Peter Danielian

A comparison of oral and vaginal misoprostol tablets in induction of labour at term

Objective To compare the efficacy of equivalent doses of orally administered with vaginally administered misoprostol in induction of labour at term.

First- and second-trimester fetal size and asthma outcomes at age 10 years.

RATIONALE Greater early fetal size is associated with reduced asthma risk and improved lung function in early childhood. OBJECTIVES To test the hypothesis that associations between early fetal size, asthma symptoms, and lung function persist into later childhood. METHODS In a longitudinal study, first- and second-trimester fetal measurements were recorded. At 10 years of age a respiratory questionnaire was completed. Spirometry, bronchial challenge, and skin-prick testing were undertaken in a subset. MEASUREMENTS AND MAIN RESULTS Fetal measurements were available in the first trimester for 853 individuals and the second trimester for 1,453. Questionnaires were returned for 927 children and 449 underwent detailed phenotyping. For each millimeter increase in first trimester size, asthma risk reduced by 6% (95% confidence interval[CI], 1–11) and FEV1 was higher by an average of 6 ml (95% CI, 1–11).First-trimester size was reduced in those with asthma at both 5 and 10 years compared with early or late onset wheeze (P , 0.02). Compared with persistent high growth in first and second trimesters,persistent low growth was associated with increased asthma risk(odds ratio, 2.8; 95% CI, 1.2–6.9) and a mean reduction in FEV1 of 103 ml (95% CI, 13–194), whereas increasing fetal size was associated with increased eczema risk (odds ratio, 2.5; 95% CI, 1.2–5.3). CONCLUSIONS Reduced fetal size from the first trimester is associated with increased risk for asthma and obstructed lung function in childhood. Relative change in size after the first trimester is associated with eczema.

Misoprostol for induction of labour at term: a more effective agent than dinoprostone vaginal gel

Objective To compare the efficacy of vaginal misoprostol and dinoprostone vaginal gel for induction of labour at term.

Sublingual compared with oral misoprostol in term labour induction: a randomised controlled trial.

Objective To compare the efficacy and patient acceptability of 50 μg of sublingual misoprostol with 100 μg of oral misoprostol in the induction of labour at term.

The unfacts of ‘request’ caesarean section

Sir, We would like to congratulate Susan Bewley and Jayne Cockburn on the comprehensive range of their recent commentary on caesarean section and the risks compared with vaginal delivery, but we were disappointed to find an obvious bias in favour of vaginal delivery. This was most obvious in their consideration of maternal mortality. They quote maternal mortality figures for 1997–1999 of 16.9 per million for vaginal delivery and 38.5 per million for elective caesarean section. The chapter by Professor Hall in the same source, specifically addressing the issue of caesarean section, indicates that this difference is not significant. In addition, this is clearly not a valid comparison: those cases of urgent and emergency caesarean section were attempting vaginal delivery. The correct estimate of maternal mortality might therefore be as high as 57 out of 1,916,000 attempted vaginal deliveries, a rate of 29.7 per million. In addition, it would be reasonable to exclude placenta praevia cases, as they have to be delivered by caesarean section, and the mortality is not related to the caesarean section itself, but is inherent to the condition (this is also acknowledged in the same chapter as above). In the same triennium there were four deaths associated with placenta praevia, two delivered by elective caesarean section and two by non-elective caesarean section. Assuming the authors are not suggesting that any of these women would have been better served by a vaginal delivery, and amending the mortality rates accordingly, there would in fact be only three deaths associated with elective caesarean section, a rate of 23.1 per million, about 75% of that associated with attempted vaginal delivery, and not much higher than the rate for successful vaginal delivery. Despite this, by the time their conclusion is reached, the authors feel happy to assert that there is a ‘. . .known and inevitable increased risk of maternal death. . .following caesarean section’. Yes, but for emergency, not elective caesarean section. We agree with the authors that the risks of all complications should be ascertained for each method of delivery so that a more informed choice can be made, but this general debate for or against caesarean section is a pointless and sterile exercise. The risk of death for an individual woman is very small (and may actually be least with elective caesarean section). In the end, the decision will be a value-judgement for the pregnant woman, who will have to balance the relative risks of everything else (perinatal mortality and morbidity, surgical morbidity, incontinence, etc.), and attempt to come to a decision which is right for her. We do not claim to know whether vaginal delivery is safer than elective caesarean section or not. The available evidence suggests that it is very likely that for maternal and perinatal mortality the differences (whichever way) are going to be very small indeed in the developed world. Everything else will always be a matter of opinion, and the cost to the NHS, and the capacity of the NHS, may be more decisive factors. The debate is ill-served when an apparently authoritative commentary is not immune from including a few ‘unfacts’ itself.

