Obstetric Flashcards
ACHoiS - (Australian Carbohydrate Intolerance Study in Pregnant Women)
Aim: to assess whether GDM is associated with adverse fetal outcomes
Method: 1000 women, 24-34 w GDM
Tx: dietary advice, BG monitoring, insulin tx, or routine care
Outcome: perinatal complications, NICU admit, Jaundice w photo, IOL, C/S, mat anxiety and depression
Results: serious complications lower in intervention group; more likely to go to NICU w intervention
Similar NVD v CS
Lower rates depression and better health status in intervention group 3/12 PP
**reduced serious adverse perinatal outcomes from 4.4% to 1.4%
Less PET
Strengths: randomized, Aussie
Weakness: IOL and NICU related tx decisions/ not blinded; Ethical concerns- women not informed of GDM despite WHO criteria changing during study
DIGITAT- disproportionate intrauterine growth intervention trial at term
Aim: compare effect of IOL vs expectant Mx for IUGR at term
2004-4008, Netherlands, intention to treat analysis
Inclusion criteria: singleton, cephalon, 36-41/40, suspected FGR: AC<10 or EFW<10th
Primary outcome: adverse neonatal outcome (death, apgar < 7 at 5 minutes, ph<7, NICU admit
Results: IOL group delivered 10 days earlier and weighed 130 g less, no statistical significant difference for primary outcome
IOL not associated with increased op/instrumental del
can have expectant Mx with intensive fetal monitoring if desired
Still rational to choose IOL to prevent possible neonatal morbidity and SB
Cochrane: fetal and umbilical Doppler USS in high-risk pregnancies (2017)
Obj: asssess effects of Doppler in high-risk preg on Obs care and fetal outcomes
Selection: randomizes and quasi-randomizes CT of Doppler USS vs none in high-risk pregnancies
Results:DV in early FGR showed improvement in neurological outcomes, assess UA PI - fewer perinatal deaths and fewer obstetric interventions
Limitations: hard to assess bias, evidence not high qualaity
TRUFFLE study (2 year neurodevelopmental and intermediate perinatal outcome)
Aim: assess whether changes in DV to be used as indication for del over CTG short term variation
Method: multi Centre, unblinded, randomized
Singleton 26-32 with early onset growth restriction and an abnormal UAPI; three groups reduced CTG STV, early DV changes (pulsatility >95th) or late DV changes (absent or reversed a wave)
Primary outcome: survival without CP or neurosensoy impairment
Results: 542 women, more free of neuroimpairment in late dv change group at 2 years of age; No difference in the proportion of infants surviving without neuroimpairment
ACTORDS - neonatal RDS after repeat exposure to antenatal corticosteroids
RCT 2006
1000 women at risk of PTB <32/40, initial steroids >7/7 previously
Do repeated doses do harm?
Excluded infection, second stage labour
Randomized to placebo or single dose beta given weekly while undelivered and <32/40
Primary outcome: freq and severity RDS, BW
secondary outcome: chorio, fevers
Results: No sig difference SB, NND, chorio; less o2 requirements, shorter mech vent, less RDS, less lung disease
Conclusion: reduces morbidity
Weakness: no long term follow up
ALPS- steroids for late pre-term
Multi Centre, RCT
Singles 34-36+5 HR for delivery during late preterm period
2 injections of betamethasone or placebo 24 hours apart
Primary outcome:neonatal treatment in first 72 hours (CPAP, O2, mech ventilation) or stillbirth or neonatal death
Results: Reduced rate of neonatal respiratory complications. No significant between group differences; hypoglycemia more common in the betamethasone group
ASTECS- steroids for term elcs
Multi Centre randomized trial
Treatment group had 2 x doses betamethasone, other group: routine care
Section performed prior to 39 weeks
Primary outcome: admission to NICU with respiratory distress
Secondary: severity of respiratory distress and level of care
Results: halved the amounts of those admitted to nicu and those with TTN in group given antenatal corticosteroids; reduced RDS from 1.1% to 0.2%
ORACLE 1: Childhood outcomes after prescription of antibiotics to pregnant women with PPROM: 7 year f/u
Lancet 2008
Questionnaire at age 7 to assess childs’s health status
Results: No difference after erythromycin with or without augmentin compared to no erythromycin. Same for augmentin.
No effect on behavior
Weaknesses
Confounded: children with unknown outcomes from lower SES
Questionnaire assessment
***ORACLE1: Broad spectrum Abx for PPROM
Lancet 2001
RCT, double blind, multicentre
Erythromycin, augmentin, both or placebo
Primary outcome: NND, chronic lung disease, major cerebral abnormality on USS
Secondary: time to del, use of surfactant and O2, maternal infection and abx requirement
Results:
Erythromycin: prolonged pregnancy, reduced surfactant and o2, few major cerebral abnormalities on USS, fewer + blood cultures
No difference death, mode of delivery, birthweight, NICU admission
Augmentin alone and augmentin + erythromycin did prolong pregnancy and reduce postnatal abx but 4x risk of NEC
Strength: large multicentre double blind RCT, high f/u
Weakness: no long term outcomes
WOMAN trial
Randomized double blind placebo
1g TXA vs placebo
Multicentre, 20000 women
Results: Rr.081 in mortality No adverse effects Give within 3hrs RR0.69 Reduces risk of bleeding to death by 1/3 Did not prevent hysterectomy
Term PROM IOL vs expectant
1996
5041 women
Randomized
IOL with IV oxy, prostaglandin, or expectant management up to 4 days
Primary outcome:neonatal infection
Secondary: caeser, women’s evaluations of their treatment
No difference in neonatal infection
Less likely to develop chorio if had IOL
Similar rates of caeser
Lower rate of maternal infection
IOL vs monitoring post dates
Randomly assigned
3407 women
IOL or have monitoring until spontaneous labour
Lower rate of caeser in IOL group
No difference in perinatal mortality and neonatal morbidity
MIG trial
RCT 2008
10 Centre’s 740 women
Randomized to have metformin with insulin if required or insulin alone
Non-blinded.
Primary outcomes: neonatal hypoglycemia, prematurity, RDS, birth trauma, phototherapy, apgar <7 at 5 minutes
Secondary outcomes: neonatal anthropometric measurements, maternal HTN, glycaemic control, postpartum glucose tolerance, maternal acceptability of treatment
Results: No significant differences, patients happier to have metformin compared to insulin
Hapo 2008
25000 women OGTT 2 hr at 24 and 32 weeks Blinded To assess what degree of hyperglycaemia on OGTT is associated with adverse fetal outcome Multicentre observational study
Adverse outcomes in GDM pregnancy: Macrosomia 27% vs 5.4% Shoulder dystocia/birth injury NICU admission Need for phototherapy Cord blood c-peptide >90%ile 32% vs 2.7% Neonatal hypoglycaemia 4.6% 2x Primary caeser 32% vs 16% PET
Clasp: a randomized trial of low-dose aspirin for the prevention and treatment of PET
RCT, multicentre, double blind
12-32/40
Randomized to 60mg aspirin daily or placebo
Women at risk of PET or IUGR with signs or symptoms of PET or IUGR in current pregnancy
No stat sig
No difference if had >20/40
Reduced prem delivery
No increase in PPH
Trend towards reduction in PET, SB and NND with preterm delivery
