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Liverpool, United States

Bricker L.,Liverpool Womens NHS Foundation Trust
Bailliere's Best Practice and Research in Clinical Obstetrics and Gynaecology | Year: 2014

Twin and triplet pregnancy is a high-risk situation, with increased risk of mortality and morbidity for both mother and babies. It is, therefore, essential that high-quality antenatal care is provided to optimise outcomes and identify and manage complications effectively. A number of additional elements of care are advised, which requires more monitoring and contact with healthcare professionals with appropriate expertise. In addition, women should be provided with accurate and relevant information and emotional support to mitigate against the anxiety and stress of these high-risk pregnancies. Early care focuses on determining chorionicity and screening for fetal complications, whereas later care concentrates on identifying and managing preterm birth, growth restriction, maternal complications, and planning for delivery. Unfortunately, the evidence base for managing these challenging pregnancies is often lacking, and a number of areas of further research is required. © 2013 Elsevier Ltd. All rights reserved. Source

Rylance S.,Liverpool Womens NHS Foundation Trust | Ward J.,Great Ormond Street Hospital
Paediatrics and International Child Health | Year: 2013

Background: There is little information regarding outcome of very low-birthweight (VLBW) infants in resource-poor settings. Objectives: To study early mortality outcome in VLBW infants admitted to the neonatal nursery, Queen Elizabeth Central Hospital, Blantyre and determine duration of hospital stay of surviving infants and their attendance for recommended follow-up. Methods: Case notes were reviewed for all infants weighing ≤1500 g at birth admitted to the neonatal unit during a 6-month period (May-October 2010) to establish survival to discharge and follow-up attendance. Results: 42% (112/268) of VLBW infants survived to discharge. Survival significantly increased with increasing birthweight (11% for infants weighing ≤1000 g vs 53% for those >1000 g, P<0.001), and greater gestation (19% for infants <32 weeks vs 68% for ≧32 weeks, P<0.001). Most deaths (88%, 137/156) occurred within the first week, 58% of them (91/156) within 48 hours of admission. Surviving infants with a birthweight of 1001-1500 g stayed in hospital for a mean 21 days (range 5-44) and those weighing ≤1000 g at birth (eight) stayed for a mean 47 days (range 35-64). A total of 108 infants were discharged from hospital, 87 of whom (81%) attended at least one follow-up visit, 62 of whom (57%) completed the recommended follow-up attendance. Conclusion: There is considerable scope to improve survival rates of VLBW infants in this setting, although staffing and economic constraints make survival of the smallest and most premature infants unrealistic. Mothers of surviving infants <1000 g should be prepared for a lengthy hospital stay. © W. S. Maney & Son Ltd 2013. Source

Dawood F.,Liverpool Womens NHS Foundation Trust
The Cochrane database of systematic reviews | Year: 2013

Several factors may influence the progression of normal labour. It has been postulated that the routine administration of intravenous fluids to keep women adequately hydrated during labour may reduce the period of contraction and relaxation of the uterine muscle, and may ultimately difference identified in the assisted delivery rate (RR 0.78, 95% CI 0.44 to 1.40). There was no clear difference between groups in the number of babies admitted to the NICU (RR 0.48, 95% CI 0.07 to 3.17).Two trials compared normal saline versus 5% dextrose. Only one reported the mean duration of labour, and there was no strong evidence of a difference between groups (MD -12.00, 95% CI -30.09 to 6.09). A trial reporting the median suggested that the duration was reduced in the dextrose group. There was no significant difference in CS or assisted deliveries (RR 0.77, 95% CI 0.41 to 1.43, two studies, 284 women) and (RR 0.59, 95% CI 0.21 to 1.63, one study, 93 women) respectively. Only one trial reported on maternal hyponatraemia (serum sodium levels < 135 mmol/L ). For neonatal complications, there was no difference in the admission to NICU) or in low Apgar scores, however 33.3% of babies developed hyponatraemia in the dextrose group compared to 13.3 % in the normal saline group (RR 0.40, 95% CI 0.17 to 0.93) (P = 0.03). One trial reported a higher incidence of neonatal hyperbilirubinaemia in the dextrose group of babies. There was no difference in neonatal hypoglycaemic episodes between groups. Although the administration of intravenous fluids compared with oral intake alone demonstrated a reduction in the duration of labour, this finding emerged from only two trials. The findings of other trials suggest that if a policy of no oral intake is applied, then the duration of labour in nulliparous women may be shortened by the administration of intravenous fluids at a rate of 250 mL/hour rather than 125 mL/hour. However, it may be possible for women to simply increase their oral intake rather than being attached to a drip and we have to consider whether it is justifiable to persist with a policy of 'nil by mouth'. One trial raised concerns about the safety of dextrose and this needs further exploration.None of the trials reported on the evaluation of maternal views of being attached to a drip during their entire labour. Furthermore, there was no objective assessment of dehydration. The evidence from this review does not provide robust evidence to recommend routine administration of intravenous fluids. Interpreting the results from trials was hampered by the low number of trials contributing data and by variation between trials. In trials where oral fluids were not restricted there was considerable variation in the amount of oral fluid consumed by women in different arms of the same trial, and between different trials. In addition, results from trials were not consistent and risk of bias varied. Some important research questions were addressed by single trials only, and important outcomes relating to maternal and infant morbidity were frequently not reported. Source

