that a few patients seemed able to convert it to etretinate (Wiegand & Jensen 1991). There is some evidence from animal studies that not all biologically active retinoids are teratogenic (Teelmann 1989). For the present, hqwever, women with severe skin disease will continue to be treated with these powerful teratogens and all doctors involved with family planning or childbirth should be aware of their significance. Robert J. G. Chalmers Consultant Dermatologist T h e Skin Hospital Chapel Street Salfnrd Manchester M60 9EP

How can we teach EBM in clinical practice?? An analysis of barriers to implementation of on-the-job EBM teaching and learning

Introduction: Evidence-based medicine (EBM) improves the quality of health care. Courses on how to teach EBM in practice are available, but knowledge does not automatically imply its application in teaching. We aimed to identify and compare barriers and facilitators for teaching EBM in clinical practice in various European countries. Methods: A questionnaire was constructed listing potential barriers and facilitators for EBM teaching in clinical practice. Answers were reported on a 7-point Likert scale ranging from not at all being a barrier to being an insurmountable barrier. Results: The questionnaire was completed by 120 clinical EBM teachers from 11 countries. Lack of time was the strongest barrier for teaching EBM in practice (median 5). Moderate barriers were the lack of requirements for EBM skills and a pyramid hierarchy in health care management structure (median 4). In Germany, Hungary and Poland, reading and understanding articles in English was a higher barrier than in the other countries. Conclusion: Incorporation of teaching EBM in practice faces several barriers to implementation. Teaching EBM in clinical settings is most successful where EBM principles are culturally embedded and form part and parcel of everyday clinical decisions and medical practice.

A New Approach to Teaching and Learning in Journal Club.

In order to develop the capacity to adapt to changing circumstances, trainee doctors need to equip themselves with skills in acquisition, appraisal and application of new knowledge.The journal club traditionally provides a forum where these skills can be fostered. A newly introduced journal club format is described, which has a careful selection of learning experiences to enhance deep learning of these skills. The journal club is placed in the context of clinical care problems that require use of information from the medical literature. These problems are converted into focused, answerable clinical questions. Based on the clinical question, systematic literature searches are conducted and the identified articles are appraised using structured methodological guidelines. Clinical problem-solving skills are acquired through use of teaching methods that are associated with learning-forunderstanding.

Teaching trainers to incorporate evidence-based medicine (EBM) teaching in clinical practice: the EU-EBM project.

BackgroundEvidence based medicine (EBM) is considered an integral part of medical training, but integration of teaching various EBM steps in everyday clinical practice is uncommon. Currently EBM is predominantly taught through theoretical courses, workshops and e-learning. However, clinical teachers lack confidence in teaching EBM in workplace and are often unsure of the existing opportunities for teaching EBM in the clinical setting. There is a need for continuing professional development (CPD) courses that train clinical trainers to teach EBM through on-the-job training by demonstration of applied EBM real time in clinical practice. We developed such a course to encourage clinically relevant teaching of EBM in post-graduate education in various clinical environments.MethodsWe devised an e-learning course targeting trainers with EBM knowledge to impart educational methods needed to teach application of EBM teaching in commonly used clinical settings. The curriculum development group comprised experienced EBM teachers, clinical epidemiologists, clinicians and educationalists from institutions in seven European countries. The e-learning sessions were designed to allow participants (teachers) to undertake the course in the workplace during short breaks within clinical activities. An independent European steering committee provided input into the process.ResultsThe curriculum defined specific learning objectives for teaching EBM by exploiting educational opportunities in six different clinical settings. The e-modules incorporated video clips that demonstrate practical and effective methods of EBM teaching in everyday clinical practice. The course encouraged focussed teaching activities embedded within a trainers personal learning plan and documentation in a CPD portfolio for reflection.ConclusionThis curriculum will help senior clinicians to identify and make the best use of available opportunities in everyday practice in clinical situations to teach various steps of EBM and demonstrate their applicability to clinical practice. Once fully implemented, the ultimate outcome of this pilot project will be a European qualification in teaching EBM, which will be used by doctors, hospitals, professional bodies responsible for postgraduate qualifications and continuing medical education.

Cervical contractions: the response of the cervix to oxytocic stimulation in the latent phase of labour

Objective To assess the cervical response to myometrial activity in early labour.