Pj Steer

An analysis of the interrelationship between maternal age, body mass index and racial origin in the development of gestational diabetes mellitus

Please cite this paper as: Makgoba M, Savvidou M, Steer P. An analysis of the interrelationship between maternal age, body mass index and racial origin in the development of gestational diabetes mellitus. BJOG 2011; DOI: 10.1111/j.1471‐0528.2011.03156.x.

Does endothelial cell activation occur with intrauterine growth restriction

It is possible that in fetal growth restriction without pre‐eclampsia endothelial cell activation does not occur. This might be either because there is no release of ‘factor X’ or because of maternal resistance to its effects. To test this hypothesis, we took blood samples from 26 women with pre‐eclampsia (without fetal growth restriction), 13 women with fetal growth restriction (without pre‐eclampsia) and 24 normal pregnant controls, and measured the circulating levels of three markers of endothelial cell activation (soluble VCAM, ICAM and E‐selectin) and three cytokines [tumour necrosis factor‐α (TNF‐α), interleukin‐6 (IL‐6) and ‐8 (IL‐8)]. The levels of the markers of endothelial cell activation were raised in both pre‐eclampsia and fetal growth restriction pregnancies compared with controls; however, the levels of TNF‐α, IL‐6 and IL‐8 were significantly raised in pregnancies complicated by pre‐eclampsia, but not in fetal growth restriction, compared with controls. These data show that endothelial cell activation is common to both pre‐eclampsia and fetal growth restriction, but that the circulating levels of cytokines are elevated only in pre‐eclampsia. Thus, it seems likely that endothelial cell activation is a consequence of a failure of trophoblast invasion and that a further step is required, possibly involving cytokine release, for the expression of the full clinical picture of pre‐eclampsia.

A randomized control study of oxytocin augmentation of labour. 1. Obstetric outcome

Sixty women who were progressing slowly in spontaneous labour were assigned at random to three management protocols. Group 1 were observed without the use of oxytocin for 8 h while groups 2 and 3 were managed with a low‐dose and high‐dose oxytocin protocol respectively. The caesarean section rates were not significantly different between the three groups: 45%, 35% and 26% respectively. Cervical dilatation rate increased significantly after oxytocin infusion in both treatment groups compared with controls. The‘delay‐to‐delivery’interval and second stage duration were significantly shorter in the high‐dose group than in the control group. There were no measureable differences in the condition of the newborn infants between the three groups.

Interrelationships Among Abnormal Cardiotocograms in Labor, Meconium Staining of the Amniotic Fluid, Arterial Cord Blood pH, and Apgar Scores

A prospective study of the relationships among fetal heart rate pattern, meconium staining of the amniotic fluid, umbilical cord artery pH, and Apgar score was carried out in 1219 consecutive births. Interpretable cardiotocogram patterns and cord arterial pH and blood gas analysis were obtained in 698 cases. The sensitivity of an abnormal cardiotocogram at any time for acidosis (more than 1 SD below the mean, pH less than 7.17) was 80%, and for severe acidosis (more than 2 SDs below the mean, pH less than 7.085) was 83%. However, the predictive value was low, and 32% of fetuses had an abnormal cardiotocogram but no acidosis. If only cardiotocogram abnormality in the first stage of labor was considered, sensitivity was still 47% for acidosis and 67% for severe acidosis, and the false-positive rate was reduced to only 14%. We attempted to improve the prediction of acidosis by including meconium staining of the amniotic fluid, but 65% of the variation in umbilical cord artery pH and 72 and 86% of the variation in 1- and 5-minUte Apgar scores, respectively, remained unexplained. In light of these poor correlations, the current practice of considering cardiotocogram abnormality, meconium staining of the amniotic fluid, acidosis, and low Apgar scores as indicating one single disorder, “fetal distress,” is not valid

Seasonal patterns and preterm birth : a systematic review of the literature and an analysis in a London-based cohort

Objective  The objectives of this study included a systematic review of the countries in which a seasonal pattern of preterm birth has been reported and an analysis on the seasonal variability of preterm birth in a London‐based cohort.

The epidemiology of preterm labour—why have advances not equated to reduced incidence?

The major burden of preterm birth is in the developing world, where most of the increasing death and morbidity is secondary to infectious diseases such as malaria, HIV, tuberculosis, bacterial vaginosis and intestinal parasites. In some developing countries, the growth of medical care has outstripped the growth of preventive public health, with an associated increase in iatrogenic preterm births. In developed countries, more than one‐third of preterm births are medically indicated because of conditions such as fulminating pre‐eclampsia or severe intrauterine growth restriction. Neither of these conditions is currently preventable. One in five preterm births is associated with multiple pregnancy, and these have been greatly increased by assisted reproduction techniques. The use of tocolytics has proved disappointing perhaps because inflammation rather than spontaneous uterine activity is increasingly recognised as the final common pathway. Inappropriate antibiotics used late in pregnancy are ineffective and may have adverse effects. Currently, the most promising interventions are public health related and include reducing the transmission of communicable diseases, improvements in the management of diabetes and reduction in harmful behaviours such as smoking and drug abuse.

The effect of oxytocin infusion on uterine activity levels in slow labour

Summary. Uterine activity was studied in 31 women who were progressing slowly in spontaneous labour. In 75%, levels of uterine activity were below the tenth centile for normal spontaneous labour (mean uterine activity integral, UAI, 593 kPas/15 min; SD 296). Following oxytocin infusion, there was a significant increase in uterine activity to a mean of 1124 kPas/15 min (SD 276), which was t h e same as in normal spontaneous labour. The response t o oxytocin was dependent upon the pre‐existing level of uterine activity, and sensitivity to oxytocin, rather than the dose rate; 84% responded t o infusion rates of < 8 mU/min. The response t o oxytocin was best expressed in terms of active contraction area (uterine activity integral, UAI) or Montevideo units, rather than the frequency or active pressure of contractions. The rate of cervical dilatation following oxytocin augmentation could not be predicted either by t h e increase in uterine activity or by the actual level of activity achieved.

Normal levels of active contraction area in spontaneous labour

Summary. A detailed study has been made of uterine activity in a group of 21 unselected women in spontaneous labour. Measurements were made of contraction frequency, active pressure, Montevideo units and active contraction area. The level of Montevideo units were comparable with ‐values previously reported in spontaneous labour. Active contraction area correlated better than any of the other measures with the rate of cervical dilatation in the active phase of labour (r= 0.69). The mean contractionarea was 1099 (SD 333) kPas/15 min.

Pulmonary hypertension and pregnancy--a review of 12 pregnancies in nine women.

Please cite this paper as: Curry R, Fletcher C, Gelson E, Gatzoulis M, Woolnough M, Richards N, Swan L, Steer P, Johnson M. Pulmonary hypertension and pregnancy—a review of 12 pregnancies in nine women. BJOG 2012;119:752–761.

UTERINE ACTIVITY IN lNDUCED LABOUR

A study was made of the characteristics of oxytocin‐induced labour. Twelve patients with, and eight without membrane rupture were closely matched for factors likely to influence the character and duration of labour. In both groups uterine activity increased until a stable state was achieved following which there was little alteration until delivery. The duration of labour was shorter in the group with ruptured membranes as compared with intact membranes although, paradoxically, the uterine activity tended to be greater when the membranes were intact.