Sarah A.,University of Liverpool | James N.,University of Liverpool | Leanne B.,Liverpool Womens NHS Foundation Trust | Susan W.,University of Liverpool
Reproductive Sciences | Year: 2016

We compared the relaxant effect of 2 known tocolytics; indomethacin and atosiban and progesterone, on pregnant human myometrial spontaneous and oxytocin-induced contractions from singleton and twin pregnancies. All agents exerted a concentration-dependent relaxant effect on myometrial contractions. There was no significant difference in the concentration- response curves between singletons and twins for progesterone or indomethacin on spontaneous contractions or atosiban on oxytocin-induced contraction. Under oxytocin however, the concentration-response curves for indomethacin and progesterone were significantly shifted to the right for both amplitude of contraction (P<.01) and activity integral (P < .01). When compared to singleton myometrium however, the concentration-response curves were significantly shifted to the right in the twin myometrium group (P < .05 progesterone and P < .001 indomethacin). We conclude that a greater concentration of progesterone and indomethacin is required to inhibit oxytocin-induced myometrial contractions in twins compared to singletons in vitro. The differences noted in the tissue pharmacologies may have implications for the successful prevention or inhibition of preterm labor in twin pregnancy. © The Author(s) 2015. Source

Gurol-Urganci I.,London School of Hygiene and Tropical Medicine | Gurol-Urganci I.,Office for Research and Clinical Audit | Cromwell D.A.,London School of Hygiene and Tropical Medicine | Edozien L.C.,University of Manchester | And 5 more authors.
BJOG: An International Journal of Obstetrics and Gynaecology | Year: 2013

Objective: To describe the trends of severe perineal tears in England and to investigate to what extent the changes in related risk factors could explain the observed trends. Design: A retrospective cohort study of singleton deliveries from a national administrative database. Setting: The English National Health Service between 1 April 2000 and 31 March 2012. Population: A cohort of 1 035 253 primiparous women who had a singleton, term, cephalic, vaginal birth. Methods: Multivariable logistic regression was used to estimate the impact of financial year of birth (labelled by starting year), adjusting for major risk factors. Main outcome measure: The rate of third-degree (anal sphincter is torn) or fourth-degree (anal sphincter as well as rectal mucosa are torn) perineal tears. Results: The rate of reported third- or fourth-degree perineal tears tripled from 1.8 to 5.9% during the study period. The rate of episiotomy varied between 30 and 36%. An increasing proportion of ventouse deliveries (from 67.8 to 78.6%) and non-instrumental deliveries (from 15.1 to 19.1%) were assisted by an episiotomy. A higher risk of third- or fourth-degree perineal tears was associated with a maternal age above 25 years, instrumental delivery (forceps and ventouse), especially without episiotomy, Asian ethnicity, a more affluent socio-economic status, higher birthweight, and shoulder dystocia. Conclusions: Changes in major risk factors are unlikely explanations for the observed increase in the rate of third- or fourth-degree tears. The improved recognition of tears following the implementation of a standardised classification of perineal tears is the most likely explanation. © 2013 RCOG. Source

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