396 results on '"Zarko Alfirevic"'
Search Results
2. Cohort profile: Improved Pregnancy Outcomes via Early Detection (IMPROvED), an International Multicentre Prospective Cohort [version 3; peer review: 2 approved]
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Kate Navaratnam, Louise C. Kenny, Darina Sheehan, Zarko Alfirevic, Christian Gluud, Philip N. Baker, Marius Kublickas, Robin Tuytten, Johannes J. Duvekot, Boel Niklasson, Pensee Wu, Caroline B. van den Berg, Ali S. Khashan, Karolina Kublickiene, Gillian M. Maher, and Fergus P. McCarthy
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Cohort profile ,preeclampsia ,biobank ,clinical data ,eng ,Medicine - Abstract
Background Improved Pregnancy Outcomes via Early Detection (IMPROvED) is a multi-centre, European phase IIa clinical study. The primary aim of IMPROvED is to enable the assessment and refinement of innovative prototype preeclampsia risk assessment tests based on emerging biomarker technologies. Here we describe IMPROvED’s profile and invite researchers to collaborate. Methods A total of 4,038 low-risk nulliparous singleton pregnancies were recruited from maternity units in Ireland (N=1,501), United Kingdom (N=1,108), The Netherlands (N=810), and Sweden (N=619) between November 2013 to August 2017. Participants were interviewed by a research midwife at ~11 weeks (optional visit), ~15 weeks, ~20 weeks, ~34 weeks’ gestation (optional visit), and postpartum (within 72-hours following delivery). Findings to date Clinical data included information on maternal sociodemographic, medical history, and lifestyle factors collected at ~15 weeks’ gestation, and maternal measurements, collected at each study visit. Biobank samples included blood, urine, and hair collected at each study visit throughout pregnancy in all units plus umbilical cord/blood samples collected at birth in Ireland and Sweden. A total of 74.0% (N=2,922) had an uncomplicated pregnancy, 3.1% (N=122) developed preeclampsia, 3.6% (N=143) had a spontaneous preterm birth, and 10.5% (N=416) had a small for gestational age baby. We evaluated a panel of metabolite biomarkers and a panel of protein biomarkers at 15 weeks and 20 weeks’ gestation for preeclampsia risk assessment. Their translation into tests with clinical application, as conducted by commercial entities, was hampered by technical issues and changes in test requirements. Work on the panel of proteins was abandoned, while work on the use of metabolite biomarkers for preeclampsia risk assessment is ongoing. Future plans In accordance with the original goals of the IMPROvED study, the data and biobank are now available for international collaboration to conduct high quality research into the cause and prevention of adverse pregnancy outcomes.
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- 2024
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3. Protocol for the development of a tool (INSPECT-SR) to identify problematic randomised controlled trials in systematic reviews of health interventions
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Elizabeth Loder, Jill Alison Hayden, David Torgerson, Tianjing Li, Wentao Li, Rui Wang, Ben W Mol, Lisa Bero, Jamie J Kirkham, Lisa Parker, Mike Clarke, Jo C Dumville, Calvin Heal, Lyle Gurrin, Andreas Lundh, Madelon van Wely, Toby Lasserson, Alison Avenell, Neil E O'Connell, Andrew Grey, Jack Wilkinson, George A Antoniou, Kylie Elizabeth Hunter, Patrick Dicker, Zarko Alfirevic, Ella Flemyng, Sarah Lensen, Emma Sydenham, Ginny Barbour, Emily Lam, Gideon Meyerowitz-Katz, James Heathers, Nicholas J L Brown, John Carlisle, Steph Grohmann, Barbara K Redman, Lene Seidler, and Kyle A Sheldrick
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Medicine - Abstract
Introduction Randomised controlled trials (RCTs) inform healthcare decisions. It is now apparent that some published RCTs contain false data and some appear to have been entirely fabricated. Systematic reviews are performed to identify and synthesise all RCTs that have been conducted on a given topic. While it is usual to assess methodological features of the RCTs in the process of undertaking a systematic review, it is not usual to consider whether the RCTs contain false data. Studies containing false data therefore go unnoticed and contribute to systematic review conclusions. The INveStigating ProblEmatic Clinical Trials in Systematic Reviews (INSPECT-SR) project will develop a tool to assess the trustworthiness of RCTs in systematic reviews of healthcare-related interventions.Methods and analysis The INSPECT-SR tool will be developed using expert consensus in combination with empirical evidence, over five stages: (1) a survey of experts to assemble a comprehensive list of checks for detecting problematic RCTs, (2) an evaluation of the feasibility and impact of applying the checks to systematic reviews, (3) a Delphi survey to determine which of the checks are supported by expert consensus, culminating in, (4) a consensus meeting to select checks to be included in a draft tool and to determine its format and (5) prospective testing of the draft tool in the production of new health systematic reviews, to allow refinement based on user feedback. We anticipate that the INSPECT-SR tool will help researchers to identify problematic studies and will help patients by protecting them from the influence of false data on their healthcare.Ethics and dissemination The University of Manchester ethics decision tool was used, and this returned the result that ethical approval was not required for this project (30 September 2022), which incorporates secondary research and surveys of professionals about subjects relating to their expertise. Informed consent will be obtained from all survey participants. All results will be published as open-access articles. The final tool will be made freely available.
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- 2024
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4. Cohort profile: Improved Pregnancy Outcomes via Early Detection (IMPROvED), an International Multicentre Prospective Cohort [version 2; peer review: 2 approved]
- Author
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Kate Navaratnam, Louise C. Kenny, Darina Sheehan, Zarko Alfirevic, Christian Gluud, Philip N. Baker, Marius Kublickas, Robin Tuytten, Johannes J. Duvekot, Boel Niklasson, Pensee Wu, Caroline B. van den Berg, Ali S. Khashan, Karolina Kublickiene, Gillian M. Maher, and Fergus P. McCarthy
- Subjects
Cohort profile ,preeclampsia ,biobank ,clinical data ,eng ,Medicine - Abstract
Background Improved Pregnancy Outcomes via Early Detection (IMPROvED) is a multi-centre, European phase IIa clinical study. The primary aim of IMPROvED is to enable the assessment and refinement of innovative prototype preeclampsia risk assessment tests based on emerging biomarker technologies. Here we describe IMPROvED’s profile and invite researchers to collaborate. Methods A total of 4,038 low-risk nulliparous singleton pregnancies were recruited from maternity units in Ireland (N=1,501), United Kingdom (N=1,108), The Netherlands (N=810), and Sweden (N=619) between November 2013 to August 2017. Participants were interviewed by a research midwife at ~11 weeks (optional visit), ~15 weeks, ~20 weeks, ~34 weeks’ gestation (optional visit), and postpartum (within 72-hours following delivery). Findings to date Clinical data included information on maternal sociodemographic, medical history, and lifestyle factors collected at ~15 weeks’ gestation, and maternal measurements, collected at each study visit. Biobank samples included blood, urine, and hair collected at each study visit throughout pregnancy in all units plus umbilical cord/blood samples collected at birth in Ireland and Sweden. A total of 74.0% (N=2,922) had an uncomplicated pregnancy, 3.1% (N=122) developed preeclampsia, 3.6% (N=143) had a spontaneous preterm birth, and 10.5% (N=416) had a small for gestational age baby. We evaluated a panel of metabolite biomarkers and a panel of protein biomarkers at 15 weeks and 20 weeks’ gestation for preeclampsia risk assessment. Their translation into tests with clinical application, as conducted by commercial entities, was hampered by technical issues and changes in test requirements. Work on the panel of proteins was abandoned, while work on the use of metabolite biomarkers for preeclampsia risk assessment is ongoing. Future plans In accordance with the original goals of the IMPROvED study, the data and biobank are now available for international collaboration to conduct high quality research into the cause and prevention of adverse pregnancy outcomes.
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- 2024
- Full Text
- View/download PDF
5. Genome and transcriptome profiling of spontaneous preterm birth phenotypes
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Juhi K. Gupta, Angharad Care, Laura Goodfellow, Zarko Alfirevic, Bertram Müller-Myhsok, and Ana Alfirevic
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Medicine ,Science - Abstract
Abstract Preterm birth (PTB) occurs before 37 weeks of gestation. Risk factors include genetics and infection/inflammation. Different mechanisms have been reported for spontaneous preterm birth (SPTB) and preterm birth following preterm premature rupture of membranes (PPROM). This study aimed to identify early pregnancy biomarkers of SPTB and PPROM from the maternal genome and transcriptome. Pregnant women were recruited at the Liverpool Women’s Hospital. Pregnancy outcomes were categorised as SPTB, PPROM (≤ 34 weeks gestation, n = 53), high-risk term (HTERM, ≥ 37 weeks, n = 126) or low-risk (no history of SPTB/PPROM) term (LTERM, ≥ 39 weeks, n = 188). Blood samples were collected at 16 and 20 weeks gestation from which, genome (UK Biobank Axiom array) and transcriptome (Clariom D Human assay) data were acquired. PLINK and R were used to perform genetic association and differential expression analyses and expression quantitative trait loci (eQTL) mapping. Several significant molecular signatures were identified across the analyses in preterm cases. Genome-wide significant SNP rs14675645 (ASTN1) was associated with SPTB whereas microRNA-142 transcript and PPARG1-FOXP3 gene set were associated with PPROM at week 20 of gestation and is related to inflammation and immune response. This study has determined genomic and transcriptomic candidate biomarkers of SPTB and PPROM that require validation in diverse populations.
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- 2022
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6. The Induction with Foley OR Misoprostol (INFORM) Study dataset. A dataset of 602 women with hypertensive disease in pregnancy, in India, randomised to either Foley catheter or oral misoprostol for induction of labour
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Shuchita Mundle, Hillary Bracken, Vaishali Khedikar, Jayashree Mulik, Brian Faragher, Thomas Easterling, Simon Leigh, Paul Granby, Alan Haycox, Mark A. Turner, Kate Lightly, Miroslava Ebringer, Zarko Alfirevic, Beverly Winikoff, and Andrew D. Weeks
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Induction ,Labour ,Hypertension ,Pre-eclampsia ,Misoprostol ,Foley catheter ,Medicine ,Biology (General) ,QH301-705.5 ,Science (General) ,Q1-390 - Abstract
Abstract Objectives Induction of labour (IOL), or starting labour artificially, can be a lifesaving intervention for pregnant women and their babies, and rates are rising significantly globally. As rates increase, it becomes increasingly important to fully evaluate all available data, especially that from low income settings where the potential benefits and harms are greater. The goal of this paper is to describe the datasets collected as part of the Induction with Foley OR Misoprostol (INFORM) Study, a randomised trial comparing two of the recommended methods of cervical ripening for labour induction, oral misoprostol and Foley catheter, in women being induced for hypertension in pregnancy, at two sites in India during 2013–15. Data description This dataset includes comprehensive data on 602 women who underwent IOL for hypertensive disorders in pregnancy. Women were randomly assigned to cervical ripening with oral misoprostol or a transcervical Foley catheter in two government hospitals in India. The main dataset has 367 variables including monitoring during the induction of labour, medications administered, timing and mode of delivery, measures of neonatal morbidity and mortality, maternal mortality and morbidity, maternal satisfaction and health economic data. The dataset is anonymised and available on ReShare.
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- 2021
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7. Oral Misoprostol alone versus oral misoprostol followed by oxytocin for labour induction in women with hypertension in pregnancy (MOLI): protocol for a randomised controlled trial
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Hillary Bracken, Kate Lightly, Shuchita Mundle, Robbie Kerr, Brian Faragher, Thomas Easterling, Simon Leigh, Mark Turner, Zarko Alfirevic, Beverly Winikoff, and Andrew Weeks
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Pre-eclampsia ,Induction of labour ,Misoprostol ,Oxytocin ,Augmentation of labour ,Randomized controlled trial ,Gynecology and obstetrics ,RG1-991 - Abstract
Abstract Background Every year approximately 30,000 women die from hypertensive disease in pregnancy. Magnesium sulphate and anti-hypertensives reduce morbidity, but delivery is the only cure. Low dose oral misoprostol, a prostaglandin E1 analogue, is a highly effective method for labour induction. Usually, once active labour has commenced, the misoprostol is replaced with an intravenous oxytocin infusion if ongoing stimulation is required. However, some studies have shown that oral misoprostol can be continued into active labour, a simpler and potentially more acceptable protocol for women. To date, these two protocols have never been directly compared. Methods This pragmatic, open-label, randomised trial will compare a misoprostol alone labour induction protocol with the standard misoprostol plus oxytocin protocol in three Indian hospitals. The study will recruit 520 pregnant women being induced for hypertensive disease in pregnancy and requiring augmentation after membrane rupture. Participants will be randomised to receive either further oral misoprostol 25mcg every 2 h, or titrated intravenous oxytocin. The primary outcome will be caesarean birth. Secondary outcomes will assess the efficacy of the induction process, maternal and fetal/neonatal complications and patient acceptability. This protocol (version 1.04) adheres to the SPIRIT checklist. A cost-effectiveness analysis, situational analysis and formal qualitative assessment of women’s experience are also planned. Discussion Avoiding oxytocin and continuing low dose misoprostol into active labour may have a number of benefits for both women and the health care system. Misoprostol is heat stable, oral medication and thus easy to store, transport and administer; qualities particularly desirable in low resource settings. An oral medication protocol requires less equipment (e.g. electronic infusion pumps) and may free up health care providers to assist with other aspects of the woman’s care. The simplicity of the protocol may also help to reduce human errors associated with the delivery of intravenous infusions. Finally, women may prefer to be mobile during labour and not restricted by an intravenous infusion. There is a need, therefore, to assess whether augmentation using oral misoprostol is superior clinically and economically to the standard protocol of intravenous oxytocin. Trial registration Clinical Trials.gov, NCT03749902 , registered on 21st Nov 2018.
