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OBJECTIVE:: Higher-dose oxytocin is more effective than lower-dose regimens to prevent postpartum hemorrhage after cesarean delivery. We compared two higher-dose regimens (80 units and 40 units) to our routine regimen (10 units) among women who delivered vaginally. METHODS:: In a double-masked randomized trial, oxytocin (80 units, 40 units, or 10 units) was administered in 500 mL over 1 hour after placental delivery. The primary outcome was a composite of any treatment of uterine atony or hemorrhage. Prespecified secondary outcomes included outcomes in the primary composite and a decline of 6% or more in hematocrit. A sample size of 600 per group (N=1,800) was planned to compare each of the 80-unit and 40-unit groups to the 10-unit group. At planned interim review (n=1,201), enrollment in the 40-unit group was stopped for futility and enrollment continued in the other groups. RESULTS:: Of 2,869 women, 1,798 were randomized as follows: 658 to 80 units; 481 to 40 units; and 659 to 10 units. Most characteristics were similar across groups. The risk of the primary outcome in the 80-unit group (6%; relative risk [RR] 0.93, 95% confidence interval [CI] 0.62-1.40) or the 40-unit group (6%; RR 0.94, 95% CI 0.61-1.47) was not different compared with the 10-unit group (7%). Treatment with additional oxytocin after the first hour was less frequent with 80 units compared with 10 units (RR 0.41, 95% CI 0.19-0.88), as was a 6% or more decline in hematocrit (RR 0.83, 95% CI 0.69-0.99); both outcomes declined with increasing oxytocin dose. Outcomes were similar between the 40-unit and 10-unit groups. CONCLUSION:: Compared with 10 units, 80 units or 40 units of prophylactic oxytocin did not reduce overall postpartum hemorrhage treatment when administered in 500 mL over 1 hour for vaginal delivery. Eighty units decreased the need for additional oxytocin and the risk of a decline in hematocrit of 6% or more. CLINICAL TRIAL REGISTRATION:: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00790062. LEVEL OF EVIDENCE:: I.
PMID: 22227638 [PubMed - as supplied by publisher]
OBJECTIVE:: To investigate whether episiotomy, perineal laceration, and operative delivery are associated with pelvic floor disorders after vaginal childbirth. METHODS:: This is a planned analysis of data for a cohort study of pelvic floor disorders. Participants who had experienced at least one vaginal birth were recruited 5-10 years after delivery of their first child. Obstetric exposures were classified by review of hospital records. At enrollment, pelvic floor outcomes, including stress incontinence, overactive bladder, anal incontinence, and prolapse symptoms were assessed with a validated questionnaire. Pelvic organ support was assessed using the Pelvic Organ Prolapse Quantification system. Logistic regression analysis was used to estimate the relative odds of each pelvic floor disorder by obstetric history, adjusting for relevant confounders. RESULTS:: Of 449 participants, 71 (16%) had stress incontinence, 45 (10%) had overactive bladder, 56 (12%) had anal incontinence, 19 (4%) had prolapse symptoms, and 64 (14%) had prolapse to or beyond the hymen on examination. Forceps delivery increased the odds of each pelvic floor disorder considered, especially overactive bladder (odds ratio [OR] 2.92, 95% confidence interval [CI] 1.44-5.93), and prolapse (OR 1.95, 95% CI 1.03-3.70). Episiotomy was not associated with any of these pelvic floor disorders. In contrast, women with a history of more than one spontaneous perineal laceration were significantly more likely to have prolapse to or beyond the hymen (OR 2.34, 95% CI 1.13-4.86). Our multivariable results suggest that one additional woman would have development of prolapse for every eight women who experienced at least one forceps birth (compared with delivering all her children by spontaneous vaginal birth). CONCLUSION:: Forceps deliveries and perineal lacerations, but not episiotomies, were associated with pelvic floor disorders 5-10 years after a first delivery. LEVEL OF EVIDENCE:: II.
PMID: 22227639 [PubMed - as supplied by publisher]
Risk of Morbid Perinatal Outcomes in Small-for-Gestational-Age Pregnancies: Customized Compared With Conventional Standards of Fetal Growth.
