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Wilson M.J.A.,Royal Hallamshire Hospital | Moore P.A.S.,Birmingham Womens Hospital NHS Foundation Trust | Shennan A.,Kings College | Lancashire R.J.,University of Birmingham | MacArthur C.,University of Birmingham
Birth | Year: 2011

Background: Epidural analgesia provides the most effective pain relief in labor, but it is not known if it causes adverse long-term effects. The objective of this study was to assess the long-term effects of two mobile epidural techniques relative to high-dose epidural analgesia in a randomized controlled trial. Methods: A total of 1,054 nulliparous women were randomized to traditional high-dose epidural, combined spinal epidural, or low-dose infusion. Women in all groups were followed-up at 12months postpartum by postal questionnaire to assess long-term symptoms. The primary long-term outcome was backache occurring within 3months of the birth persisting for longer than 6weeks. Secondary outcomes were frequent headaches and fecal and urinary stress incontinence. Results: No significant differences were found in long-term backache after combined spinal epidural or low-dose infusion relative to high-dose epidural. Significantly less headache occurred in combined spinal epidural analgesia than high-dose epidural (OR: 0.57, 95% CI: 0.36-0.92), but no difference was found for low-dose infusion. Significantly less fecal incontinence (OR: 0.51, 95% CI: 0.30-0.87) and stress incontinence (OR: 0.65, 95% CI: 0.42-1.00) occurred with low-dose infusion. Conclusion: Trial evidence showed no long-term disadvantages and possible benefits of low-dose mobile relative to high-dose epidural analgesia. © 2011, Copyright the Authors. Journal compilation © 2011, Wiley Periodicals, Inc. Source


Morris R.K.,University of Birmingham | Morris R.K.,Foundation Medicine | Riley R.D.,University of Birmingham | Doug M.,Birmingham Womens Hospital NHS Foundation Trust | And 3 more authors.
BMJ (Online) | Year: 2012

Objective To determine the diagnostic accuracy of two "spot urine" tests for significant proteinuria or adverse pregnancy outcome in pregnant women with suspected pre-eclampsia. Design Systematic review and meta-analysis. Data sources Searches of electronic databases 1980 to January 2011, reference list checking, hand searching of journals, and contact with experts. Inclusion criteria Diagnostic studies, in pregnant women with hypertension, that compared the urinary spot protein to creatinine ratio or albumin to creatinine ratio with urinary protein excretion over 24 hours or adverse pregnancy outcome. Study characteristics, design, and methodological and reporting quality were objectively assessed. Data extraction Study results relating to diagnostic accuracy were extracted and synthesised using multivariate random effects meta-analysis methods. Results Twenty studies, testing 2978 women (pregnancies), were included. Thirteen studies examining protein to creatinine ratio for the detection of significant proteinuria were included in the multivariate analysis. Threshold values for protein to creatinine ratio ranged between 0.13 and 0.5, with estimates of sensitivity ranging from 0.65 to 0.89 and estimates of specificity from 0.63 to 0.87; the area under the summary receiver operating characteristics curve was 0.69. On average, across all studies, the optimum threshold (that optimises sensitivity and specificity combined) seems to be between 0.30 and 0.35 inclusive.] However, no threshold gave a summary estimate above 80% for both sensitivity and specificity, and considerable heterogeneity existed in diagnostic accuracy across studies at most thresholds. No studies looked at protein to creatinine ratio and adverse pregnancy outcome. For albumin to creatinine ratio, meta-analysis was not possible. Results from a single study suggested that the most predictive result, for significant proteinuria, was with the DCA 2000 quantitative analyser (>2 mg/mmol) with a summary sensitivity of 0.94 (95% confidence interval 0.86 to 0.98) and a specificity of 0.94 (0.87 to 0.98). In a single study of adverse pregnancy outcome, results for perinatal death were a sensitivity of 0.82 (0.48 to 0.98) and a specificity of 0.59 (0.51 to 0.67). Conclusion The maternal "spot urine" estimate of protein to creatinine ratio shows promising diagnostic value for significant proteinuria in suspected pre-eclampsia. The existing evidence is not, however, sufficient to determine how protein to creatinine ratio should be used in clinical practice, owing to the heterogeneity in test accuracy and prevalence across studies. Insufficient evidence is available on the use of albumin to creatinine ratio in this area. Insufficient evidence exists for either test to predict adverse pregnancy outcome. Source


Platts J.,University of Manchester | Mitchell E.A.,University of Auckland | Stacey T.,Mid Yorkshire Hospitals NHS Trust | Martin B.L.,Birmingham Womens Hospital NHS Foundation Trust | And 3 more authors.
BMC Pregnancy and Childbirth | Year: 2014