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- 2021
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8. Developing a topic-based repository of clinical trial individual patient data: experiences and lessons learned from a pilot project
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Nancy Medley, Anna Cuthbert, Richard Crew, Lesley Stewart, Catrin Tudur Smith, and Zarko Alfirevic
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IPD ,Individual patient data ,Data sharing ,Repository ,Barriers ,Medicine - Abstract
Abstract Background Building a dataset of individual participant data (IPD) for meta-analysis represents considerable research investment as well as collaboration across multiple institutions and researchers. Making arrangements to curate and share the dataset beyond the IPD meta-analysis project for which it was established, for reuse in future research projects, would maximise the value of this investment. Methods Our aim was to establish the Cochrane repository for individual patient data from clinical trials in pregnancy and childbirth (CRIB) as an example of how an IPD repository could become part of Cochrane infrastructure. We believed that establishing CRIB under Cochrane auspices would engender trust and encourage trial investigators to share data, and at the same time position Cochrane to take steps towards expanding the number of reviews with IPD synthesis. Results CRIB was designed as a web-based platform to receive, host and facilitate onward sharing of de-identified data. Development was not straightforward and we did not fully achieve our aim as intended. We describe the challenges encountered and suggest ways that future repositories might overcome these. In particular, securing the legal agreements required to facilitate data sharing proved to be the main barrier, being time-consuming and more complex than anticipated. Conclusions We would recommend that researchers conducting IPD meta-analysis should consider discussing the option to transfer the curated IPD datasets to a repository at the end of the initial meta-analysis and this should be recognised within the data sharing agreements made with the original data contributors.
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- 2021
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9. The PLANES study: a protocol for a randomised controlled feasibility study of the placental growth factor (PlGF) blood test-informed care versus standard care alone for women with a small for gestational age fetus at or after 32 + 0 weeks’ gestation
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Joanna Gent, Sian Bullough, Jane Harrold, Richard Jackson, Kerry Woolfall, Lazaros Andronis, Louise Kenny, Christine Cornforth, Alexander E. P. Heazell, Emily Benbow, Zarko Alfirevic, and Andrew Sharp
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Fetal growth restriction (FGR) ,Intrauterine growth restriction ,Small for gestational age (SGA) ,Placenta ,Placental growth factor ,Soluble fms-like tyrosine kinase ,Medicine (General) ,R5-920 - Abstract
Abstract Background Stillbirth remains a major concern across the globe and in some high-resource countries, such as the UK; efforts to reduce the rate have achieved only modest reductions. One third of stillborn babies are small for gestational age (SGA), and these pregnancies are also at risk of neonatal adverse outcomes and lifelong health problems, especially when delivered preterm. Current UK clinical guidance advocates regular monitoring and early term delivery of the SGA fetus; however, the most appropriate regimen for surveillance of these babies remains unclear and often leads to increased intervention for a large number of these women. This pilot trial will determine the feasibility of a large-scale trial refining the risk of adverse pregnancy outcome in SGA pregnancies using biomarkers of placental function sFlt-1/PlGF, identifying and intervening in only those deemed at highest risk of stillbirth. Methods PLANES is a randomised controlled feasibility study of women with an SGA fetus that will be conducted at two tertiary care hospitals in the UK. Once identified on ultrasound, women will be randomised into two groups in a 3:1 ratio in favour of sFlt-1/PlGF ratio led management vs standard care. Women with an SGA fetus and a normal sFlt-1/PlGF ratio will have a repeat ultrasound and sFlt-1/PlGF ratio every 2 weeks with planned birth delayed until 40 weeks. In those women with an SGA fetus and an abnormal sFlt-1/PlGF ratio, we will offer birth from 37 weeks or sooner if there are other concerning features on ultrasound. Women assigned to standard care will have an sFlt-1/PlGF ratio taken, but the results will be concealed from the clinical team, and the woman’s pregnancy will be managed as per the local NHS hospital policy. This integrated mixed method study will also involve a health economic analysis and a perspective work package exploring trial feasibility through interviews and questionnaires with participants, their partners, and clinicians. Discussion Our aim is to determine feasibility through the assessment of our ability to recruit and retain participants to the study. Results from this pilot study will inform the design of a future large randomised controlled trial that will be adequately powered for adverse pregnancy outcome. Such a study would provide the evidence needed to guide future management of the SGA fetus. Trial registration ISRCTN58254381 . Registered on 4 July 2019
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- 2020
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10. Association of maternal prenatal selenium concentration and preterm birth: a multicountry meta-analysis
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Anisur Rahman, Fyezah Jehan, Ana Alfirevic, Kenneth Maleta, Ulla Ashorn, Per Ashorn, Kelli K Ryckman, Tahmeed Ahmed, Usha Dhingra, Arup Dutta, Saikat Deb, Sunil Sazawal, Rajiv Bahl, Salahuddin Ahmed, Stephen H Kennedy, Monjur Rahman, Jesmin Pervin, Cathrine Hoyo, Rasheda Khanam, Sayedur Rahman, James A Litch, Aneeta Hotwani, Daniel E Roth, Ge Zhang, Abdullah Al Mahmud, Mikko Hallman, Huan Xu, Usma Mehmood, Zarko Alfirevic, Jeffrey C Murray, Bellington Vwalika, Susan Murphy, Patrick Musonda, Nagendra Monangi, Angharad Care, Fahad Aftab, Waqasuddin Khan, Joan T Price, Yuemei Fan, Thanh Q Le, Julio A Landero, Gerald F Combs, Elizabeth Belling, Joanne Chappell, Fansheng Kong, Criag Lacher, Nabidul Haque Chowdhury, Furqan Kabir, Imran Nisar, Ambreen Nizar, Javairia Khalid, Said Ali, Mohammed Hamad Juma, Md Munirul Islam, Laura Goodfellow, Juhi K Gupta, Larry Rand, Courtney Baruch-Gravett, Abdullah Baqui, Jane Hirst, Laura L Jelliffe-Pawlowski, Jeffrey Stringer, and Louis Muglia
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Medicine (General) ,R5-920 ,Infectious and parasitic diseases ,RC109-216 - Abstract
Background Selenium (Se), an essential trace mineral, has been implicated in preterm birth (PTB). We aimed to determine the association of maternal Se concentrations during pregnancy with PTB risk and gestational duration in a large number of samples collected from diverse populations.Methods Gestational duration data and maternal plasma or serum samples of 9946 singleton live births were obtained from 17 geographically diverse study cohorts. Maternal Se concentrations were determined by inductively coupled plasma mass spectrometry analysis. The associations between maternal Se with PTB and gestational duration were analysed using logistic and linear regressions. The results were then combined using fixed-effect and random-effect meta-analysis.Findings In all study samples, the Se concentrations followed a normal distribution with a mean of 93.8 ng/mL (SD: 28.5 ng/mL) but varied substantially across different sites. The fixed-effect meta-analysis across the 17 cohorts showed that Se was significantly associated with PTB and gestational duration with effect size estimates of an OR=0.95 (95% CI: 0.9 to 1.00) for PTB and 0.66 days (95% CI: 0.38 to 0.94) longer gestation per 15 ng/mL increase in Se concentration. However, there was a substantial heterogeneity among study cohorts and the random-effect meta-analysis did not achieve statistical significance. The largest effect sizes were observed in UK (Liverpool) cohort, and most significant associations were observed in samples from Malawi.Interpretation While our study observed statistically significant associations between maternal Se concentration and PTB at some sites, this did not generalise across the entire cohort. Whether population-specific factors explain the heterogeneity of our findings warrants further investigation. Further evidence is needed to understand the biologic pathways, clinical efficacy and safety, before changes to antenatal nutritional recommendations for Se supplementation are considered.
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- 2021
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11. Publisher Correction: Genome and transcriptome profiling of spontaneous preterm birth phenotypes
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Juhi K. Gupta, Angharad Care, Laura Goodfellow, Zarko Alfirevic, Bertram Müller‑Myhsok, and Ana Alfirevic
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Medicine ,Science - Published
- 2022
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12. Skeletal abnormalities secondary to antenatal etidronate treatment for suspected generalised arterial calcification of infancy
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Neha Agarwal, Umber Agarwal, Zarko Alfirevic, Joyce Lim, Musa Kaleem, Caren Landes, M. Zulf Mughal, and R. Ramakrishnan
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Antenatal ,Bisphosphonates ,GACI ,Diseases of the musculoskeletal system ,RC925-935 - Abstract
Background: Generalised arterial calcification of infancy (GACI) is a rare disorder characterised by the deposition of hydroxyapatite crystals within the vessel walls. It is associated with a high mortality rate. Bisphosphonates have been used with some success in the treatment of GACI. However, there is a paucity of data on the antenatal use of bisphosphonates for GACI. In this paper, we report development of the skeletal changes suggestive of hypophosphatasia (HPP) in an infant with GACI, whose mother was treated with etidronate during pregnancy. Case report: A Caucasian infant boy had a suspected antenatal diagnosis of GACI based on the findings suggestive of calcification of the annulus of the tricuspid valve and wall of the right ventricular (RV) outflow tract and main pulmonary artery on foetal echocardiography and the genetic analysis which showed a pathogenic heterozygous mutation in ABCC6. Based on these findings, mother was started on etidronate treatment from 26 weeks of gestation. A healthy male baby was delivered at 38 weeks of gestation. Initial postnatal echocardiogram on day 1 of life was normal with good biventricular function; subtle changes suggestive of microcalcifications were detected on the CT angiography. Serum calcium, phosphate, alkaline phosphatase and renal profile were normal. Further, the serum inorganic pyrophosphate (PPi) level was significantly low. Skeletal changes suggestive of HPP were seen on the radiographs. The baby developed cardiac dysfunction on day 4 of life with evidence of ischaemic changes on electrocardiogram (ECG).Treatment with etidronate was started in view of probable evolving coronary calcifications. Despite treatment with cardiac supportive measures and bisphosphonate, he succumbed to death in the third week of life. Discussion: We believe, this is the first report of skeletal changes suggestive of HPP, arising secondary to antenatal etidronate (first generation bisphosphonate) used for the treatment of suspected GACI due to a heterozygous ABCC6 mutation.
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- 2020
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13. Protocol for the development of a salutogenic intrapartum core outcome set (SIPCOS)
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Valerie Smith, Deirdre Daly, Ingela Lundgren, Tine Eri, Cecily Begley, Mechthild M. Gross, Soo Downe, Zarko Alfirevic, and Declan Devane
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Salutogenic ,Salutogenesis ,Core outcome set ,COS ,Intrapartum care ,Maternity research ,Medicine (General) ,R5-920 - Abstract
Abstract Background Maternity intrapartum care research and clinical care more often focus on outcomes that minimise or prevent adverse health rather than on what constitutes positive health and wellbeing (salutogenesis). This was highlighted recently in a systematic review of reviews of intrapartum reported outcomes where only 8% of 1648 individual outcomes, from 102 systematic reviews, were agreed as being salutogenically-focused. Added to this is variation in the outcomes measured in individual studies rendering it very difficult for researchers to synthesise, fully, the evidence from studies on a particular topic. One of the suggested ways to address this is to develop and apply an agreed standardised set of outcomes, known as a ‘core outcome set’ (COS). In this paper we present a protocol for the development of a salutogenic intrapartum COS (SIPCOS) for use in maternity care research and a SIPCOS for measuring in daily intrapartum clinical care. Methods The study proposes three phases in developing the final SIPCOSs. Phase one, which is complete, involved the conduct of a systematic review of reviews to identify a preliminary list of salutogenically-focused outcomes that had previously been reported in systematic reviews of intrapartum interventions. Sixteen unique salutogenically-focused outcome categories were identified. Phase two will involve prioritising these outcomes, from the perspective of key stakeholders (users of maternity services, clinicians and researchers) by asking them to rate the importance of each outcome for inclusion in the SIPCOSs. A final consensus meeting (phase three) will be held, bringing international stakeholders together to review the preliminary SIPCOSs resulting from the survey and to agree and finalise the final SIPCOSs for use in future maternity care research and daily clinical care. Discussion The expectation in developing the SIPCOSs is that they will be collected and reported in all future studies evaluating intrapartum interventions and measured/recorded in future intrapartum clinical care, as routine, alongside other outcomes also deemed important in the context of the study or clinical scenario. Using the SIPCOSs in this way, will promote and encourage standardised measurements of positive health outcomes in maternity care, into the future.
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- 2017
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14. Reducing the impact of preterm birth: Preterm birth commissioning in the United Kingdom
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Lisa Story, Nigel A.B. Simpson, Anna L. David, Zarko Alfirevic Z, Phillip R. Bennett, Matthew Jolly, and Andrew H. Shennan
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Gynecology and obstetrics ,RG1-991 - Abstract
Reducing preterm birth is a priority for Maternity and Children’s services. In the recent UK Department of Health publication ‘Safer Maternity Care’ the Secretary of State for Health aimed to achieve the national maternity safety ambition by pledging to reduce the rate of preterm birth from 8% to 6%. It was proposed that specialist preterm birth services should be established in the UK in order to achieve this aim. In response the Preterm Clinical Network has written Commissioning Guidance aimed to establish best practice pathways and agreed models of care to reduce variation nationally. They have been developed by clinical experts in the field, from within the UK, to provide recommendations for commissioning groups and to recommend pathways to organisations with the aim of reducing the incidence of preterm birth. Three key areas of care provision are focused on: prediction, prevention and preparation of women at high risk of PTB. This Expert Opinion, will summarise the Commissioning Guidance. Keywords: Preterm birth, UK commissioning guidance, Safer maternity care
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- 2019
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15. Early Pregnancy Biomarkers in Pre-Eclampsia: A Systematic Review and Meta-Analysis
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Pensée Wu, Caroline van den Berg, Zarko Alfirevic, Shaughn O’Brien, Maria Röthlisberger, Philip Newton Baker, Louise C. Kenny, Karolina Kublickiene, and Johannes J. Duvekot
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pre-eclampsia ,early pregnancy biomarkers ,meta-analysis ,Biology (General) ,QH301-705.5 ,Chemistry ,QD1-999 - Abstract
Pre-eclampsia (PE) complicates 2%–8% of all pregnancies and is an important cause of perinatal morbidity and mortality worldwide. In order to reduce these complications and to develop possible treatment modalities, it is important to identify women at risk of developing PE. The use of biomarkers in early pregnancy would allow appropriate stratification into high and low risk pregnancies for the purpose of defining surveillance in pregnancy and to administer interventions. We used formal methods for a systematic review and meta-analyses to assess the accuracy of all biomarkers that have been evaluated so far during the first and early second trimester of pregnancy to predict PE. We found low predictive values using individual biomarkers which included a disintegrin and metalloprotease 12 (ADAM-12), inhibin-A, pregnancy associated plasma protein A (PAPP-A), placental growth factor (PlGF) and placental protein 13 (PP-13). The pooled sensitivity of all single biomarkers was 0.40 (95% CI 0.39–0.41) at a false positive rate of 10%. The area under the Summary of Receiver Operating Characteristics Curve (SROC) was 0.786 (SE 0.02). When a combination model was used, the predictive value improved to an area under the SROC of 0.893 (SE 0.03). In conclusion, although there are multiple potential biomarkers for PE their efficacy has been inconsistent and comparisons are difficult because of heterogeneity between different studies. Therefore, there is an urgent need for high quality, large-scale multicentre research in biomarkers for PE so that the best predictive marker(s) can be identified in order to improve the management of women destined to develop PE.