Obstet Gynecol. 2012 Jan;119(1):21-7
Authors: Larkin JC, Hill LM, Speer PD, Simhan HN
Abstract
OBJECTIVE: : To estimate and compare the risk of morbid perinatal outcomes in pregnancies identified as small for gestational age (SGA) with customized compared with conventional standards of fetal growth.
METHODS: : Ultrasound-derived estimates of fetal weight were used to generate a fetal growth trajectory (N=7,510). The gestational age at delivery and pathologic and physiologic variables from 5,072 pregnancies were used to calculate a customized threshold for SGA. In a separate analysis of 32,070 pregnancies, rates of morbid outcomes were compared in participants classified as SGA according to a population-based birth weight standard only (SGApop only), a customized standard only (SGAcust only), and both methods (SGAboth).
RESULTS: : Eight-hundred seventy-five (2.7%) participants were SGApop only, 1,970 (6.1%) participants were SGAboth, and 609 (1.9%) participants were SGAcust only. The odds ratios of neonatal death in SGApop only and SGAcust only pregnancies were 1.78 (95% confidence interval [CI] 0.2-13.1) and 54.6 (95% CI 29.0-102.8), respectively. Rates of prematurity in the SGApop only and SGAcust only cohorts were 4.8% and 64.5%, respectively. After adjustment for the effect of prematurity, odds ratios of neonatal death in the SGApop only and SGAcust only cohorts were 4.8 (95% CI 0.6-37.0) and 2.9 (95% CI 1.4-6.1), respectively.
CONCLUSION: : After adjustment for confounding stemming from premature delivery, there is little difference in the risk of adverse outcomes between SGAcust only and SGApop only participants. Adoption of customized fetal growth standards into clinical practice may not improve the ability to identify pregnancies with increased risk of perinatal morbidity.
OBJECTIVE:: To assess whether exercise during pregnancy can prevent gestational diabetes and improve insulin resistance. METHODS:: A total of 855 women in gestational week 18-22 were randomly assigned to receiving a 12-week standard exercise program (intervention group) or standard antenatal care (control group). The exercise program followed standard recommendations and included moderate-intensity to high-intensity activity 3 or more days per week. Primary outcomes were gestational diabetes and insulin resistance estimated by the homeostasis model assessment method. For the power calculation, we assumed a gestational diabetes prevalence of 9% in the control group and a prevalence of 4% in the exercise group (risk difference of 5%). Under these assumptions, a two-sample comparison with a 5% level of significance and power of 0.80 gave a study population of 381 patients in each group. RESULTS:: At 32-36 weeks of gestation there were no differences between groups in prevalence of gestational diabetes: 25 of 375 (7%) in the intervention group compared with 18 of 327 (6%) in the control group (P=.52). There were no differences in insulin resistance between groups when adjusting for baseline values. Only 55% of women in the intervention group managed to follow the recommended exercise protocol. No serious adverse events related to physical exercise were seen, and the outcomes of pregnancy were similar in the two groups. CONCLUSION:: There was no evidence that offering women a 12-week standard exercise program during the second half of pregnancy prevents gestational diabetes or improves insulin resistance in healthy pregnant women with normal body mass indexes. CLINICAL TRIAL REGISTRATION:: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00476567. LEVEL OF EVIDENCE:: I.
PMID: 22183208 [PubMed - as supplied by publisher]
Prognosis for live birth in women with recurrent miscarriage: what is the best measure of success?
Obstet Gynecol. 2012 Jan;119(1):37-43
Authors: Lund M, Kamper-Jørgensen M, Nielsen HS, Lidegaard O, Andersen AM, Christiansen OB
Abstract
OBJECTIVE: : To establish a method of estimating the proportion of women with a subsequent live birth after a well-defined time period in an open cohort of women referred to a tertiary recurrent miscarriage clinic.
METHODS: : We performed a descriptive cohort study with register-based follow-up at a tertiary center for investigation and treatment of recurrent miscarriage in Denmark. All women with primary or secondary recurrent miscarriage referred to the clinic from 1986 to 2008 were included in the study (n=987). Main outcome measures were age-specific and miscarriage-specific proportions of women with a live birth after the first consultation and similar hazard ratios compared with the prognosis in women aged 30-34 years with three miscarriages before the first consultation.
