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Rylance S.,Liverpool Womens NHS Foundation Trust | Yan J.,Royal Melbourne Hospital
Paediatrics and International Child Health | Year: 2014

Objectives: To assess the correlation between total serum bilirubin (TSB) and transcutaneous bilirubin (TcB) values in Malawian newborn infants, and to investigate whether TcB can be used safely to guide phototherapy treatment in the absence of TSB results. Methods: 128 newborn jaundiced infants were studied in the neonatal nursery at Queen Elizabeth Central Hospital, Blantyre. Paired TSB and TcB measurements (from forehead and sternum) were compared using the linear regression and Bland-Altman methods. Clinical decisions based on TcB results were compared with those based on 'gold standard' TSB results. Results: For infants not under phototherapy, the lowest TcB reading (from forehead or sternum) gave the strongest correlation with TSB: r=0.83 for term infants and r=0.71 for premature infants. For infants undergoing phototherapy, the highest TcB reading gave the strongest correlation with TSB: r=0.66 for term infants and r=0.71 for premature infants. TcB values overestimated the degree of jaundice. For infants not under phototherapy, the mean (SD) bias and imprecision of TcB was 25 (72) μmol/L for term infants and 37 (73) μmol/L for premature infants. For infants under phototherapy, the mean bias and imprecision was 30 (79) μmol/L for term infants and 44 (77) μmol/L for premature infants. For infants not under phototherapy, using the lowest TcB reading to guide treatment decisions (n=167) had good sensitivity (91%) and specificity (90%). For infants undergoing phototherapy, using the highest TcB reading to guide treatment decisions (n=129) had good sensitivity (94%), but lower specificity (36%). Conclusions: TcB can be used to safely guide phototherapy treatment in a resource-poor setting. © W. S. Maney & Son Ltd 2014.


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 6 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.


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.


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.


Kerrigan A.M.,Liverpool Womens NHS Foundation Trust | Kingdon C.,University of Central Lancashire
Midwifery | Year: 2010

Objectives: to establish the incidence of obesity in the pregnant population in a large city in the North West of England, identify links between obesity and social deprivation, and compare outcomes of pregnancy in obese and non-obese women. Design: retrospective cohort study using maternal records. Setting: largest maternity hospital in Europe. Participants: 8176 women who gave birth at the study hospital in 2006. Findings: data showed that 17.7% of women were clinically obese. Obesity rates increased with advancing age. The incidence of pre-eclampsia, gestational diabetes, induction of labour, caesarean section and fetal macrosomia was significantly higher amongst the obese population. No relationship was found between obesity and social deprivation. Conclusions: this study ascertained the exact incidence of maternal obesity in the local area and showed the increased risks associated with obesity and pregnancy. Implications for practice: this study supports the need for a shared-care approach to antenatal care and that obese women should give birth in consultant-led units. The support of a named midwife should be available to these women throughout the childbearing experience, and preconception care advocated. © 2008 Elsevier Ltd. All rights reserved.


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.


McNamee K.,Liverpool Womens NHS Foundation Trust | Dawood F.,Liverpool Womens NHS Foundation Trust | Farquharson R.,Liverpool Womens NHS Foundation Trust
Current Opinion in Obstetrics and Gynecology | Year: 2012

PURPOSE OF REVIEW: Acquired and inherited thrombophilia is an important research avenue in the recurrent miscarriage field. The optimum treatment for patients with recurrent miscarriage and a confirmed thrombophilia remains a contentious issue. We aim to appraise and explore the latest research in the field of thrombophilia and recurrent miscarriage in this review. RECENT FINDINGS: Antiphospholipid syndrome (APS) is the only proven thrombophilia that is associated with adverse pregnancy outcomes. Research involving inherited thrombophilia and recurrent miscarriage is limited to small observational studies with small and heterogeneous populations. Aspirin and heparin therapy are frequently prescribed for APS, yet there is no robust evidence for the most efficacious regime. The combination of inherited hypercoagulability and environmental factors in association with recurrent miscarriage has recently been explored as an aid to identify high-risk individuals. SUMMARY: The cause of recurrent miscarriage is multifactorial and appropriate treatment continues to be a challenge. Laboratory tests need to be standardized and well designed multicentre research trials are essential to expand on the current knowledge base with the aim to produce strong evidence-based medicine. © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins.