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- 2015
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16. Which method is best for the induction of labour? A systematic review, network meta-analysis and cost-effectiveness analysis
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Zarko Alfirevic, Edna Keeney, Therese Dowswell, Nicky J Welton, Nancy Medley, Sofia Dias, Leanne V Jones, Gillian Gyte, and Deborah M Caldwell
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labour induction ,systematic review ,network meta-analysis ,cost-effectiveness analysis ,comparative effectiveness research ,Medical technology ,R855-855.5 - Abstract
Background: More than 150,000 pregnant women in England and Wales have their labour induced each year. Multiple pharmacological, mechanical and complementary methods are available to induce labour. Objective: To assess the relative effectiveness, safety and cost-effectiveness of labour induction methods and, data permitting, effects in different clinical subgroups. Methods: We carried out a systematic review using Cochrane methods. The Cochrane Pregnancy and Childbirth Group’s Trials Register was searched (March 2014). This contains over 22,000 reports of controlled trials (published from 1923 onwards) retrieved from weekly searches of OVID MEDLINE (1966 to current); Cochrane Central Register of Controlled Trials (The Cochrane Library); EMBASE (1982 to current); Cumulative Index to Nursing and Allied Health Literature (1984 to current); ClinicalTrials.gov; the World Health Organization International Clinical Trials Registry Portal; and hand-searching of relevant conference proceedings and journals. We included randomised controlled trials examining interventions to induce labour compared with placebo, no treatment or other interventions in women eligible for third-trimester induction. We included outcomes relating to efficacy, safety and acceptability to women. In addition, for the economic analysis we searched the Database of Abstracts of Reviews of Effects, and Economic Evaluations Databases, NHS Economic Evaluation Database and the Health Technology Assessment database. We carried out a network meta-analysis (NMA) using all of the available evidence, both direct and indirect, to produce estimates of the relative effects of each treatment compared with others in a network. We developed a de novo decision tree model to estimate the cost-effectiveness of various methods. The costs included were the intervention and other hospital costs incurred (price year 2012–13). We reviewed the literature to identify preference-based utilities for the health-related outcomes in the model. We calculated incremental cost-effectiveness ratios, expected costs, utilities and net benefit. We represent uncertainty in the optimal intervention using cost-effectiveness acceptability curves. Results: We identified 1190 studies; 611 were eligible for inclusion. The interventions most likely to achieve vaginal delivery (VD) within 24 hours were intravenous oxytocin with amniotomy [posterior rank 2; 95% credible intervals (CrIs) 1 to 9] and higher-dose (≥ 50 µg) vaginal misoprostol (rank 3; 95% CrI 1 to 6). Compared with placebo, several treatments reduced the odds of caesarean section, but we observed considerable uncertainty in treatment rankings. For uterine hyperstimulation, double-balloon catheter had the highest probability of being among the best three treatments, whereas vaginal misoprostol (≥ 50 µg) was most likely to increase the odds of excessive uterine activity. For other safety outcomes there were insufficient data or there was too much uncertainty to identify which treatments performed ‘best’. Few studies collected information on women’s views. Owing to incomplete reporting of the VD within 24 hours outcome, the cost-effectiveness analysis could compare only 20 interventions. The analysis suggested that most interventions have similar utility and differ mainly in cost. With a caveat of considerable uncertainty, titrated (low-dose) misoprostol solution and buccal/sublingual misoprostol had the highest likelihood of being cost-effective. Limitations: There was considerable uncertainty in findings and there were insufficient data for some planned subgroup analyses. Conclusions: Overall, misoprostol and oxytocin with amniotomy (for women with favourable cervix) is more successful than other agents in achieving VD within 24 hours. The ranking according to safety of different methods was less clear. The cost-effectiveness analysis suggested that titrated (low-dose) oral misoprostol solution resulted in the highest utility, whereas buccal/sublingual misoprostol had the lowest cost. There was a high degree of uncertainty as to the most cost-effective intervention. Future work: Future trials should be powered to detect a method that is more cost-effective than misoprostol solution and report outcomes included in this NMA. Study registration: This study is registered as PROSPERO CRD42013005116. Funding: The National Institute for Health Research Health Technology Assessment programme.
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- 2016
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17. Amnioinfusion in preterm premature rupture of membranes (AMIPROM): a randomised controlled trial of amnioinfusion versus expectant management in very early preterm premature rupture of membranes – a pilot study
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Devender Roberts, Sarah Vause, William Martin, Pauline Green, Stephen Walkinshaw, Leanne Bricker, Caroline Beardsmore, Ben NJ Shaw, Andrew McKay, Gaynor Skotny, Paula Williamson, and Zarko Alfirevic
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randomised controlled trial ,amnioinfusion ,expectant management ,premature rupture ,membranes ,preterm prelabour rupture ,pilot study ,Medical technology ,R855-855.5 - Abstract
Background: Fetal survival is severely compromised when the amniotic membrane ruptures between 16 and 24 weeks of pregnancy. Reduced amniotic fluid levels are associated with poor lung development, whereas adequate levels lead to better perinatal outcomes. Restoring amniotic fluid by means of ultrasound-guided amnioinfusion (AI) may be of benefit in improving perinatal and long-term outcomes in children of pregnancies with this condition. Objective: The AI in preterm premature rupture of membranes (AMIPROM) pilot study was conducted to assess the feasibility of recruitment, the methods for conduct and the retention through to long-term follow-up of participants with very early rupture of amniotic membranes (between 16 and 24 weeks of pregnancy). It was also performed to assess outcomes and collect data to inform a larger, more definitive, clinical trial. Design: A prospective, non-blinded randomised controlled trial. A computer-generated random sequence using a 1 : 1 ratio was used. Randomisation was stratified for pregnancies in which the amniotic membrane ruptured between 16+0 and 19+6 weeks’ gestation and 20+0 and 24+0 weeks’ gestation. The randomisation sequence was generated in blocks of four. Telephone randomisation and intention-to-treat analysis were used. Setting: Four UK hospital-based fetal medicine units – Liverpool Women’s NHS Trust, St. Mary’s Hospital, Manchester, Birmingham Women’s NHS Foundation Trust and Wirral University Hospitals Trust. Participants: Women with confirmed preterm prelabour rupture of membranes between 16+0 and 24+0 weeks’ gestation. Women with multiple pregnancies, resultant fetal abnormalities or obstetric indication for immediate delivery were excluded. Interventions: Participants were randomly allocated to either serial weekly transabdominal AI or expectant management (Exp) until 37 weeks of pregnancy, if the deepest pool of amniotic fluid was
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- 2014
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18. Pathway analysis of genetic factors associated with spontaneous preterm birth and pre-labor preterm rupture of membranes.
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Antonio Capece, Olga Vasieva, Shireen Meher, Zarko Alfirevic, and Ana Alfirevic
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Medicine ,Science - Abstract
Pre-term birth (PTB) remains the leading cause of infant mortality and morbidity. Its etiology is multifactorial, with a strong genetic component. Genetic predisposition for the two subtypes, spontaneous PTB with intact membranes (sPTB) and preterm prelabor rapture of membranes (PPROM), and differences between them, have not yet been systematically summarised.Our literature search identified 15 association studies conducted in 3,600 women on 2175 SNPs in 274 genes. We used Ingenuity software to impute gene pathways and networks related to sPTB and PPROM. Detailed insight in the defined functional ontologies clearly separated integrated datasets for sPTB and PPROM. Our analysis of upstream regulators of genes suggests that glucocorticoid receptor (NR3C1), peroxisome proliferator activated receptor γ (PPARG) and interferon regulating factor 3 (IRF3) may be sPTB specific. PPROM-specific genes may be regulated by estrogen receptor2 (ESR2) and signal transducer and activator of transcription (STAT1). The inflammatory transcription factor NFκB is linked to both sPTB and PPROM, however, their inflammatory response is distinctly different.Based on our analyses, we propose an autoimmune/hormonal regulation axis for sPTB, whilst pathways implicated in the etiology of PPROM include hematologic/coagulation function disorder, collagen metabolism, matrix degradation and local inflammation. Our hypothesis generating study has identified new candidate genes in the pathogenesis of PPROM and sPTB, which should be validated in large cohorts.
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- 2014
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19. Uterine rupture by intended mode of delivery in the UK: a national case-control study.
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Kathryn E Fitzpatrick, Jennifer J Kurinczuk, Zarko Alfirevic, Patsy Spark, Peter Brocklehurst, and Marian Knight
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Medicine - Abstract
Recent reports of the risk of morbidity due to uterine rupture are thought to have contributed in some countries to a decrease in the number of women attempting a vaginal birth after caesarean section. The aims of this study were to estimate the incidence of true uterine rupture in the UK and to investigate and quantify the associated risk factors and outcomes, on the basis of intended mode of delivery.A UK national case-control study was undertaken between April 2009 and April 2010. The participants comprised 159 women with uterine rupture and 448 control women with a previous caesarean delivery. The estimated incidence of uterine rupture was 0.2 per 1,000 maternities overall; 2.1 and 0.3 per 1,000 maternities in women with a previous caesarean delivery planning vaginal or elective caesarean delivery, respectively. Amongst women with a previous caesarean delivery, odds of rupture were also increased in women who had ≥ two previous caesarean deliveries (adjusted odds ratio [aOR] 3.02, 95% CI 1.16-7.85) and
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- 2012
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20. Home labour induction with retrievable prostaglandin pessary and continuous telemetric trans-abdominal fetal ECG monitoring.
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Zubair Rauf, Ediri O'Brien, Tamara Stampalija, Florin P Ilioniu, Tina Lavender, and Zarko Alfirevic
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Medicine ,Science - Abstract
OBJECTIVE: To evaluate the feasibility of continuous telemetric trans-abdominal fetal electrocardiogram (a-fECG) in women undergoing labour induction at home. STUDY DESIGN: Low risk women with singleton term pregnancy undergoing labour induction with retrievable, slow-release dinoprostone pessaries (n = 70) were allowed home for up to 24 hours, while a-fECG and uterine activity were monitored in hospital via wireless technology. Semi-structured diaries were analysed using a combined descriptive and interpretive approach. RESULTS: 62/70 women (89%) had successful home monitoring; 8 women (11%) were recalled because of signal loss. Home monitoring lasted between 2-22 hours (median 10 hours). Good quality signal was achieved most of the time (86%, SD 10%). 3 women were recalled back to hospital for suspicious a-fECG. In 2 cases suspicious a-fECG persisted, requiring Caesarean section after recall to hospital. 48/51 women who returned the diary coped well (94%); 46/51 were satisfied with home monitoring (90%). CONCLUSIONS: Continuous telemetric trans-abdominal fetal ECG monitoring of ambulatory women undergoing labour induction is feasible and acceptable to women.
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- 2011
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21. Quantifying the impact of deprivation on preterm births: a retrospective cohort study.
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David Taylor-Robinson, Umber Agarwal, Peter J Diggle, Mary Jane Platt, Bill Yoxall, and Zarko Alfirevic
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Medicine ,Science - Abstract
Social deprivation is associated with higher rates of preterm birth and subsequent infant mortality. Our objective was to identify risk factors for preterm birth in the UK's largest maternity unit, with a particular focus on social deprivation, and related factors.Retrospective cohort study of 39,873 women in Liverpool, UK, from 2002-2008. Singleton pregnancies were stratified into uncomplicated low risk pregnancies and a high risk group complicated by medical problems. Multiple logistic regression, and generalized additive models were used to explore the effect of covariates including area deprivation, smoking status, BMI, parity and ethnicity on the risk of preterm birth (34⁺⁰ weeks). In the low risk group, preterm birth rates increased with deprivation, reaching 1.6% (CI₉₅ 1.4 to 1.8) in the most deprived quintile; the unadjusted odds ratio comparing an individual in the most deprived quintile, to one in the least deprived quintile was 1.5 (CI₉₅ 1.2 to 1.9). Being underweight and smoking were both independently associated with preterm birth in the low risk group, and adjusting for these factors explained the association between deprivation and preterm birth. Preterm birth was five times more likely in the high risk group (RR 4.8 CI₉₅ 4.3 to 5.4), and there was no significant relationship with deprivation.Deprivation has significant impact on preterm birth rates in low risk women. The relationship between low socio-economic status and preterm births appears to be related to low maternal weight and smoking in more deprived groups.
