Michael Helewa

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

OBJECTIVEnWe 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.nnnSTUDY DESIGNnIn 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.nnnRESULTSnOf 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.nnnCONCLUSIONnVitamin 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.

The Control of Hypertension In Pregnancy Study pilot trial

Objectiveu2002 To determine whether ‘less tight’ (versus ‘tight’) control of nonsevere hypertension results in a difference in diastolic blood pressure (dBP) between groups.

Asymptomatic uterine incarceration at term: a rare complication of pregnancy.

BACKGROUNDnUterine retroversion before 12 to 14 weeks gestation occurs in approximately 15% of pregnancies and is usually considered an innocuous finding. When the uterus remains retroverted as the pregnancy advances, the growing uterine corpus becomes impacted in the hollow of the pelvic cavity and uterine incarceration may develop. Incarcerated retroverted uterus at term is an extremely rare and serious complication of pregnancy.nnnCASEnA 30-year-old primigravida with asymptomatic uterine incarceration at term underwent a challenging Caesarean section because of the distortion of her anatomy.nnnCONCLUSIONnRecognition of a gravid uterus that is retroverted and incarcerated at term or near-term is critical because Caesarean section is necessary for delivery and that is likely to be challenging.

Caesarean Sections in Canada: What Constitutes an Appropriate Rate?

Abstract Lowering the Caesarean section rate in Canada remains a complex task. With a national average of 19 percent in 1993, significant geographic variations are noted. Differences in population demography, availability of obstetrical services, habits and practice patterns, public input in the format of care, and litigation issues are at the core of these regional variations. All these factors have made attempts to lower Caesarean section rates a monumental effort. By modulating the four major indications for the Caesarean birth and increasing trials of labour for patients with a previous Caesarean section, vaginal birth for the breech, refining the diagnosis of dystocia and fetal distress, it is conceivable that the Caesarean section rate in Canada can be reduced to 12 percent. However, a global, totalitarian approach that takes into account all the intricate and interdependent factors leading to the regional variations, should be undertaken to achieve that goal.

Are Most Patients on the Labour Floor in Active Labour? A Descriptive Study of a Canadian Obstetrical Unit

INTRODUCTIONnIn its guideline on intrapartum fetal surveillance, the Society of Obstetricians and Gynaecologists of Canada (SOGC) recommended the availability of 1:1 nursing care (1 nurse to 1 patient) for women in active labour. The common perception is that the majority of women in labour and delivery units are in active labour. Identifying the proportion of women in active labour versus those who are not in active labour is crucial for the allocation of nursing care resources.nnnOBJECTIVESnWe sought to obtain a quantitative description of our obstetrical population to determine the distribution of women in the labour and delivery (L&D) unit, the obstetrical triage unit, and the labour, delivery, recovery, and postpartum (LDRP) unit and to determine the proportion of women in active labour who were receiving 1:1 nursing care.nnnMETHODSnWe randomly sampled and surveyed nursing care activities and patient distribution in a 1-hour period each day over a period of 4 months; each hour of the day was assessed on 5 separate occasions. The 3 units (L&D, LDRP, and obstetrical triage) were surveyed simultaneously.nnnRESULTSnIn the L&D unit, 31% of women were in active labour; of those, 92% received 1:1 nursing care. The remaining women (69%) were either in the early phase of labour, had significant obstetrical complications, were undergoing Caesarean section, or had just delivered. In the LDRP unit, 13% of women were in active labour, and 87% were postpartum. Almost one-half the women (45%) in the obstetrical triage unit were being assessed for possible labour or possible rupture of membranes, while the remainder were being assessed for other pregnancy-related problems.nnnCONCLUSIONnContrary to common perception, the majority of women in the L&D unit were admitted for reasons other than active labour but required care in that unit. The concept of providing 1:1 nursing care solely to women in active labour would leave the labour units understaffed. We recommend that institutions use a more precise classification system, rather than the presence or absence of labour, to determine individual patient risk and the appropriate nursing resource requirements.

