114 research outputs found
Fetal and umbilical Doppler ultrasound in high-risk pregnancies
No full textBackground: Abnormal blood flow patterns in fetal circulation detected by Doppler ultrasound may indicate poor fetal prognosis. It is also possible that false positive Doppler ultrasound findings could lead to adverse outcomes from unnecessary interventions, including preterm delivery. Objectives: The objective of this review was to assess the effects of Doppler ultrasound used to assess fetal well-being in high-risk pregnancies on obstetric care and fetal outcomes. Search methods: We updated the search of Cochrane Pregnancy and Childbirth's Trials Register on 31 March 2017 and checked reference lists of retrieved studies. Selection criteria: Randomised and quasi-randomised controlled trials of Doppler ultrasound for the investigation of umbilical and fetal vessels waveforms in high-risk pregnancies compared with no Doppler ultrasound. Cluster-randomised trials were eligible for inclusion but none were identified. Data collection and analysis: Two review authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. Data entry was checked. We assessed the quality of evidence using the GRADE approach. Main results: Nineteen trials involving 10,667 women were included. Risk of bias in trials was difficult to assess accurately due to incomplete reporting. None of the evidence relating to our main outcomes was graded as high quality. The quality of evidence was downgraded due to missing information on trial methods, imprecision in risk estimates and heterogeneity. Eighteen of these studies compared the use of Doppler ultrasound of the umbilical artery of the unborn baby with no Doppler or with cardiotocography (CTG). One more recent trial compared Doppler examination of other fetal blood vessels (ductus venosus) with computerised CTG. The use of Doppler ultrasound of the umbilical artery in high-risk pregnancy was associated with fewer perinatal deaths (risk ratio (RR) 0.71, 95% confidence interval (CI) 0.52 to 0.98, 16 studies, 10,225 babies, 1.2% versus 1.7 %, number needed to treat (NNT) = 203; 95% CI 103 to 4352, evidence graded moderate). The results for stillbirths were consistent with the overall rate of perinatal deaths, although there was no clear difference between groups for this outcome (RR 0.65, 95% CI 0.41 to 1.04; 15 studies, 9560 babies, evidence graded low). Where Doppler ultrasound was used, there were fewer inductions of labour (average RR 0.89, 95% CI 0.80 to 0.99, 10 studies, 5633 women, random-effects, evidence graded moderate) and fewer caesarean sections (RR 0.90, 95% CI 0.84 to 0.97, 14 studies, 7918 women, evidence graded moderate). There was no comparative long-term follow-up of babies exposed to Doppler ultrasound in pregnancy in women at increased risk of complications. No difference was found in operative vaginal births (RR 0.95, 95% CI 0.80 to 1.14, four studies, 2813 women), nor in Apgar scores less than seven at five minutes (RR 0.92, 95% CI 0.69 to 1.24, seven studies, 6321 babies, evidence graded low). Data for serious neonatal morbidity were not pooled due to high heterogeneity between the three studies that reported it (1098 babies) (evidence graded very low). The use of Doppler to evaluate early and late changes in ductus venosus in early fetal growth restriction was not associated with significant differences in any perinatal death after randomisation. However, there was an improvement in long-term neurological outcome in the cohort of babies in whom the trigger for delivery was either late changes in ductus venosus or abnormalities seen on computerised CTG. Authors' conclusions: Current evidence suggests that the use of Doppler ultrasound on the umbilical artery in high-risk pregnancies reduces the risk of perinatal deaths and may result in fewer obstetric interventions. The results should be interpreted with caution, as the evidence is not of high quality. Serial monitoring of Doppler changes in ductus venosus may be beneficial, but more studies of high quality with follow-up including neurological development are needed for evidence to be conclusive
Specialised antenatal clinics for women with a multiple pregnancy for improving maternal and infant outcomes
No full textBackground: Regular antenatal care for women with a multiple pregnancy is accepted practice, and while most women have an increase in the number of antenatal visits, there is no consensus as to what constitutes optimal care. 'Specialised' antenatal clinics have been advocated as a way of improving outcomes for women and their infants. Objectives: To assess, using the best available evidence, the benefits and harms of 'specialised' antenatal clinics compared with 'standard' antenatal care for women with a multiple pregnancy. Search methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2015) and reference lists of retrieved studies. Selection criteria: All published, unpublished, and ongoing randomised controlled trials with reported data that compared outcomes in mothers and babies with a multiple pregnancy who received antenatal care specifically designed for women with a multiple pregnancy (as defined by the trial authors) with outcomes in controls who received 'standard' antenatal care (as defined by the trial authors). Data collection and analysis: Two of the review authors independently assessed trials for inclusion and trial quality. Both review authors extracted data. Data were checked for accuracy. We graded the quality of the evidence using GRADEpro software. Main results: Findings were based on the results of a single study with some design limitations. Data were available from one study involving 162 women with a multiple pregnancy. For the only reported primary outcome, perinatal mortality, we are uncertain whether specialised antenatal clinics makes any difference compared to standard care (risk ratio (RR) 1.02; 95% confidence interval (CI) 0.26 to 4.03; 324 infants, very low quality evidence). Women receiving specialised antenatal care were significantly more likely to birth by caesarean section (RR 1.38; 95% CI 1.06 to 1.81; 162 women, moderate quality evidence). Data were not reported in the study on the following primary outcomes: small-for-gestational age, very preterm birth or maternal death. There were no differences identified between specialised antenatal care and standard care for other secondary outcomes examined: postnatal depression (RR 0.48; 95% CI 0.19 to 1.20; 133 women, very low quality evidence), breastfeeding (RR 0.63; 95% CI 0.24 to 1.68; 123 women, very low quality evidence), stillbirth (RR 0.68; 0.12 to 4.04) or neonatal death (RR 2.05; 95% CI 0.19 to 22.39) (324 infants). Authors' conclusions: There is currently limited information available from randomised controlled trials to assess the role of 'specialised' antenatal clinics for women with a multiple pregnancy compared with 'standard' antenatal care in improving maternal and infant health outcomes. The value of 'specialised' multiple pregnancy clinics in improving health outcomes for women and their infants requires evaluation in appropriately powered and designed randomised controlled trials.Jodie M Dodd , Therese Dowswell, Caroline A Crowthe