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- 2011
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22. Preterm prelabour rupture of membranes before 23 weeks’ gestation: prospective observational study
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Goodfellow, Laura, primary, Care, Angharad, additional, Curran, Ciara, additional, Roberts, Devender, additional, Turner, Mark A, additional, Knight, Marian, additional, and Zarko, Alfirevic, additional
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- 2024
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23. Non‐immune hydrops fetalis: a practical guide for obstetricians
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Delima Khairudin, Zarko Alfirevic, Fionnuala Mone, and Kate Navaratnam
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General Medicine - Published
- 2023
24. Assessing the usefulness of randomised trials in obstetrics and gynaecology
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Janneke van ’t Hooft, Charlotte E. van Dijk, Cathrine Axfors, Zarko Alfirevic, Martijn A. Oudijk, Khalid S. Khan, Ben W. J. Mol, Patrick M. Bossuyt, John P. A. Ioannidis, Graduate School, APH - Personalized Medicine, APH - Quality of Care, ARD - Amsterdam Reproduction and Development, Obstetrics and Gynaecology, Epidemiology and Data Science, and APH - Methodology
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Obstetrics and Gynecology - Published
- 2023
25. Methods of induction of labour: a network meta-analysis
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Siwanon Rattanakanokchai, Ioannis D Gallos, Chumnan Kietpeerakool, Nuntasiri Eamudomkarn, Zarko Alfirevic, Olufemi T Oladapo, Doris Chou, Ben Willem J Mol, Wentao Li, Pisake Lumbiganon, Arri Coomarasamy, and Malcolm J Price
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Pharmacology (medical) - Published
- 2023
26. Induction of labour: first, do no harm
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Andrew D Weeks and Zarko Alfirevic
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Labor, Obstetric ,Pregnancy ,Humans ,Female ,General Medicine ,Labor, Induced - Published
- 2022
27. Foetal loss after chorionic villus sampling and amniocentesis in twin pregnancies: A multicentre retrospective cohort study
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Kate Navaratnam, Delima Khairudin, Robyn Chilton, Andrew Sharp, George Attilakos, Daniel Stott, Sophie Relph, Rebecca Spencer, Dominique A. Badr, Andrew Carlin, Jacques Jani, Mark D. Kilby, Mercede Sebghati, Asma Khalil, and Zarko Alfirevic
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Fetus ,Chorionic Villi Sampling ,Pregnancy ,Amniocentesis ,Pregnancy, Twin ,Obstetrics and Gynecology ,Humans ,Female ,Genetics (clinical) ,Retrospective Studies - Abstract
OBJECTIVE: We aimed to determine foetal losses for DCDA and MCDA twins following transabdominal CVS or amniocentesis performed
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- 2022
28. Developing a topic-based repository of clinical trial individual patient data: experiences and lessons learned from a pilot project
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Lesley A. Stewart, Catrin Tudur Smith, Anna Cuthbert, Nancy Medley, Zarko Alfirevic, and Richard Crew
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Knowledge management ,Medicine (miscellaneous) ,Pilot Projects ,Reuse ,03 medical and health sciences ,0302 clinical medicine ,Medicine ,Humans ,030212 general & internal medicine ,business.industry ,Information Dissemination ,030503 health policy & services ,Individual participant data ,Repository ,Patient data ,Investment (macroeconomics) ,Research Personnel ,Data sharing ,Clinical trial ,IPD ,Commentary ,Position (finance) ,Individual patient data ,0305 other medical science ,business ,Host (network) ,Barriers - Abstract
Background Building a dataset of individual participant data (IPD) for meta-analysis represents considerable research investment as well as collaboration across multiple institutions and researchers. Making arrangements to curate and share the dataset beyond the IPD meta-analysis project for which it was established, for reuse in future research projects, would maximise the value of this investment. Methods Our aim was to establish the Cochrane repository for individual patient data from clinical trials in pregnancy and childbirth (CRIB) as an example of how an IPD repository could become part of Cochrane infrastructure. We believed that establishing CRIB under Cochrane auspices would engender trust and encourage trial investigators to share data, and at the same time position Cochrane to take steps towards expanding the number of reviews with IPD synthesis. Results CRIB was designed as a web-based platform to receive, host and facilitate onward sharing of de-identified data. Development was not straightforward and we did not fully achieve our aim as intended. We describe the challenges encountered and suggest ways that future repositories might overcome these. In particular, securing the legal agreements required to facilitate data sharing proved to be the main barrier, being time-consuming and more complex than anticipated. Conclusions We would recommend that researchers conducting IPD meta-analysis should consider discussing the option to transfer the curated IPD datasets to a repository at the end of the initial meta-analysis and this should be recognised within the data sharing agreements made with the original data contributors.
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- 2021
29. Interventions to Prevent Spontaneous Preterm Birth in Women With Singleton Pregnancy Who Are at High Risk: Systematic Review and Network Meta-Analysis
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Angharad Care, Sarah J Nevitt, Nancy Medley, Sarah Donegan, Laura Good, Lynn Hampson, Catrin Tudur Smith, and Zarko Alfirevic
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Administration, Intravaginal ,Treatment Outcome ,Pregnancy ,Management of Technology and Innovation ,Network Meta-Analysis ,Obstetrics and Gynecology ,Humans ,Premature Birth ,Bayes Theorem ,Female ,General Medicine ,Progesterone ,Randomized Controlled Trials as Topic - Abstract
ObjectivesTo compare the efficacy of bed rest, cervical cerclage (McDonald, Shirodkar, or unspecified type of cerclage), cervical pessary, fish oils or omega fatty acids, nutritional supplements (zinc), progesterone (intramuscular, oral, or vaginal), prophylactic antibiotics, prophylactic tocolytics, combinations of interventions, placebo or no treatment (control) to prevent spontaneous preterm birth in women with a singleton pregnancy and a history of spontaneous preterm birth or short cervical length.DesignSystematic review with bayesian network meta-analysis.Data sourcesThe Cochrane Pregnancy and Childbirth Group’s Database of Trials, the Cochrane Central Register of Controlled Trials, Medline, Embase, CINAHL, relevant journals, conference proceedings, and registries of ongoing trials.Eligibility criteria for selecting studiesRandomised controlled trials of pregnant women who are at high risk of spontaneous preterm birth because of a history of spontaneous preterm birth or short cervical length. No language or date restrictions were applied.OutcomesSeven maternal outcomes and 11 fetal outcomes were analysed in line with published core outcomes for preterm birth research. Relative treatment effects (odds ratios and 95% credible intervals) and certainty of evidence are presented for outcomes of preterm birth ResultsSixty one trials (17 273 pregnant women) contributed data for the analysis of at least one outcome. For preterm birth ConclusionVaginal progesterone should be considered the preventative treatment of choice for women with singleton pregnancy identified to be at risk of spontaneous preterm birth because of a history of spontaneous preterm birth or short cervical length. Future randomised controlled trials should use vaginal progesterone as a comparator to identify better treatments or combination treatments.Systematic review registrationPROSPERO CRD42020169006
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- 2022
30. Evaluating Progestogens for Preventing Preterm birth International Collaborative (EPPPIC): meta-analysis of individual participant data from randomised controlled trials
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Lesley A Stewart, Mark Simmonds, Lelia Duley, Alexis Llewellyn, Sahar Sharif, Ruth AE Walker, Lucy Beresford, Kath Wright, Mona M Aboulghar, Zarko Alfirevic, Azam Azargoon, Rashmi Bagga, Elham Bahrami, Sean C Blackwell, Steve N Caritis, C Andrew Combs, Jennifer M Croswell, Caroline A Crowther, Anita F Das, Kay Dickersin, Kristina C Dietz, Andrew Elimian, William A Grobman, Alexander Hodkinson, Kimberley A Maurel, David S McKenna, Ben W Mol, Kelle Moley, Jamie Mueller, Anwar Nassar, Jane E Norman, John Norrie, John M O'Brien, Raphael Porcher, Shalini Rajaram, Line Rode, Dwight J Rouse, Carol Sakala, Ewoud Schuit, Marie-Victoire Senat, Joe L Simpson, Katherine Smith, Anne Tabor, Elizabeth A Thom, Melanie A van Os, Evelyn P Whitlock, Stephen Wood, Tom Walley, and Obstetrics and Gynaecology
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medicine.medical_specialty ,medicine.medical_treatment ,Pregnancy, High-Risk ,030204 cardiovascular system & hematology ,progesterone ,Injections, Intramuscular ,Risk Assessment ,Miscarriage ,03 medical and health sciences ,0302 clinical medicine ,Pregnancy ,medicine ,Humans ,030212 general & internal medicine ,Progesterone ,Randomized Controlled Trials as Topic ,Progestogen ,Obstetrics ,business.industry ,17-alpha-Hydroxyprogesterone ,Absolute risk reduction ,Infant, Newborn ,Pregnancy Outcome ,Obstetrics and Gynecology ,Preterm birth ,General Medicine ,medicine.disease ,17-alpha-hydroxyprogesterone ,Administration, Intravaginal ,Meta-analysis ,Relative risk ,Premature Birth ,Female ,pregnancy ,Outcomes research ,business ,Premature rupture of membranes ,Decision Making, Shared - Abstract
BACKGROUND: Preterm birth is a global health priority. Using a progestogen during high-risk pregnancy could reduce preterm birth and adverse neonatal outcomes.METHODS: We did a systematic review of randomised trials comparing vaginal progesterone, intramuscular 17-hydroxyprogesterone caproate (17-OHPC), or oral progesterone with control, or with each other, in asymptomatic women at risk of preterm birth. We identified published and unpublished trials that completed primary data collection before July 30, 2016, (12 months before data collection began), by searching MEDLINE, Embase, CINAHL, the Maternity and Infant Care Database, and relevant trial registers between inception and July 30, 2019. Trials of progestogen to prevent early miscarriage or immediately-threatened preterm birth were excluded. Individual participant data were requested from investigators of eligible trials. Outcomes included preterm birth, early preterm birth, and mid-trimester birth. Adverse neonatal sequelae associated with early births were assessed using a composite of serious neonatal complications, and individually. Adverse maternal outcomes were investigated as a composite and individually. Individual participant data were checked and risk of bias assessed independently by two researchers. Primary meta-analyses used one-stage generalised linear mixed models that incorporated random effects to allow for heterogeneity across trials. This meta-analysis is registered with PROSPERO, CRD42017068299.FINDINGS: Initial searches identified 47 eligible trials. Individual participant data were available for 30 of these trials. An additional trial was later included in a targeted update. Data were therefore available from a total of 31 trials (11 644 women and 16185 offspring). Trials in singleton pregnancies included mostly women with previous spontaneous preterm birth or short cervix. Preterm birth before 34 weeks was reduced in such women who received vaginal progesterone (nine trials, 3769 women; relative risk [RR] 0·78, 95% CI 0·68-0·90), 17-OHPC (five trials, 3053 women; 0·83, 0·68-1·01), and oral progesterone (two trials, 181 women; 0·60, 0·40-0·90). Results for other birth and neonatal outcomes were consistently favourable, but less certain. A possible increase in maternal complications was suggested, but this was uncertain. We identified no consistent evidence of treatment interaction with any participant characteristics examined, although analyses within subpopulations questioned efficacy in women who did not have a short cervix. Trials in multifetal pregnancies mostly included women without additional risk factors. For twins, vaginal progesterone did not reduce preterm birth before 34 weeks (eight trials, 2046 women: RR 1·01, 95% CI 0·84-1·20) nor did 17-OHPC for twins or triplets (eight trials, 2253 women: 1·04, 0·92-1·18). Preterm premature rupture of membranes was increased with 17-OHPC exposure in multifetal gestations (rupture INTERPRETATION: Vaginal progesterone and 17-OHPC both reduced birth before 34 weeks' gestation in high-risk singleton pregnancies. Given increased underlying risk, absolute risk reduction is greater for women with a short cervix, hence treatment might be most useful for these women. Evidence for oral progesterone is insufficient to support its use. Shared decision making with woman with high-risk singleton pregnancies should discuss an individual's risk, potential benefits, harms and practicalities of intervention. Treatment of unselected multifetal pregnancies with a progestogen is not supported by the evidence.FUNDING: Patient-Centered Outcomes Research Institute.
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- 2021
31. Foley catheter vs oral misoprostol for induction of labor: individual participant data meta‐analysis
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M. Goonewardene, Katrien Oude Rengerink, K.W. Bloemenkamp, Heidi Kruit, Zarko Alfirevic, M. Flanagan, Hillary Bracken, M L G Ten Eikelder, S. Goni, Andrew Weeks, Wentao Li, Ben W.J. Mol, Shuchita Mundle, J. I. Kemper, and Kirsten R Palmer
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medicine.medical_specialty ,Catheters ,Neonatal intensive care unit ,Foley catheter ,Administration, Oral ,law.invention ,03 medical and health sciences ,0302 clinical medicine ,Randomized controlled trial ,Pregnancy ,law ,Oxytocics ,medicine ,Humans ,Radiology, Nuclear Medicine and imaging ,Labor, Induced ,030212 general & internal medicine ,Misoprostol ,Randomized Controlled Trials as Topic ,030219 obstetrics & reproductive medicine ,Radiological and Ultrasound Technology ,Obstetrics ,business.industry ,Obstetrics and Gynecology ,Gestational age ,General Medicine ,16. Peace & justice ,medicine.disease ,Intensive care unit ,3. Good health ,Reproductive Medicine ,Relative risk ,Female ,Maternal death ,Urinary Catheterization ,business ,medicine.drug - Abstract
Objective To compare the effectiveness and safety of Foley catheter and oral misoprostol for induction of labor (IOL). Methods The Cochrane Review on Mechanical Methods for Induction of Labour and Ovid MEDLINE, EMBASE via Ovid, Ovid Emcare, CINAHL Plus, ClinicalTrials.gov and Scopus, from inception to April 2019, were searched for randomized controlled trials (RCTs) comparing Foley catheter to oral misoprostol for IOL in viable singleton gestations. Eligible trials for which raw data were obtained were included and individual participant data meta-analysis was performed. Primary outcomes were vaginal birth, a composite of adverse perinatal outcome (including stillbirth, neonatal death, neonatal seizures, admission to the neonatal intensive care unit, severe respiratory compromise or meconium aspiration syndrome) and a composite of adverse maternal outcome (including admission to the intensive care unit, maternal infection, severe postpartum hemorrhage, maternal death or uterine rupture). The quality of the included RCTs was assessed using the Cochrane Risk of Bias 2 tool and the certainty of evidence was evaluated using the GRADE approach. A two-stage random-effects model was used for meta-analysis according to the intention-to-treat principle and interactions between treatment and baseline characteristics were assessed. Results Of seven eligible trials, four provided individual participant data for a total of 2815 participants undergoing IOL, of whom 1399 were assigned to Foley catheter and 1416 to oral misoprostol. All four trials provided data for each of the primary outcomes in all 2815 women. Compared with those receiving oral misoprostol, Foley catheter recipients had a slightly decreased chance of vaginal birth (risk ratio (RR), 0.95 (95% CI, 0.91-0.99); I2 , 2.0%; moderate-certainty evidence). A trend towards a lower rate of composite adverse perinatal outcome was found in women undergoing IOL using a Foley catheter compared with oral misoprostol (RR, 0.71 (95% CI, 0.48-1.05); I2 , 14.9%; low-certainty evidence). Composite adverse maternal outcome did not differ between the groups (RR, 1.00 (95% CI, 0.97-1.03); I2 , 0%; moderate-certainty evidence). Meta-analyses of effect modifications did not show significant interactions between intervention and parity or gestational age for any of the primary outcomes. Conclusions For women undergoing IOL, Foley catheter is less effective than oral misoprostol, as it was associated with fewer vaginal births. However, while we found no significant difference in maternal safety, Foley catheter induction may reduce adverse perinatal outcomes. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.