Background: The United Kingdom has one of the highest rates of stillbirth in Europe, resulting in approximately 4,000 stillbirths every year. Potentially modifiable risk factors for late stillbirths are maternal age, obesity and smoking, but the population attributable risk associated with these risk factors is small.Recently the Auckland Stillbirth Study reported that maternal sleep position was associated with late stillbirth. Women who did not sleep on their left side on the night before the death of the baby had double the risk compared with sleeping on other positions. The population attributable risk was 37%. This novel observation needs to be replicated or refuted.Methods/Design: Case control study of late singleton stillbirths without congenital abnormality. Controls are women with an ongoing singleton pregnancy, who are randomly selected from participating maternity units booking list of pregnant women, they are allocated a gestation for interview based on the distribution of gestations of stillbirths from the previous 4 years for the unit. The number of controls selected is proportional to the number of stillbirths that occurred at the hospital over the previous 4 years.Data collection: Interviewer administered questionnaire and data extracted from medical records. Sample size: 415 cases and 830 controls. This takes into account a 30% non-participation rate, and will detect an OR of 1.5 with a significance level of 0.05 and power of 80% for variables with a prevalence of 57%, such as non-left sleeping position.Statistical analysis: Mantel-Haenszel odds ratios and unconditional logistic regression to adjust for potential confounders.Discussion: The hypotheses to be tested here are important, biologically plausible and amenable to a public health intervention. Although this case-control study cannot prove causation, there is a striking parallel with research relating to sudden infant death syndrome, where case-control studies identified prone sleeping position as a major modifiable risk factor. Subsequently mothers were advised to sleep babies prone (" Back to Sleep" campaign), which resulted in a dramatic drop in SIDS. This study will provide robust evidence to help determine whether such a public health intervention should be considered.Trial registration number: NCT02025530. © 2014 Platts et al.; licensee BioMed Central Ltd. Source


Israfil-Bayli F.,Birmingham Womens Hospital NHS Foundation Trust | Toozs-Hobson P.,Birmingham Womens Hospital NHS Foundation Trust | Lees C.,University of Cambridge | Slack M.,University of Cambridge | And 2 more authors.
Medical Hypotheses | Year: 2013

Cervical weakness is an important cause of late miscarriage and extreme preterm labour. Women have been traditionally offered a cervical cerclage procedure, though studies failed to demonstrate a therapeutic effect. None of these studies has addressed the effect of non-braided to braided suture material on cerclage outcome. Type of suture material is an important determinant of surgical outcomes. This issue is of particular relevance to cerclage because the traditionally braided suture has been associated with increased risk of infection in other surgical procedures. Indeed, infection is an important underlying cause for cerclage failure. It is for this reason that some surgeons use non-braided suture material. Therefore, we hypothesise that the unrealised benefit of cervical cerclage is at least in part due to the type of suture material used. In this article, we present the rationale behind our hypothesis and a proposed way of testing it. © 2013 Elsevier Ltd. Source


Israfil-Bayli F.,Birmingham Womens Hospital NHS Foundation Trust | Toozs-Hobson P.,Birmingham Womens Hospital NHS Foundation Trust | Lees C.,Imperial College London | Slack M.,University of Cambridge | Ismail K.,University College Birmingham
Trials | Year: 2015

Background: Cervical incompetence is one of the causes of preterm birth and mid-trimester pregnancy loss. Cervical cerclage is a surgical procedure to treat cervical incompetence. Cervical cerclage reduces the incidence of preterm birth in women at risk of recurrent preterm birth, without a statistically significant reduction in perinatal mortality or neonatal morbidity. Multifilament/braided sutures such as Mersilene tape have been traditionally used for cervical cerclage. Braided sutures, particularly mesh-like non-absorbable sutures, have been associated with an increased risk of infection and, hence, some obstetricians prefer to use monofilament/non-braided sutures. However, these claims are not substantiated by any scientific or clinical evidence. Methods/Design: Women eligible for elective or ultrasound-indicated cerclage at 12 to 21 + 6 weeks of gestation will be randomised to having the procedure using either a monofilament non-braided suture (Ethilon) or a Multifilament braided suture (Mersilene tape) inserted using a McDonald technique. Consent for participation in the Cerclage outcome by the type of suture (COTS) study will be obtained from each eligible participant. Clinical trials registration: COTS is registered with the International Standard Research for Clinical Trials (ISRCTN17866773). Registered on 27 March 2013. © 2014 Israfil-Bayli et al.; licensee BioMed Central Ltd. Source

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