Active management of term prelabour rupture of membranes with oral misoprostol

Objective To compare the active management of term prelabour rupture of membranes with oral misoprostol with conservative management for 24 hours followed by induction with oxytocin or prostaglandin E2 (PGE2) gel.

Smoking cessation in pregnancy

Background: Pregnant women who continue to smoke expose their developing fetus to a wide range of risks. Assisting these patients to stop smoking can be an important intervention for the health of the baby and the mother. The management of pregnant smokers can be challenging, due to the potential risks of pharmacotherapy. There are a number of options available to the clinician to aid smoking cessation in non pregnant women. These include nicotine replacement therapy (NRT), bupropion, varenicline, and a range of non-drug therapies. Objective: To provide guidance to prescribers on the best way to manage smoking cessation in the pregnant patient, reviewing the risks and efficacy of the different approaches. Methods: An extensive literature search was carried out to find original studies which examined issues surrounding the safety and efficacy of methods of smoking cessation in pregnancy. Results/conclusion: NRT is the agent of choice for smoking cessation in pregnancy as the safety of other therapies in pregnancy have not yet been proved.

B-Lynch sutures for major primary postpartum haemorrhage at caesarean section.

Summary This was a retrospective observational study of 11 consecutive patients of major primary postpartum haemorrhage (PPH) who had the B-Lynch suture at the time of caesarean section, performed between 1 March 2001 and 31 March 2004 at a teaching hospital in Scotland. Case-note review was performed in 123 patients, who had major primary PPH to identify patients who had B-Lynch sutures at the time of caesarean section. The patients age, parity, gestation of pregnancy at which the B-Lynch suture was performed, the indication for caesarean section and the cause of primary major PPH were recorded. The operative details, intraoperative and immediate postoperative complications and the need for subsequent hysterectomy were noted. The patients were followed-up with clinic visits at 6 weeks and any further hospital referral for late postoperative complications and whether subsequent successful pregnancy was achieved, were documented. The incidence of major PPH in our centre was 0.5% of the total deliveries, of which 11 cases had the B-Lynch suture applied at the time of caesarean section. The patients were aged between 25 and 38 years old (mean 31 years). Parity ranged from 0 to 1 and the gestational age at which the procedure was performed ranged from 34 to 41 weeks (mean 38 weeks). Ten operations (91%) were performed by senior registrars supervised by the consultant on call and one (9%) case was performed by a consultant on call. All cases had the B-Lynch sutures performed for major primary PPH caused by uterine atony at the time of caesarean section. The weight of the babies delivered ranged between 2,110 – 4,820 g (mean 3,500 g). The total blood loss at surgery ranged from 2,000 – 10,000 ml (mean 3,500 ml). Only three patients (28%) required hysterectomy. All the patients made a good postoperative recovery. The hospital stay ranged from 4 – 24 days (mean 8 days). The patient who remained in hospital for 24 days did so because her baby was admitted into the neonatal unit. All the patients were reviewed 6 weeks postnatally. There was no significant morbidity. A subsequent successful pregnancy has been achieved in one patient.

A randomised comparison of oral misoprostol and vaginal prostaglandin E2 tablets in labour induction at term

Objective  To compare the efficacy of 100 μg of oral misoprostol with 3 mg prostaglandin E2 vaginal tablets in term labour induction.

Maternal vitamin D and E intakes during early pregnancy are associated with airway epithelial cell responses in neonates

Antenatal factors including maternal diet may predispose to airway disease, possibly by impacting on fetal airway development.