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- 2021
32. Controversies in the prevention of spontaneous preterm birth in asymptomatic women: an evidence summary and expert opinion
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Angharad Care, Zarko Alfirevic, and Laura Goodfellow
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Pessary ,medicine.medical_specialty ,030219 obstetrics & reproductive medicine ,Obstetrics ,business.industry ,medicine.medical_treatment ,Obstetrics and Gynecology ,Vaginal pessary ,Cervical shortening ,Asymptomatic ,03 medical and health sciences ,0302 clinical medicine ,Pregnancy ,Risk Factors ,Expert opinion ,Genital tract ,medicine ,Humans ,Premature Birth ,Female ,Cervical cerclage ,medicine.symptom ,business ,Risk Reduction Behavior ,Cervical length - Abstract
Preterm birth prevention is multifaceted and produces many nuanced questions. This review addresses six important clinical questions about preterm birth prevention as voted for by members of the UK Preterm Clinical Network. The questions cover the following areas: preterm birth prevention in 'low-risk' populations; screening for asymptomatic genital tract infection in women at high risk of preterm birth; cervical length screening with cerclage or vaginal pessary in situ; cervical shortening whilst using progesterone; use of vaginal progesterone in combination with cervical cerclage; and optimal advice about intercourse for women at high risk of preterm birth.
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- 2020
33. Amnioinfusion versus Usual Care in Women with Prelabor Rupture of Membranes in Midtrimester: A Systematic Review and Meta-Analysis of Short- and Long-Term Outcomes
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Annemijn A. de Ruigh, Noor E. Simons, Larissa I. van der Windt, Sofie H. Breuking, Janneke van ‘t Hooft, Augustinus S. van Teeffelen, Zarko Alfirevic, Devender Roberts, Ben W. Mol, Eva Pajkrt, Obstetrics and gynaecology, and Amsterdam Reproduction & Development (AR&D)
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Embryology ,Fetal Membranes, Premature Rupture ,Perinatal Death ,Infant, Newborn ,Obstetrics and Gynecology ,Infant ,Obstetric ,General Medicine ,Second ,Newborn ,Delivery, Obstetric ,Pregnancy ,Pregnancy Trimester, Second ,Pediatrics, Perinatology and Child Health ,Premature Rupture/therapy ,Humans ,Premature Birth ,Radiology, Nuclear Medicine and imaging ,Female ,Pregnancy Trimester ,Child ,Fetal Membranes ,Delivery ,Perinatal Mortality ,Randomized Controlled Trials as Topic - Abstract
Introduction: Midtrimester prelabor rupture of membranes (PROM) between 16 and 24 weeks of gestational age is a major obstetric complication with high rates of perinatal morbidity and mortality. Amnioinfusion has been proposed in women with midtrimester PROM to target oligohydramnios and subsequently enhance pulmonary development and perinatal outcomes. Material and Methods: The purpose of this study was to perform a systematic review and meta-analysis including all randomized clinical trials investigating amnioinfusion versus no intervention in women with PROM between 16+0 and 24+0 weeks of gestational age. Databases Central, Embase, Medline, ClinicalTrials.gov and references of identified articles were searched from inception of database to December 2021. The primary outcome was perinatal mortality. Secondary outcomes included neonatal, maternal, and long-term developmental outcomes as defined in the core outcome set for preterm birth studies. Summary measures were reported as pooled relative risk (RR) or mean difference with corresponding 95% confidence interval (CI). Results: Two studies (112 patients, 56 in the amnioinfusion group and 56 in the no intervention group) were included in this review. Pooled perinatal mortality was 66.1% (37/56) in the amnioinfusion group compared with 71.4% (40/56) in no intervention group (RR 0.92, 95% CI: 0.72–1.19). Other neonatal and maternal core outcomes were similar in both groups, although due to the relatively small number of events and wide CIs, there is a possibility that amnioinfusion can be associated with clinically important benefits and harms. Long-term healthy survival was seen in 35.7% (10/28) of children assessed for follow-up and treated with amnioinfusion versus 28.6% (8/28) after no intervention (RR 1.30, 95% CI: 0.47–3.60, “best case scenario”). Conclusions: Based on these findings, the benefits of amnioinfusion for midtrimester PROM
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- 2022
34. Maged et al. Am J Perinatol. 2020 Apr;37(5):491-49
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Jim Thornton, Zarko Alfirevic, Vincenzo Berghella, Wessel Ganzevoort, Louise Kenny, Ben Mol, Francis Muriithi, Dwight Rouse, Andrew Shennan, Annika Strandell, Joris A.M. van der Post, Madelon van Wely, Obstetrics and Gynaecology, APH - Quality of Care, Amsterdam Reproduction & Development (AR&D), Center for Reproductive Medicine, APH - Methodology, APH - Personalized Medicine, and Obstetrics and gynaecology
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Pediatrics, Perinatology and Child Health ,Obstetrics and Gynecology - Abstract
N/A.
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- 2022
35. Amniocentesis and chorionic villus sampling
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Gynaecologists, K Navaratnam, and Zarko Alfirevic
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Gynecology ,medicine.medical_specialty ,medicine.diagnostic_test ,Obstetrics ,business.industry ,medicine ,MEDLINE ,Amniocentesis ,Obstetrics and Gynecology ,Chorionic villus sampling ,Guideline ,business - Published
- 2021
36. Maternal selenium levels and whole genome screen in recurrent spontaneous preterm birth population: A nested case control study
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Nagendra Monangi, Julio Landero, Angharad Care, Ana Alfirevic, Joanne Chappell, Ge Zhang, Bertram Müller-Myhsok, Laura Goodfellow, Zarko Alfirevic, Andrew Sharp, Elizabeth Belling, Juhi K. Gupta, and Louis J. Muglia
- Subjects
medicine.medical_specialty ,Population ,Genome-wide association study ,Logistic regression ,Selenium ,Pregnancy ,Statistical significance ,Medicine ,Humans ,education ,Genetic association ,Nutrition ,education.field_of_study ,Models, Statistical ,business.industry ,Obstetrics ,Obstetrics and Gynecology ,Preterm birth ,medicine.disease ,Prognosis ,Reproductive Medicine ,Case-Control Studies ,Nested case-control study ,Term Birth ,Premature Birth ,Female ,Genome wide association study ,business - Abstract
Objective: To establish if low maternal selenium (Se) was associated with sPTB in women with recurrent sPTB and identify genetic link with maternal Se levels. Design: Nested case-control study. Setting: Tertiary Maternity Hospital. Population: Plasma and whole blood from pregnant women with history of early sPTB/PPROM < 34 +0 and European ancestry were obtained at 20 weeks (range 15–24 weeks). ‘Cases’ were recurrent PTB/PPROM < 34 +0 weeks and term (≥37 +0) deliveries were classified as ‘high-risk controls.’ Women with previous term births and index birth ≥ 39 weeks were ‘low-risk controls’. Methods: Maternal plasma Se measured by ICP-MS was used as a continuous phenotype in a GWAS analysis. Se was added to a logistic regression model using PTB predictor variables. Main outcome measures: Maternal Se concentration, recurrent early sPTB/PPROM. Results: 53/177 high-risk women had a recurrent sPTB/PPROM < 34 +0weeks and were 2.7 times more likely to have a Se level < 83.3 ppm at 20weeks of pregnancy compared with low-risk term controls (n = 179), (RR 2.7, 95%CI 1.5–4.8; p =.001). One SNP from a non-coding region (FOXN3 intron variant, rs55793422) reached genome-wide significance level (p = 3.73E −08). Targeted analysis of Se gene variant did not show difference between preterm and term births. (χ 2 test, OR = 0.95; 95%CI = 0.59–1.56; p = 0.82). When Se levels were added to a clinical prediction model, only an additional 5% of cases (n = 3) and 0.6% (n = 1) of controls were correctly identified. Conclusions: Low plasma Se is associated with sPTB risk but is not sufficiently predictive at individual patient level. We did not find a genetic association between maternal Se levels and Se-related genes.
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- 2021
37. The Induction with Foley OR Misoprostol (INFORM) Study dataset. A dataset of 602 women with hypertensive disease in pregnancy, in India, randomised to either Foley catheter or oral misoprostol for induction of labour
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Andrew Weeks, Shuchita Mundle, Miroslava Ebringer, Jayashree Mulik, Hillary Bracken, Thomas R. Easterling, Kate Lightly, Zarko Alfirevic, Beverly Winikoff, Vaishali Khedikar, Paul Granby, Brian Faragher, Mark A. Turner, Alan Haycox, and Simon Leigh
- Subjects
Low income ,medicine.medical_specialty ,Science (General) ,Catheters ,Foley catheter ,QH301-705.5 ,Labour ,Hypertension in Pregnancy ,India ,wa_395 ,wa_310 ,Data Note ,General Biochemistry, Genetics and Molecular Biology ,Induction ,Q1-390 ,Pregnancy ,Oxytocics ,Humans ,Medicine ,wq_200 ,Labor, Induced ,Biology (General) ,Misoprostol ,Foley ,business.industry ,Obstetrics ,wj_100 ,Infant, Newborn ,General Medicine ,medicine.disease ,Mode of delivery ,Hypertensive disease ,Hypertension ,Female ,business ,Pre-eclampsia ,Dataset ,Cervical Ripening ,medicine.drug - Abstract
Objectives Induction of labour (IOL), or starting labour artificially, can be a lifesaving intervention for pregnant women and their babies, and rates are rising significantly globally. As rates increase, it becomes increasingly important to fully evaluate all available data, especially that from low income settings where the potential benefits and harms are greater. The goal of this paper is to describe the datasets collected as part of the Induction with Foley OR Misoprostol (INFORM) Study, a randomised trial comparing two of the recommended methods of cervical ripening for labour induction, oral misoprostol and Foley catheter, in women being induced for hypertension in pregnancy, at two sites in India during 2013–15. Data description This dataset includes comprehensive data on 602 women who underwent IOL for hypertensive disorders in pregnancy. Women were randomly assigned to cervical ripening with oral misoprostol or a transcervical Foley catheter in two government hospitals in India. The main dataset has 367 variables including monitoring during the induction of labour, medications administered, timing and mode of delivery, measures of neonatal morbidity and mortality, maternal mortality and morbidity, maternal satisfaction and health economic data. The dataset is anonymised and available on ReShare.
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- 2021
38. Metabolic profiling of maternal serum of women a high-risk of spontaneous preterm birth using NMR and MGWAS approach
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Bertram Müller-Myhsok, Marie M. Phelan, Juhi K. Gupta, Lu-Yun Lian, Ana Alfirevic, Angharad Care, Laura Goodfellow, and Zarko Alfirevic
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Magnetic Resonance Spectroscopy ,Microarray ,Metabolite ,Physiology ,Biochemistry ,Molecular Bases of Health & Disease ,chemistry.chemical_compound ,Pregnancy ,Risk Factors ,biomarker discovery ,Genotype ,Medicine ,Prospective Studies ,Biomarker discovery ,Research Articles ,Oligonucleotide Array Sequence Analysis ,integumentary system ,mGWAS ,Genomics ,multiple omics ,Phenotype ,Cohort ,Metabolome ,Premature Birth ,Gestation ,Translational Science ,Female ,Analysis of variance ,Adult ,Biophysics ,Gestational Age ,Polymorphism, Single Nucleotide ,Risk Assessment ,Predictive Value of Tests ,Humans ,Metabolomics ,SNP ,Genetic Predisposition to Disease ,Systems Biology & Networks ,Lactic Acid ,TNF Receptor-Associated Factor 1/genetics ,Molecular Biology ,business.industry ,Premature Birth/blood ,Preterm birth ,Lactic Acid/blood ,Cell Biology ,TNF Receptor-Associated Factor 1 ,NMR ,Metabolism ,chemistry ,Case-Control Studies ,Neural Networks, Computer ,business ,Biomarkers ,Biomarkers/blood ,Genome-Wide Association Study - Abstract
Preterm birth (PTB) is a leading global cause of infant mortality. Risk factors include genetics, lifestyle choices and infection. Understanding the mechanism of PTB could aid the development of novel approaches to prevent PTB. This study aimed to investigate the metabolic biomarkers of PTB in early pregnancy and the association of significant metabolites with participant genotypes. Maternal sera collected at 16 and 20 weeks of gestation, from women who previously experienced PTB (high-risk) and women who did not (low-risk controls), were analysed using 1H nuclear magnetic resonance (NMR) metabolomics and genome-wide screening microarray. ANOVA and probabilistic neural network (PNN) modelling were performed on the spectral bins. Metabolomics genome-wide association (MGWAS) of the spectral bins and genotype data from the same participants was applied to determine potential metabolite-gene pathways. Phenylalanine, acetate and lactate metabolite differences between PTB cases and controls were obtained by ANOVA and PNN showed strong prediction at week 20 (AUC = 0.89). MGWAS identified several metabolite bins with strong genetic associations. Cis-eQTL analysis highlighted TRAF1 (involved in the inflammatory pathway) local to a non-coding SNP associated with lactate at week 20 of gestation. MGWAS of a well-defined cohort of participants highlighted a lactate-TRAF1 relationship that could potentially contribute to PTB.