2000: Year of the Breech

Abstract Objective: Management of the term breech occupied centre stage in the year 2000 following publication of the Canadian-led multicentre international randomized term breech trial (TBT). The objective of this manuscript is to highlight important recent publications related to the term breech leading to the publication of the TBT, to assess the direction in which our specialty is heading, and to describe the new challenges in dealing with this malpresentation. Method: Medline search of English language publications for the years 1999 to 2000 related to interventions in management, education, training, and womens views related to the term breech. Articles are analyzed and personal opinion and critique are presented. Results: By early 2000, it was evident that a significant percentage of frank/complete term breech presenting fetuses were being delivered by Caesarean section in many centres, especially in North America. The multicentre randomized clinical trial on the management of the breech, the TBT, offered the highest level of evidence to date, and documented that a policy of planned Caesarean delivery of the term breech results in lower perinatal mortality and morbidity, but not higher maternal morbidity when compared to outcomes with a planned vaginal delivery. The term breech fetus, however, remains intrinsically at a higher risk of neurologic dysfunctional anomalies irrespective of method of delivery. Equally, a policy of planned Caesarean section does not always abolish significant perinatal morbidity, nor abolish vaginal birth of the breech. External cephalic version (ECV) at term, but not preterm, significantly reduces the risk of this malpresentation at term, and training in ECV should be offered in all centres. With a reduction in opportunities for teaching in vaginal birth of the breech, innovative ways in teaching have to be implemented to provide our future obstetricians with the ability to deal with the occasional vaginal breech birth. Womens surveys showed that women remain more anxious regarding planned vaginal delivery of a breech than with a planned Caesarean section, but many are unaware that ECV could also be offered. Conclusion: With the advent of the evidence supporting a policy of planned Caesarean section for the term frank/complete breech, new challenges are taking shape. We should remain objective in assessing actual risks and acknowledge the outcome limitations inherent with adopting a national policy of planned Caesarean section. We face new resource challenges with emerging new trends in delivery of the breech. We should continue to offer non-coercive counselling to our patients, and strive to teach and educate our staff and residents in the skills of vaginal breech delivery.

Rupture of the Pregnant Uterus: The Evidence from this Decade on Risk Factors, Predictability and Prognosis

Abstract Objectives: to identify the incidence of risk factors for and the tools to predict and diagnose uterine wall disruptions. To elaborate on the perinatal and maternal prognosis and on the future reproductive potential of patients who suffered uterine wall disruptions. Method: this is a comprehensive review of the evidence published over the past decade in the English language. Publications were retrieved through Medline search, categorized as to topic and evaluated as to quality of evidence. Results: in contrast to the incidence of uterine rupture in the developing world, the incidence in the developed world is low (0.04%). Grand multiparity, dysfunctional labour and fetal malpresentations remain the major risk factors for uterine wall disruption in the unscarred uterus. Undertaking a trial of labour in the previously scarred uterus is identified as the major risk factor for uterine rupture. Evidence supports the recommendation of a cautionary and highly selective approach to the use of oxytocin to correct dysfunctional labour at any phase, and in the use of prostaglandin for ripening the cervix and induction of labour. Use of epidural anaesthesia, fetal macrosomia, type of lower uterine segment scar (vertical or horizontal) and previous Caesarean section for cephalopelvic disproportion do not seem to be important risk factors. Evidence is lacking as to the safety of trials of labour in multifetal pregnancies. Past history of a previous vaginal birth after Caesarean section (VBAC) seems to be reassuring. Sonography emerges as having a role in evaluating the potential for uterine rupture in labour. Use of partographs in labour could help to reduce the risk of uterine rupture. The most consistent sign of uterine wall disruption in labour is a non-reassuring fetal heart pattern, the severity of which seems to correlate well with the degree of disruption and fetal expulsion. Expediting delivery within 18 minutes of a non-reassuring fetal heart rate pattern carries a good neonatal prognosis, but maternal reproductive potential, while possible, will become guarded. Conclusion: while rare, uterine wall disruption may carry high rates of perinatal morbidity and mortality and maternal morbidity. In the past decade, risk factors have been better defined, with trials of labour after a previous Caesarean section being the most prominent of the risk factors. Overzealous advocacy of such trials cannot be supported. Trials of labour after previous Caesarean section need to be undertaken on a selective basis. Evidence is needed about the safety of trials of labour when certain conditions prevail, including those pertaining to the use of oxytocin, prostaglandin, trials involving patients with more than one previous Caesarean section, and the multifetal pregnancy. Sonography and partographs seem to have potential roles as tools that might help in the selection of candidates for a safe trial of scar and identify women at increased risk for uterine wall disruption.

Control of hypertension in pregnancy and small for gestational age infants (CHIPS): A randomised controlled trial of a diastolic bp (DBP) of 100 vs. 85 MMHG for mild-moderate pre-existing hypertension or non-proteinuric gestational hypertension

modification and standardization of protocol and to formulate a regime for the women of the Indian sub-continent. Study Methods: Four hundred and fifty cases of eclampsia and four hundred and forty cases of imminent eclampsia were included in this single center prospective study. *Low Dose Magnesium Sulphate Regime for eclampsia: Leading Dose 4 gm. Magnesium Sulphate I.V/I.M. Maintenance Dose 2 gm. 3 hourly for 24 hours. *Low Dose Magnesium Sulphate Regime for imminent eclampsia: 2 gm. I.V./I.M. 3 hourly on appearance of premonitory symptoms and continued till symptoms and signs disappeared. Results: In 86% of the patients of eclampsia, the convulsions were controlled by loading dose itself, while in 13% of the patients, who had one or two subsequent convulsions, they were effectively controlled by an additional dose of 2 gm. Magnesium Sulphate. In imminent eclampsia group, it was effective as prophylaxis in 99.09% wilt 0.9% of the cases had convulsions in spite of prophylaxis. Conclusion: Low Dose Magnesium Sulphate Therpay is very effective for the control and prevention of convulsions in eclampsia and imminent eclampsia without any drug toxicity in women with low weight.