RESULTS: : Five years after the first consultation, 66.7% (95% confidence interval [CI] 63.7-69.7) had achieved a live birth, increasing to 71.1% (95% CI 68.0-74.2) 15 years after the first consultation. There was a significantly decreased chance of at least one subsequent live birth with increasing maternal age (log-rank P<.01) and increasing number of miscarriages (log-rank P<.01) at first consultation.
CONCLUSION: : Approximately two thirds of women with recurrent miscarriage referred to a tertiary center succeed in having at least one live birth within 5 years after their first consultation. Our study allows for a descriptive overview of the course of live birth outcome in women with recurrent miscarriage, but not for evaluation of the effect of treatment.
Increased live birth rate in twin pregnancies resulting from embryo assistance.
Obstet Gynecol. 2012 Jan;119(1):44-9
Authors: Miró F, Vidal E, Balasch J
Abstract
OBJECTIVE: : To estimate why the live birth rate per implanted embryo is higher in twin than in singleton pregnancies.
METHODS: : Data from 1,159 singleton and 523 dichorionic twin pregnancies, obtained after assisted conception, were included. To account for the higher live birth rate observed in twin pregnancies, two possibilities were considered: embryo collaboration and assistance. To test these hypotheses, we compared the observed values for each possible outcome in twin pregnancies (double birth, single birth, double loss) with the expected values regarding as the null hypothesis that the survival of either embryo is independent from the presence of the other. The effect of maternal age was also examined.
RESULTS: : Live birth rate, per implanted embryo, was higher in twin than in singleton pregnancies: 83% compared with 76% (odds ratio 1.53, 95% confidence interval 1.24-1.88; P<.001). There were significant differences between the observed outcomes in twin pregnancies and those expected assuming no interaction between embryos (P<.001). The number of double births was higher than expected (71.9% observed compared with 57.7% expected), whereas single births were lower to a similar extent (22% observed compared with 36.5% expected). In contrast, observed and expected double losses were similar (6.1% observed compared with 5.8% expected). Although the overall rate of miscarriage was higher for women aged 34 years and older, the difference in live birth rate between twin and singleton pregnancies was 2.4-fold higher than in younger women.
CONCLUSION: : The higher live birth rate occurring in twin pregnancies can be accounted for by assistance, whereby some embryos that would fail as singletons survive in a twin pregnancy when implanted along with a fit sibling. This effect is more pronounced in older mothers.
OBJECTIVE:: To determine the optimum timing for planned delivery of uncomplicated monochorionic and dichorionic twin pregnancies. METHODS:: Unselected twin pregnancies were recruited for this prospective cohort study (N=1,028), which was conducted in eight tertiary referral perinatal centers in Ireland. Perinatal mortality and a composite measure of perinatal morbidity (respiratory distress, necrotizing enterocolitis, hypoxic ischemic encephalopathy, periventricular leukomalacia, or sepsis) were compared between uncomplicated twins that underwent planned preterm delivery compared with monochorionic twins that continued in utero beyond 34 weeks of gestation, and dichorionic twins who continued beyond 36 weeks. RESULTS:: Perinatal outcome data were recorded for 100% of the 1,001 twin pairs that completed the study (n=200 monochorionic and n=801 dichorionic). Overall perinatal mortality was 30 per 1,000 in monochorionic twins and 3.8 per 1,000 among dichorionic twins. The prospective risk of in utero death was 1.5% after 34 weeks of gestation for uncomplicated monochorionic pregnancies, with no deaths among dichorionic twins after 33 weeks. The risk of a composite measure of perinatal morbidity for uncomplicated monochorionic twins fell from 41% (13/32 neonates, 3/6 among elective deliveries) at 34 weeks to 5% (4/84) at 37 weeks (P<.001). Among dichorionic twins, the risk of morbidity fell from 4% (2/52) among elective deliveries at 36 weeks to 1% (5/344) in pregnancies continuing to 38 weeks (P=.231). CONCLUSION:: Applying a strategy of close fetal surveillance, perinatal morbidity can be minimized by allowing uncomplicated monochorionic pregnancies continue to 37 weeks of gestation and dichorionic twins to 38 weeks. Among monochorionic twins, this approach must be balanced against a 1.5% risk of late in utero death. LEVEL OF EVIDENCE:: II.
PMID: 22183211 [PubMed - as supplied by publisher]
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