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- 2021
39. Plasma long-chain omega-3 fatty acid status and risk of recurrent early spontaneous preterm birth: a prospective observational study
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Andrew Sharp, Laura Goodfellow, Ana Alfirevic, Jelena Ivandic, Zarko Alfirevic, Devender Roberts, Jane Harrold, Borna Poljak, Bertram Müller-Myhsok, Angharad Care, Maria Makrides, and Robert A. Gibson
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Adult ,Relative risk reduction ,medicine.medical_specialty ,Population ,03 medical and health sciences ,0302 clinical medicine ,Pregnancy ,Risk Factors ,Fatty Acids, Omega-3 ,medicine ,Humans ,Prospective Studies ,030212 general & internal medicine ,Omega 3 fatty acid ,education ,education.field_of_study ,030219 obstetrics & reproductive medicine ,Obstetrics ,business.industry ,Obstetrics and Gynecology ,Prenatal Care ,General Medicine ,Odds ratio ,medicine.disease ,Eicosapentaenoic acid ,United Kingdom ,Dietary Supplements ,Premature Birth ,Term Birth ,Gestation ,Female ,business - Abstract
Introduction A 2018 Cochrane review found that omega-3 supplementation in pregnancy was associated with a risk reduction of early preterm birth of 0.58; prompting calls for universal supplementation. Recent analysis suggests the benefit may be confined to women with a low baseline omega-3 fatty acid status. However, the contemporary omega-3 fatty acid status of pregnant women in the UK is largely unknown. This is particularly pertinent for women with a previous preterm birth, in whom a small relative risk reduction would have a larger reduction of absolute risk. This study aimed to assess the omega-3 fatty acid status of a UK pregnant population and determine the association between the long-chain omega-3 fatty acids and recurrent spontaneous early preterm birth. Material and methods A total of 283 high-risk women with previous early preterm birth were recruited to the prospective observational study in Liverpool, UK. Additionally, 96 pregnant women with previous term births and birth ≥39+0 weeks in the index pregnancy provided a low-risk population sample. Within the high-risk group we assessed the odds ratio of recurrent early preterm birth compared with birth at ≥37+0 weeks of gestation according to plasma eicosapentaenoic acid plus docosahexaenoic acid (EPA+DHA) at 15-22 weeks of gestation. Results Our participants had low EPA+DHA; 62% (143/229) of women with previous preterm birth and 69% (68/96) of the population sample had levels within the lowest two quintiles of a previously published pregnancy cohort. We found no association between long-chain omega-3 status and recurrent early preterm birth (n = 51). The crude odds ratio of a recurrent event was 0.91 (95% CI 0.38-2.15, p = 0.83) for women in the lowest, compared with the highest three quintiles of EPA+DHA. Conclusions In the majority of our participants, levels of long-chain omega-3 were low; within the range that may benefit from supplementation. However, levels showed no association with risk of recurrent early spontaneous preterm birth. This could be because our population levels were too low to show benefit in being omega-3 "replete"; or else omega-3 levels may be of lesser importance in recurrent early preterm birth.
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- 2021
40. Pregnancy and Childbirth: A Cochrane Pocketbook
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G. Justus Hofmeyr, James P. Neilson, Zarko Alfirevic, Caroline A. Crowther, Lelia Duley, Metin Gulmezoglu, Gillian M. L. Gyte, Ellen D. Hodnett and G. Justus Hofmeyr, James P. Neilson, Zarko Alfirevic, Caroline A. Crowther, Lelia Duley, Metin Gulmezoglu, Gillian M. L. Gyte, Ellen D. Hodnett
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- 2011
41. Oral Misoprostol alone versus oral misoprostol followed by oxytocin for labour induction in women with hypertension in pregnancy (MOLI): protocol for a randomised controlled trial
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Beverly Winikoff, Hillary Bracken, Brian Faragher, Simon Leigh, Thomas R. Easterling, Kate Lightly, Shuchita Mundle, Robbie Kerr, Mark A. Turner, Andrew Weeks, and Zarko Alfirevic
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Augmentation of labour ,medicine.medical_specialty ,Hypertension in Pregnancy ,Reproductive medicine ,Administration, Oral ,India ,Oxytocin ,wa_310 ,law.invention ,Study Protocol ,03 medical and health sciences ,chemistry.chemical_compound ,0302 clinical medicine ,Clinical Protocols ,Randomized controlled trial ,Pregnancy ,law ,Oral administration ,Oxytocics ,Pragmatic Clinical Trials as Topic ,Induction of labour ,medicine ,Humans ,Labor, Induced ,030212 general & internal medicine ,wq_300 ,Prostaglandin E1 ,Misoprostol ,030219 obstetrics & reproductive medicine ,Obstetrics ,business.industry ,Obstetrics and Gynecology ,Hypertension, Pregnancy-Induced ,Gynecology and obstetrics ,medicine.disease ,qv_170 ,Hospitals ,Treatment Outcome ,chemistry ,RG1-991 ,Administration, Intravenous ,Female ,business ,Pre-eclampsia ,medicine.drug - Abstract
Background Every year approximately 30,000 women die from hypertensive disease in pregnancy. Magnesium sulphate and anti-hypertensives reduce morbidity, but delivery is the only cure. Low dose oral misoprostol, a prostaglandin E1 analogue, is a highly effective method for labour induction. Usually, once active labour has commenced, the misoprostol is replaced with an intravenous oxytocin infusion if ongoing stimulation is required. However, some studies have shown that oral misoprostol can be continued into active labour, a simpler and potentially more acceptable protocol for women. To date, these two protocols have never been directly compared. Methods This pragmatic, open-label, randomised trial will compare a misoprostol alone labour induction protocol with the standard misoprostol plus oxytocin protocol in three Indian hospitals. The study will recruit 520 pregnant women being induced for hypertensive disease in pregnancy and requiring augmentation after membrane rupture. Participants will be randomised to receive either further oral misoprostol 25mcg every 2 h, or titrated intravenous oxytocin. The primary outcome will be caesarean birth. Secondary outcomes will assess the efficacy of the induction process, maternal and fetal/neonatal complications and patient acceptability. This protocol (version 1.04) adheres to the SPIRIT checklist. A cost-effectiveness analysis, situational analysis and formal qualitative assessment of women’s experience are also planned. Discussion Avoiding oxytocin and continuing low dose misoprostol into active labour may have a number of benefits for both women and the health care system. Misoprostol is heat stable, oral medication and thus easy to store, transport and administer; qualities particularly desirable in low resource settings. An oral medication protocol requires less equipment (e.g. electronic infusion pumps) and may free up health care providers to assist with other aspects of the woman’s care. The simplicity of the protocol may also help to reduce human errors associated with the delivery of intravenous infusions. Finally, women may prefer to be mobile during labour and not restricted by an intravenous infusion. There is a need, therefore, to assess whether augmentation using oral misoprostol is superior clinically and economically to the standard protocol of intravenous oxytocin. Trial registration Clinical Trials.gov, NCT03749902, registered on 21st Nov 2018.
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- 2021
42. Genome and transcriptome profiling of spontaneous preterm birth phenotypes
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Juhi K. Gupta, Angharad Care, Laura Goodfellow, Zarko Alfirevic, Bertram Müller-Myhsok, and Ana Alfirevic
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Receptors, Cell Surface/genetics ,Adult ,Fetal Membranes, Premature Rupture ,Science ,Quantitative Trait Loci ,Nerve Tissue Proteins ,Receptors, Cell Surface ,Article ,Pregnancy ,Genetics research ,Genetics ,Nerve Tissue Proteins/genetics ,Humans ,Forkhead Transcription Factors/genetics ,Multidisciplinary ,Gene Expression Profiling ,PPAR gamma/genetics ,Premature Birth/blood ,Pregnancy Outcome ,Fetal Membranes, Premature Rupture/blood ,Forkhead Transcription Factors ,Publisher Correction ,PPAR gamma ,MicroRNAs ,Medicine ,Premature Birth ,Female ,Systems biology ,Biomarkers/blood ,Biomarkers ,Genome-Wide Association Study - Abstract
Preterm birth (PTB) occurs before 37 weeks of gestation. Risk factors include genetics and infection/inflammation. Different mechanisms have been reported for spontaneous preterm birth (SPTB) and preterm birth following preterm premature rupture of membranes (PPROM). This study aimed to identify early pregnancy biomarkers of SPTB and PPROM from the maternal genome and transcriptome. Pregnant women were recruited at the Liverpool Women’s Hospital. Pregnancy outcomes were categorised as SPTB, PPROM (≤ 34 weeks gestation, n = 53), high-risk term (HTERM, ≥ 37 weeks, n = 126) or low-risk (no history of SPTB/PPROM) term (LTERM, ≥ 39 weeks, n = 188). Blood samples were collected at 16 and 20 weeks gestation from which, genome (UK Biobank Axiom array) and transcriptome (Clariom D Human assay) data were acquired. PLINK and R were used to perform genetic association and differential expression analyses and expression quantitative trait loci (eQTL) mapping. Several significant molecular signatures were identified across the analyses in preterm cases. Genome-wide significant SNP rs14675645 (ASTN1) was associated with SPTB whereas microRNA-142 transcript and PPARG1-FOXP3 gene set were associated with PPROM at week 20 of gestation and is related to inflammation and immune response. This study has determined genomic and transcriptomic candidate biomarkers of SPTB and PPROM that require validation in diverse populations.
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- 2021
43. A prediction model for short-term neonatal outcomes in severe early-onset fetal growth restriction
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Edward D. Johnstone, Jane Harrold, Peter von Dadelszen, Asma Khalil, Richard J. Jackson, Mark A. Turner, Philip N. Baker, Zarko Alfirevic, Louise C. Kenny, Christine Cornforth, Aris T. Papageorghiou, and Andrew Sharp
- Subjects
Adult ,Gestational hypertension ,Placental growth factor ,medicine.medical_specialty ,Ultrasonography, Prenatal ,Preeclampsia ,fetal growth restriction ,03 medical and health sciences ,0302 clinical medicine ,Pregnancy ,medicine.artery ,medicine ,Birth Weight ,Humans ,030212 general & internal medicine ,Fetus ,Fetal Growth Retardation ,Models, Statistical ,030219 obstetrics & reproductive medicine ,Obstetrics ,business.industry ,Infant, Newborn ,Pregnancy Outcome ,Obstetrics and Gynecology ,Umbilical artery ,medicine.disease ,Blood pressure ,Reproductive Medicine ,embryonic structures ,PlGF ratio [sFlt-1] ,Gestation ,Female ,stillbirth ,business ,Biomarkers - Abstract
BackgroundSevere early-onset fetal growth restriction (FGR) predisposes to fetal death, neonatal death, neonatal morbidity and neurodisability. The use of placental biomarkers has been proposed for risk stratification in pre-eclampsia, but they could be equally useful in fetal growth restriction in aiding management.ObjectiveTo determine the efficacy of angiogenic biomarkers at predicting adverse pregnancy outcome in severe early-onset fetal growth restriction.Study designThis is a secondary analysis of the multicentre, placebo-controlled STRIDER UK randomised controlled trial of singleton pregnancies with severe early-onset fetal growth restriction.Women with FGR pregnancies between 22+0 and 29+6 weeks of gestation were randomly assigned to receive either sildenafil 25 mg three times daily or placebo until 32+0 weeks’ gestation or delivery. We developed prediction models based upon maternal demographics (age, parity, blood pressure, preeclampsia, gestational hypertension), fetal biometric (estimated fetal weight) and Doppler measurements (Middle Cerebral Artery (MCA), Umbilical Artery (UA)) and maternal angiogenic biomarkers [placental growth factor (PlGF), soluble endoglin (sEng), soluble fms-like tyrosine kinase 1 (sFlt-1) and sFlt-1:PlGF ratio) using both univariate and multivariate analysis.ResultsA complete data set was available for 105 of 135 randomised women. Multivariate regression analysis identified estimated fetal weight (EFW) and sFlt-1:PlGF as independent predictors of livebirth (EFW OR: 1.01 (1.008, 1.021); p ConclusionsIn severe early-onset FGR pregnancies livebirth and overall survival can be predicted using a model involving EFW and sFlt-1:PlGF ratio. This model require validation in a larger cohort but may allow informed decision making about pregnancy management, especially in previable cases.