McNamee K.,Liverpool Womens NHS Foundation Trust | Dawood F.,Liverpool Womens NHS Foundation Trust | Farquharson R.G.,Liverpool Womens NHS Foundation Trust
Best Practice and Research: Clinical Obstetrics and Gynaecology | Year: 2012

Early pregnancy loss is the most common pregnancy complication. About 15% of pregnancies result in pregnancy loss and 1% of women experience recurrent miscarriage (more than three consecutive miscarriages). The influence of thrombophilia in pregnancy is a popular research topic in recurrent miscarriage. Both acquired and inherited thrombophilia are associated with a risk of pregnancy failure. Antiphospholipid syndrome is the only thrombophilia known to have a direct adverse effect on pregnancy. Historically, clinical research studying thrombophilia treatment in recurrent miscarriage has been of limited value owing to small participant numbers, poor study design and heterogeneity. The debate on the efficacy of aspirin and heparin has advanced with recently published randomised-controlled trials. Multi-centre collaboration is required to ascertain the effect of thrombophilia on early pregnancy loss and to establish an evidence-based treatment protocol. © 2011 Elsevier Ltd. All rights reserved.


Ford J.M.,Liverpool WomenS NHS Foundation Trust | Scholefield H.,Liverpool WomenS NHS Foundation Trust
Current Opinion in Anaesthesiology | Year: 2014

Purpose of Review: The aim of the study was to provide a summary of recent guidance on sepsis in obstetrics. RECENT FINDINGS: Morbidity and mortality from sepsis is increasing in the UK and other developed countries. In many cases, care has been found to be substandard. Common themes are a failure to recognize and respond to the sick woman and inadequate antibiotic and fluid management in the septic parturient. SUMMARY: Increased awareness of obstetric sepsis is required. Women and their families need to be informed about it and staff must have the skills and competencies to recognize this early. The management of severe sepsis in obstetrics is multidisciplinary. Implementation of the goals of the Surviving Sepsis Campaign into obstetric practice is important to improve outcomes. More research is needed to validate the parameters used in this and early warning scores for the obstetric population. © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins.


Roberts D.,Liverpool Womens NHS Foundation Trust
The Cochrane database of systematic reviews | Year: 2014

Twin-twin transfusion syndrome, a condition affecting monochorionic twin pregnancies, is associated with a high risk of perinatal mortality and morbidity. A number of treatments have been introduced to treat the condition but it is unclear which intervention improves maternal and fetal outcome. The objective of this review was to evaluate the impact of treatment modalities in twin-twin transfusion syndrome. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2013). Randomised and quasi-randomised studies of amnioreduction versus laser coagulation, septostomy versus laser coagulation or septostomy versus amnioreduction. Two review authors independently assessed eligibility and extracted data. We contacted study authors for additional information. Three studies (253 women and 506 babies) were included. All three trials were judged to be of moderate quality. One study compared amnioreduction with septostomy (71 women), whilst the other two studies compared amnioreduction with endoscopic laser coagulation (182 women). Not all trials provided outcome data that could be included in all meta-analyses. Amnioreduction compared with laser coagulation Although there was no difference in overall death between amnioreduction and laser coagulation (average risk ratio (RR) 0.87; 95% confidence interval (CI) 0.55 to 1.38 adjusted for clustering, two trials) or death of at least one infant per pregnancy (RR 0.91; 95% CI 0.75 to 1.09, two trials), or death of both infants per pregnancy (average RR 0.76; 95% 0.27 to 2.10, two trials), more babies were alive without neurological abnormality at the age of six years in the laser group than in the amnioreduction groups (RR 1.57; 95% CI 1.05 to 2.34 adjusted for clustering, one trial). There were no significant differences in the babies alive at six years with major neurological abnormality treated by laser coagulation or amnioreduction (RR 0.97; 95% CI 0.34 to 2.77 adjusted for clustering, one trial). Outcomes for death in this 2013 update are different from the previous 2008 update, where improvements in perinatal death and death of both infants per pregnancy were shown in the laser intervention arm. The NIHCD trial included in this update exerts an opposite direction of effects to the Eurofetus study, which was previously the only included laser study, hence the difference in outcome. Amnioreduction compared with septostomy There are no differences in overall death (RR 0.83; 95% CI 0.47 to 1.47, adjusted for clustering, one trial), death of at least one infant per pregnancy (RR 0.80; 95% CI 0.48 to 1.35, one trial), or death of both infants per pregnancy (RR 0.90; 95% CI 0.37 to 2.22, one trial) or gestational age at birth (RR 1.20; 95% CI -0.81 to 3.21, one trial) between amnioreduction and septostomy. Endoscopic laser coagulation of anastomotic vessels should continue to be considered in the treatment of all stages of twin-twin transfusion syndrome to improve neurodevelopmental outcomes.Further research targeted towards assessing the effect of treatment on milder (Quintero stage 1 and 2) and more severe (Quintero stage 4) forms of twin-twin transfusion syndrome is required. Studies should aim to assess long-term outcomes of survivors.

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