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- 2019
44. ISUOG Practice Guidelines: ultrasound assessment of fetal biometry and growth
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Aris T. Papageorghiou, F. Figueras, R. Napolitano, Alexandros Sotiriadis, Laurent Salomon, Julien Stirnemann, George S. H. Yeo, Russell L. Deter, F. da Silva Costa, Ants Toi, Zarko Alfirevic, Wesley Lee, Asma Khalil, Phyllis Glanc, and Tullio Ghi
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medicine.medical_specialty ,Biometry ,Amniotic fluid ,medicine.medical_treatment ,Intrauterine growth restriction ,Crown-Rump Length ,Ultrasonography, Prenatal ,03 medical and health sciences ,0302 clinical medicine ,Pregnancy ,Fetal macrosomia ,Humans ,Medicine ,Radiology, Nuclear Medicine and imaging ,030212 general & internal medicine ,Societies, Medical ,Crown-rump length ,Fetus ,Fetal Growth Retardation ,030219 obstetrics & reproductive medicine ,Assisted reproductive technology ,Radiological and Ultrasound Technology ,business.industry ,Obstetrics ,Obstetrics and Gynecology ,Gestational age ,General Medicine ,medicine.disease ,Reproductive Medicine ,Practice Guidelines as Topic ,Female ,business - Abstract
INTRODUCTION These Guidelines aim to describe appropriate assessment of fetal biometry and diagnosis of fetal growth disorders. These disorders consist mainly of fetal growth restriction (FGR), also referred to as intrauterine growth restriction (IUGR) and often associated with small‐for‐gestational age (SGA), and large‐for‐gestational age (LGA), which may lead to fetal macrosomia; both have been associated with a variety of adverse maternal and perinatal outcomes. Screening for, and adequate management of, fetal growth abnormalities are essential components of antenatal care, and fetal ultrasound plays a key role in assessment of these conditions. The fetal biometric parameters measured most commonly are biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC) and femur diaphysis length (FL). These biometric measurements can be used to estimate fetal weight (EFW) using various different formulae1. It is important to differentiate between the concept of fetal size at a given timepoint and fetal growth, the latter being a dynamic process, the assessment of which requires at least two ultrasound scans separated in time. Maternal history and symptoms, amniotic fluid assessment and Doppler velocimetry can provide additional information that may be used to identify fetuses at risk of adverse pregnancy outcome. Accurate estimation of gestational age is a prerequisite for determining whether fetal size is appropriate‐for‐gestational age (AGA). Except for pregnancies arising from assisted reproductive technology, the date of conception cannot be determined precisely. Clinically, most pregnancies are dated by the last menstrual period, though this may sometimes be uncertain or unreliable. Therefore, dating pregnancies by early ultrasound examination at 8–14 weeks, based on measurement of the fetal crown–rump length (CRL), appears to be the most reliable method to establish gestational age. Once the CRL exceeds 84 mm, HC should be used for pregnancy dating2–4. HC, with or without FL, can be used for estimation of gestational age from the mid‐trimester if a first‐trimester scan is not available and the menstrual history is unreliable. When the expected delivery date has been established by an accurate early scan, subsequent scans should not be used to recalculate the gestational age1. Serial scans can be used to determine if interval growth has been normal. In these Guidelines, we assume that the gestational age is known and has been determined as described above, the pregnancy is singleton and the fetal anatomy is normal. Details of the grades of recommendation used in these Guidelines are given in Appendix 1. Reporting of levels of evidence is not applicable to these Guidelines.Pautas de ISUOG para la práctica: evaluación ecográfica de la biometría y el crecimiento fetal INTRODUCCIÓN: El objetivo de estas Pautas es describir la evaluación adecuada de la biometría fetal y el diagnóstico de los trastornos del crecimiento fetal. Estos trastornos consisten principalmente en la restricción del crecimiento fetal (RCF), también conocida como restricción del crecimiento intrauterino (RCIU), que a menudo está asociada con un tamaño pequeño para la edad gestacional (PEG) o grande para la edad gestacional (GEG), que pueden dar lugar a la macrosomía fetal; ambos se han asociado con una variedad de resultados maternos y perinatales adversos. La detección y el tratamiento adecuado de las anomalías del crecimiento fetal son componentes esenciales de la atención prenatal, y la ecografía fetal desempeña un papel fundamental en la evaluación de estas afecciones. Los parámetros biométricos fetales medidos con mayor frecuencia son (todas las siglas procedentes del inglés) el diámetro biparietal (BPD), el perímetro cefálico (HC), el perímetro abdominal (AC) y la longitud de la diáfisis del fémur (FL). Estas mediciones biométricas se pueden utilizar para estimar el peso del feto (PEF) mediante fórmulas diferentesISUOG实践指南:胎儿生物测量与生长的超声评估 引言: 本指南旨在描述胎儿生物测量的正确评估及胎儿生长障碍的诊断。这些疾病主要包括又称为宫内生长受限(IUGR)且往往与小于胎龄(SGA)有关的胎儿生长受限(FGR),以及可能导致胎儿巨大的大于胎龄(LGA)。这两种疾病都与各种孕产期围产期不良结局有关。胎儿生长异常的筛查和适当处理是产前保健的重要组成部分,胎儿超声检测在这些疾病的评估中起着关键作用。最常测量的胎儿生物特征参数有双顶径(BPD)、头围(HC)、腹围(AC)和股骨骨干长度(FL)。可以根据这些生物特征测量值,运用各种不同的公式估算胎儿体重(EFW)。
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- 2019
45. Does water birth affect the risk of obstetric anal sphincter injury? Development of a prognostic model
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Helen Louise Preston, Gillian Fowler, Zarko Alfirevic, and Steven Lane
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Adult ,Male ,Multivariate statistics ,medicine.medical_specialty ,Multivariate analysis ,Urology ,030232 urology & nephrology ,Anal Canal ,Black People ,Risk Assessment ,Young Adult ,03 medical and health sciences ,0302 clinical medicine ,Asian People ,Pregnancy ,Risk Factors ,Humans ,Medicine ,Natural Childbirth ,Retrospective Studies ,Water birth ,Univariate analysis ,Models, Statistical ,030219 obstetrics & reproductive medicine ,business.industry ,Vaginal delivery ,Obstetrics ,Obstetrics and Gynecology ,Retrospective cohort study ,Odds ratio ,United Kingdom ,Confidence interval ,Parity ,Wounds and Injuries ,Female ,business ,Forecasting - Abstract
Obstetric anal sphincter injury (OASI) is a significant complication of vaginal delivery. Water birth has become a popular preference for women giving birth in the UK, however, there is limited data on the risk of OASI following water birth. Our aim was to assess OASI risk in low-risk women giving birth in water without medical intervention compared with on land and to create a prognostic model for OASI prediction. This was a retrospective study of 15,734 low-risk women giving birth by spontaneous vaginal delivery between January 2008 and October 2014 in a midwifery-led unit (MLU). Patient factors and delivery data were analysed to identify differences between water and land births. Univariate analysis determined factors that statistically predicted OASI and was then used to create multivariate analysis. Significant multivariate factors were used to create a prognostic model to predict likelihood of OASI. OASI rates were 1.6% on land and 3.3% in water [odds ratio (OR) 2.10, 95% confidence interval (CI) 1.5–2.94). Multivariate analysis confirmed water birth, ethnicity and parity as independent risk factors for OASI (adjusted OR water birth: 1.77 (CI 1.25–2.51). Our prognostic model showed Black and Asian primigravidae following water birth had the highest risk of OASI and white multiparae on land the lowest. This study of comparable low-risk women shows an increased risk of OASI following water birth compared with land birth. Use of this prognostic model will help women determine their risk of OASI following birth in water or on land.
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- 2019
46. Screening and management of the small for gestational age fetus in the UK: A survey of practice
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Andrew Sharp, Zarko Alfirevic, Umber Agarwal, and C. Duong
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Adult ,congenital, hereditary, and neonatal diseases and abnormalities ,medicine.medical_specialty ,Gestational Age ,Ultrasonography, Prenatal ,Umbilical Arteries ,03 medical and health sciences ,0302 clinical medicine ,Pregnancy ,medicine.artery ,Screening method ,medicine ,Humans ,030212 general & internal medicine ,Fundal height ,reproductive and urinary physiology ,Response rate (survey) ,Small for gestational age fetus ,Fetus ,Fetal Growth Retardation ,030219 obstetrics & reproductive medicine ,Obstetrics ,business.industry ,Infant, Newborn ,Obstetrics and Gynecology ,Ultrasonography, Doppler ,Umbilical artery ,medicine.disease ,United Kingdom ,female genital diseases and pregnancy complications ,Fetal Weight ,Reproductive Medicine ,Health Care Surveys ,Infant, Small for Gestational Age ,Small for gestational age ,Gestation ,Female ,business - Abstract
Background Antenatal detection of the small for gestational (SGA) fetus has become an important indicator of quality of antenatal care in the UK. This has been driven by a desire to reduce stillbirth in this at risk group. Methods We conducted a postal survey of 187 NHS consultant units within the UK to determine what the current practice for the detection and subsequent management of the suspected SGA fetus was following the guidance from the Royal College of Obstetricians and Gynaecologists (RCOG) in 2013. Results The survey was performed in 3 rounds between 2016 and 2017 with a response rate of 65%. 85% of units assessed risk factors for SGA at booking. 81% of units used a customized symphysis fundal height (SFH) chart to screen for SGA with 95% of them using a cut off of
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- 2018
47. Vaginal bacterial load in the second trimester is associated with early preterm birth recurrence: a nested case-control study
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Jhhm van de Wijgert, Jelena Ivandic, Devender Roberts, Angharad Care, Christina Bronowski, Borna Poljak, Alistair C. Darby, Bertram Müller-Myhsok, Ana Alfirevic, Marijn C. Verwijs, Zarko Alfirevic, A C Gill, Laura Goodfellow, and Andrew Sharp
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Adult ,Fetal Membranes, Premature Rupture ,medicine.medical_specialty ,Gestational Age ,Young Adult ,Pregnancy ,RNA, Ribosomal, 16S ,Statistical significance ,Lactobacillus ,Lactobacillus iners ,medicine ,Humans ,Rupture of membranes ,Lactobacillus crispatus ,biology ,business.industry ,Obstetrics ,Microbiota ,Obstetrics and Gynecology ,Odds ratio ,medicine.disease ,biology.organism_classification ,Bacterial Load ,Confidence interval ,Case-Control Studies ,Pregnancy Trimester, Second ,Vagina ,Nested case-control study ,Premature Birth ,Gestation ,Female ,business ,Dysbiosis - Abstract
ObjectiveTo assess the association between vaginal microbiome (VMB) composition and recurrent early spontaneous preterm birth (sPTB)/preterm prelabour rupture of membranes (PPROM).DesignNested case-control study.SettingUK tertiary referral hospital.SampleHigh-risk women with previous sPTB/PPROM +0 weeks gestation who had a recurrence (n=22) or delivered at ≥37+0 weeks without PPROM (n=87).MethodsVaginal swabs collected between 15-22 weeks gestation were analysed by 16S rRNA gene sequencing and 16S quantitative PCR.Main outcome measureRecurrent early sPTB/PPROM.Results28/109 high-risk women had anaerobic vaginal dysbiosis, with the remainder dominated by lactobacilli (L. iners 36/109, L. crispatus 23/109, or other 22/109). VMB type, diversity, and stability were not associated with recurrence. Women with a recurrence, compared to those without, had a higher median vaginal bacterial load (8.64 vs. 7.89 log10 cells/μl, adjusted odds ratio (aOR)=1.90, 95% confidence interval (CI)=1.01-3.56, p=0.047) and estimated Lactobacillus concentration (8.59 vs. 7.48 log10 cells/μl, aOR=2.35, CI=1.20-4.61, p=0.013). A higher recurrence risk was associated with higher median bacterial loads for each VMB type after stratification, although statistical significance was reached only for L. iners-domination (aOR=3.44, CI=1.06-11.15, p=0.040). Women with anaerobic dysbiosis or L. iners-domination had a higher median vaginal bacterial load than women with a VMB dominated by L. crispatus or other lactobacilli (8.54, 7.96, 7.63, and 7.53 log10 cells/μl, respectively).ConclusionsVaginal bacterial load is associated with early sPTB/PPROM recurrence. Domination by lactobacilli other than L. iners may protect women from developing high bacterial loads. Future PTB studies should quantify vaginal bacteria and yeasts.FundingWellbeing of Women, London, UKTweetable abstractIncreased vaginal bacterial load in the second trimester may be associated with recurrent early spontaneous preterm birth.
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- 2021
48. Uterotonic agents for first-line treatment of postpartum haemorrhage: a network meta-analysis
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Malcolm J Price, Shireen Meher, G Justus Hofmeyr, Ioannis D. Gallos, Andrew Weeks, Olufemi T Oladapo, Arri Coomarasamy, Fernando Althabe, Mariana Widmer, Argyro Papadopoulou, Zarko Alfirevic, Ahmet Metin Gülmezoglu, Eleanor Thomas, William R Parry Smith, Aurelio Tobias, and Joshua P. Vogel
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medicine.medical_specialty ,Blood transfusion ,medicine.medical_treatment ,Network Meta-Analysis ,Uterotonic ,Oxytocin ,03 medical and health sciences ,0302 clinical medicine ,Bias ,Pregnancy ,Oxytocics ,medicine ,Confidence Intervals ,Childbirth ,Humans ,Pharmacology (medical) ,Ergometrine ,Blood Transfusion ,030212 general & internal medicine ,Ergonovine ,Misoprostol ,Randomized Controlled Trials as Topic ,business.industry ,Obstetrics ,Postpartum Hemorrhage ,medicine.disease ,Clinical trial ,Relative risk ,Maternal death ,Drug Therapy, Combination ,Female ,business ,030217 neurology & neurosurgery ,medicine.drug - Abstract
BackgroundPostpartum haemorrhage (PPH), defined as a blood loss of 500 mL or more after birth, is the leading cause of maternal death worldwide. The World Health Organization (WHO) recommends that all women giving birth should receive a prophylactic uterotonic agent. Despite the routine administration of a uterotonic agent for prevention, PPH remains a common complication causing one-quarter of all maternal deaths globally. When prevention fails and PPH occurs, further administration of uterotonic agents as 'first-line' treatment is recommended. However, there is uncertainty about which uterotonic agent is best for the 'first-line' treatment of PPH.ObjectivesTo identify the most effective uterotonic agent(s) with the least side-effects for PPH treatment, and generate a meaningful ranking among all available agents according to their relative effectiveness and side-effect profile.Search methodsWe searched the Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (5 May 2020), and the reference lists of all retrieved studies.Selection criteriaAll randomised controlled trials or cluster-randomised trials comparing the effectiveness and safety of uterotonic agents with other uterotonic agents for the treatment of PPH were eligible for inclusion.Data collection and analysisTwo review authors independently assessed all trials for inclusion, extracted data and assessed each trial for risk of bias. Our primary outcomes were additional blood loss of 500 mL or more after recruitment to the trial until cessation of active bleeding and the composite outcome of maternal death or severe morbidity. Secondary outcomes included blood loss-related outcomes, morbidity outcomes, and patient-reported outcomes. We performed pairwise meta-analyses and indirect comparisons, where possible, but due to the limited number of included studies, we were unable to conduct the planned network meta-analysis. We used the GRADE approach to assess the certainty of evidence.Main resultsSeven trials, involving 3738 women in 10 countries, were included in this review. All trials were conducted in hospital settings. Randomised women gave birth vaginally, except in one small trial, where women gave birth either vaginally or by caesarean section. Across the seven trials (14 trial arms) the following agents were used: six trial arms used oxytocin alone; four trial arms used misoprostol plus oxytocin; three trial arms used misoprostol; one trial arm used Syntometrine® (oxytocin and ergometrine fixed-dose combination) plus oxytocin infusion. Pairwise meta-analysis of two trials (1787 participants), suggests that misoprostol, as first-line treatment uterotonic agent, probably increases the risk of blood transfusion (risk ratio (RR) 1.47, 95% confidence interval (CI) 1.02 to 2.14, moderate-certainty) compared with oxytocin. Low-certainty evidence suggests that misoprostol administration may increase the incidence of additional blood loss of 1000 mL or more (RR 2.57, 95% CI 1.00 to 6.64). The data comparing misoprostol with oxytocin is imprecise, with a wide range of treatment effects for the additional blood loss of 500 mL or more (RR 1.66, 95% CI 0.69 to 4.02, low-certainty), maternal death or severe morbidity (RR 1.98, 95% CI 0.36 to 10.72, low-certainty, based on one study n = 809 participants, as the second study had zero events), and the use of additional uterotonics (RR 1.30, 95% CI 0.57 to 2.94, low-certainty). The risk of side-effects may be increased with the use of misoprostol compared with oxytocin: vomiting (2 trials, 1787 participants, RR 2.47, 95% CI 1.37 to 4.47, high-certainty) and fever (2 trials, 1787 participants, RR 3.43, 95% CI 0.65 to 18.18, low-certainty). According to pairwise meta-analysis of four trials (1881 participants) generating high-certainty evidence, misoprostol plus oxytocin makes little or no difference to the use of additional uterotonics (RR 0.99, 95% CI 0.94 to 1.05) and to blood transfusion (RR 0.95, 95% CI 0.77 to 1.17) compared with oxytocin. We cannot rule out an important benefit of using the misoprostol plus oxytocin combination over oxytocin alone, for additional blood loss of 500 mL or more (RR 0.84, 95% CI 0.66 to 1.06, moderate-certainty). We also cannot rule out important benefits or harms for additional blood loss of 1000 mL or more (RR 0.76, 95% CI 0.43 to 1.34, moderate-certainty, 3 trials, 1814 participants, one study reported zero events), and maternal mortality or severe morbidity (RR 1.09, 95% CI 0.35 to 3.39, moderate-certainty). Misoprostol plus oxytocin increases the incidence of fever (4 trials, 1866 participants, RR 3.07, 95% CI 2.62 to 3.61, high-certainty), and vomiting (2 trials, 1482 participants, RR 1.85, 95% CI 1.16 to 2.95, high-certainty) compared with oxytocin alone. For all outcomes of interest, the available evidence on the misoprostol versus Syntometrine® plus oxytocin combination was of very low-certainty and these effects remain unclear. Although network meta-analysis was not performed, we were able to compare the misoprostol plus oxytocin combination with misoprostol alone through the common comparator of oxytocin. This indirect comparison suggests that the misoprostol plus oxytocin combination probably reduces the risk of blood transfusion (RR 0.65, 95% CI 0.42 to 0.99, moderate-certainty) and may reduce the risk of additional blood loss of 1000 mL or more (RR 0.30, 95% CI 0.10 to 0.89, low-certainty) compared with misoprostol alone. The combination makes little or no difference to vomiting (RR 0.75, 95% CI 0.35 to 1.59, high-certainty) compared with misoprostol alone. Misoprostol plus oxytocin compared to misoprostol alone are compatible with a wide range of treatment effects for additional blood loss of 500 mL or more (RR 0.51, 95% CI 0.20 to 1.26, low-certainty), maternal mortality or severe morbidity (RR 0.55, 95% CI 0.07 to 4.24, low-certainty), use of additional uterotonics (RR 0.76, 95% CI 0.33 to 1.73, low-certainty), and fever (RR 0.90, 95% CI 0.17 to 4.77, low-certainty).Authors' conclusionsThe available evidence suggests that oxytocin used as first-line treatment of PPH probably is more effective than misoprostol with less side-effects. Adding misoprostol to the conventional treatment of oxytocin probably makes little or no difference to effectiveness outcomes, and is also associated with more side-effects. The evidence for most uterotonic agents used as first-line treatment of PPH is limited, with no evidence found for commonly used agents, such as injectable prostaglandins, ergometrine, and Syntometrine®.
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- 2020
49. The PLANES study: a protocol for a randomised controlled feasibility study of the placental growth factor (PlGF) blood test-informed care versus standard care alone for women with a small for gestational age fetus at or after 32 + 0 weeks’ gestation
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Emily Benbow, Joanna Gent, Christine Cornforth, Andrew Sharp, Jane Harrold, Louise C. Kenny, Kerry Woolfall, Sian Bullough, Zarko Alfirevic, Richard J. Jackson, Alexander E. P. Heazell, and Lazaros Andronis
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Fetal growth restriction (FGR) ,medicine.medical_specialty ,Placenta ,Medicine (miscellaneous) ,Intrauterine growth restriction ,Soluble fms-like tyrosine kinase ,law.invention ,03 medical and health sciences ,Study Protocol ,0302 clinical medicine ,Randomized controlled trial ,law ,Placental growth factor ,medicine ,Blood test ,030212 general & internal medicine ,reproductive and urinary physiology ,lcsh:R5-920 ,Pregnancy ,Fetus ,030219 obstetrics & reproductive medicine ,medicine.diagnostic_test ,Obstetrics ,business.industry ,medicine.disease ,Regimen ,Small for gestational age (SGA) ,Gestation ,Small for gestational age ,RG ,lcsh:Medicine (General) ,business - Abstract
Background Stillbirth remains a major concern across the globe and in some high-resource countries, such as the UK; efforts to reduce the rate have achieved only modest reductions. One third of stillborn babies are small for gestational age (SGA), and these pregnancies are also at risk of neonatal adverse outcomes and lifelong health problems, especially when delivered preterm. Current UK clinical guidance advocates regular monitoring and early term delivery of the SGA fetus; however, the most appropriate regimen for surveillance of these babies remains unclear and often leads to increased intervention for a large number of these women. This pilot trial will determine the feasibility of a large-scale trial refining the risk of adverse pregnancy outcome in SGA pregnancies using biomarkers of placental function sFlt-1/PlGF, identifying and intervening in only those deemed at highest risk of stillbirth. Methods PLANES is a randomised controlled feasibility study of women with an SGA fetus that will be conducted at two tertiary care hospitals in the UK. Once identified on ultrasound, women will be randomised into two groups in a 3:1 ratio in favour of sFlt-1/PlGF ratio led management vs standard care. Women with an SGA fetus and a normal sFlt-1/PlGF ratio will have a repeat ultrasound and sFlt-1/PlGF ratio every 2 weeks with planned birth delayed until 40 weeks. In those women with an SGA fetus and an abnormal sFlt-1/PlGF ratio, we will offer birth from 37 weeks or sooner if there are other concerning features on ultrasound. Women assigned to standard care will have an sFlt-1/PlGF ratio taken, but the results will be concealed from the clinical team, and the woman’s pregnancy will be managed as per the local NHS hospital policy. This integrated mixed method study will also involve a health economic analysis and a perspective work package exploring trial feasibility through interviews and questionnaires with participants, their partners, and clinicians. Discussion Our aim is to determine feasibility through the assessment of our ability to recruit and retain participants to the study. Results from this pilot study will inform the design of a future large randomised controlled trial that will be adequately powered for adverse pregnancy outcome. Such a study would provide the evidence needed to guide future management of the SGA fetus. Trial registration ISRCTN58254381. Registered on 4 July 2019
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- 2020
50. Home versus inpatient induction of labour for improving birth outcomes
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Alfred Osoti, Gillian Ml Gyte, Zarko Alfirevic, Vicky Nogueira Pileggi, Rachel Plachcinski, and Elaine Finucane
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medicine.medical_specialty ,Neonatal intensive care unit ,Dinoprostone ,law.invention ,Catheterization ,03 medical and health sciences ,0302 clinical medicine ,Patient satisfaction ,Randomized controlled trial ,law ,Pregnancy ,Oxytocics ,Ambulatory Care ,Medicine ,Childbirth ,Humans ,Pharmacology (medical) ,030212 general & internal medicine ,Labor, Induced ,Randomized Controlled Trials as Topic ,business.industry ,Obstetrics ,Cesarean Section ,Infant, Newborn ,Pregnancy Outcome ,Length of Stay ,Hospitalization ,Neonatal infection ,Patient Satisfaction ,Meta-analysis ,Delayed-Action Preparations ,Observational study ,Female ,Patient Safety ,RG ,business ,030217 neurology & neurosurgery ,Cohort study ,Cervical Ripening - Abstract
Background\ud The setting in which induction of labour takes place (home or inpatient) is likely to have implications for safety, women's experiences and costs.\ud \ud Home induction may be started at home with the subsequent active phase of labour happening either at home or in a healthcare facility (hospital, birth centre, midwifery‐led unit). More commonly, home induction starts in a healthcare facility, then the woman goes home to await the start of labour. Inpatient induction takes place in a healthcare facility where the woman stays while awaiting the start of labour.\ud \ud Objectives\ud To assess the effects on neonatal and maternal outcomes of third trimester home induction of labour compared with inpatient induction using the same method of induction.\ud \ud Search methods\ud For this update, we searched the Cochrane Pregnancy and Childbirth Group's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (31 January 2020)), and reference lists of retrieved studies.\ud \ud Selection criteria\ud Published and unpublished randomised controlled trials (RCTs) in which home and inpatient settings for induction have been compared. We included conference abstracts but excluded quasi‐randomised trials and cross‐over studies.\ud \ud Data collection and analysis\ud Two review authors independently assessed study reports for inclusion. Two review authors carried out data extraction and assessment of risk of bias independently. GRADE assessments were checked by a third review author.\ud \ud Main results\ud We included seven RCTs, six of which provided data on 1610 women and their babies. Studies were undertaken between 1998 and 2015, and all were in high‐ or upper‐middle income countries. Most women were induced for post dates. Three studies reported government funding, one reported no funding and three did not report on their funding source. Most GRADE assessments gave very low‐certainty evidence, downgrading mostly for high risk of bias and serious imprecision.\ud \ud 1. Home compared to inpatient induction with vaginal prostaglandin E (PGE) (two RCTs, 1028 women and babies; 1022 providing data).\ud \ud Although women's satisfaction may be slightly better in home settings, the evidence is very uncertain (mean difference (MD) 0.16, 95% confidence interval (CI) ‐0.02 to 0.34, 1 study, 399 women), very low‐certainty evidence.\ud \ud There may be little or no difference between home and inpatient induction for other primary outcomes, with all evidence being very low certainty:\ud \ud ‐ spontaneous vaginal birth (average risk ratio (RR) [aRR] 0.91, 95% CI 0.69 to 1.21, 2 studies, 1022 women, random‐effects method);\ud \ud ‐ uterine hyperstimulation (RR 1.19, 95% CI 0.40 to 3.50, 1 study, 821 women);\ud \ud ‐ caesarean birth (RR 1.01, 95% CI 0.81 to 1.28, 2 studies, 1022 women);\ud \ud ‐ neonatal infection (RR 1.29, 95% CI 0.59 to 2.82, 1 study, 821 babies);\ud \ud ‐ admission to neonatal intensive care unit (NICU) (RR 1.20, 95% CI 0.50 to 2.90, 2 studies, 1022 babies).\ud \ud Studies did not report serious neonatal morbidity or mortality.\ud \ud 2. Home compared to inpatient induction with controlled release PGE (one RCT, 299 women and babies providing data).\ud \ud There was no information on whether the questionnaire on women's satisfaction with care used a validated instrument, but the findings presented showed no overall difference in scores.\ud \ud We found little or no difference between the groups for other primary outcomes, all also being very low‐certainty evidence:\ud \ud ‐ spontaneous vaginal birth (RR 0.94, 95% CI 0.77 to 1.14, 1 study, 299 women);\ud \ud ‐ uterine hyperstimulation (RR 1.01, 95% CI 0.51 to 1.98, 1 study, 299 women);\ud \ud ‐ caesarean births (RR 0.95, 95% CI 0.64 to 1.42, 1 study, 299 women);\ud \ud ‐ admission to NICU (RR 1.38, 0.57 to 3.34, 1 study, 299 babies).\ud \ud The study did not report on neonatal infection nor serious neonatal morbidity or mortality.\ud \ud 3. Home compared to inpatient induction with balloon or Foley catheter (four RCTs; three studies, 289 women and babies providing data).\ud \ud It was again unclear whether questionnaires reporting women's experiences/satisfaction with care were validated instruments, with one study (48 women, 69% response rate) finding women were similarly satisfied.\ud \ud Home inductions may reduce the number of caesarean births, but the data are also compatible with a slight increase and are of very low‐certainty (RR 0.64, 95% CI 0.41 to 1.01, 2 studies, 159 women).\ud \ud There was little or no difference between the groups for other primary outcomes with all being very low‐certainty evidence:\ud \ud ‐ spontaneous vaginal birth (RR 1.04, 95% CI 0.54 to 1.98, 1 study, 48 women):\ud \ud ‐ uterine hyperstimulation (RR 0.45, 95% CI 0.03 to 6.79, 1 study, 48 women);\ud \ud ‐ admission to NICU (RR 0.37, 95% CI 0.07 to 1.86, 2 studies, 159 babies).\ud \ud There were no serious neonatal infections nor serious neonatal morbidity or mortality in the one study (involving 48 babies) assessing these outcomes.\ud \ud Authors' conclusions\ud Data on the effectiveness, safety and women's experiences of home versus inpatient induction of labour are limited and of very low‐certainty. Given that serious adverse events are likely to be extremely rare, the safety data are more likely to come from very large observational cohort studies rather than relatively small RCTs.
- Published
- 2020
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