Reduction of the number of fetuses for women with a multiple pregnancy
No full textBackground: When couples are faced with the dilemma of a higher-order multiple pregnancy there are three options. Termination of the entire pregnancy has generally not been acceptable to women, especially for those with a past history of infertility. Attempting to continue with all the fetuses is associated with inherent problems of preterm birth, survival and long-term morbidity. The other alternative relates to reduction in the number of fetuses by selective termination. The acceptability of these options for the couple will depend on their social background and underlying beliefs. This review focused on reduction in the number of fetuses. Objectives: To assess a policy of multifetal reduction with a policy of expectant management of women with a multiple pregnancy. Search methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 July 2015). Selection criteria: Randomised controlled trials with reported data that compared outcomes in mothers and babies who were managed expectantly with outcomes in women who underwent selective fetal reduction of a multiple pregnancy. Data collection and analysis: We planned that two review authors would independently assess trials for inclusion and risk of bias, extract data and check them for accuracy. However, no randomised trials were identified. Main results There were no randomised controlled trials identified. Authors' conclusions: We found no available data from randomised trials to inform the risks and benefits of pregnancy reduction procedures for women with a multiple pregnancy. While randomised controlled trials will provide the most reliable evidence about the risks and benefits of fetal reduction procedures, reduction in the number of fetuses by selective termination may not be acceptable to women, particularly couples with a past history of infertility. The acceptability of this option, and willingness to undergo randomisation will depend on the couple's social background and beliefs, and consequently, recruitment to such a trial may prove exceptionally difficult.Jodie M Dodd, Therese Dowswell, Caroline A Crowthe
Adjusting stroke patients' poor position: An observational study
No full textAlthough nurses' role in rehabilitation has been generally ill-defined and consistently undervalued, of all professional groups, nurses working with stroke patients have potentially the greatest contribution to make. Stroke patients are believed to benefit from good posture yet they can spend long periods in inappropriate positions. This study examined the positioning, handling and mobilizing of stroke patients in hospital. Non-participant observation was used to gather data on stroke patients' position and nurses' activities. This paper addresses two basic questions - what causes the adjustment of patients from poor to good position and who is involved in achieving this adjustment. Poor position was observed to end 158 times in 380 'patient hours' of observation. The most frequent causes of positional improvement were activities whose primary intention was unrelated to position correction. The deliberate adjustment of patients' position by nurses was a rare event which occupied a small part of nurses' time. The potential for a more considered and consistent nursing approach appears to be great
Adjusting stroke patients' poor position: An observational study
No full textAlthough nurses' role in rehabilitation has been generally ill-defined and consistently undervalued, of all professional groups, nurses working with stroke patients have potentially the greatest contribution to make. Stroke patients are believed to benefit from good posture yet they can spend long periods in inappropriate positions. This study examined the positioning, handling and mobilizing of stroke patients in hospital. Non-participant observation was used to gather data on stroke patients' position and nurses' activities. This paper addresses two basic questions - what causes the adjustment of patients from poor to good position and who is involved in achieving this adjustment. Poor position was observed to end 158 times in 380 'patient hours' of observation. The most frequent causes of positional improvement were activities whose primary intention was unrelated to position correction. The deliberate adjustment of patients' position by nurses was a rare event which occupied a small part of nurses' time. The potential for a more considered and consistent nursing approach appears to be great
Routine pre-pregnancy health promotion for improving pregnancy outcomes
No full textBACKGROUND: A number of potentially modifiable risk factors are known to be associated with poor pregnancy outcomes. These include smoking, drinking excess alcohol, and poor nutrition. Routine health promotion (encompassing education, advice and general health assessment) in the pre-pregnancy period has been proposed for improving pregnancy outcomes by encouraging behavioural change, or allowing early identification of risk factors. While results from observational studies have been encouraging, this review examines evidence from randomised controlled trials of preconception health promotion.OBJECTIVES: To assess the effectiveness of routine pre-pregnancy health promotion for improving pregnancy outcomes when compared with no pre-pregnancy care or usual care.SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (February 2009).SELECTION CRITERIA: Randomised and quasi-randomised trials examining health promotion interventions which aim to identify and modify risk factors before pregnancy. The review focuses on all women of childbearing age rather than those in high-risk groups. We have excluded trials where interventions are aimed specifically at women with established medical, obstetric or genetic risks or already receiving treatment as part of programmes for high-risk groups.DATA COLLECTION AND ANALYSIS: Two review authors independently assessed eligibility and carried out data extraction.MAIN RESULTS: Four trials (2300 women) are included. The interventions ranged from brief advice through to education on health and lifestyle over several sessions. For most outcomes, data were only available from individual studies. Only one study followed up through pregnancy and there was no strong evidence of a difference between groups for preterm birth, congenital anomalies or weight for gestational age; only one finding (mean birthweight) reached statistical significance (mean difference -97.00, 95% confidence interval (CI) -168.05 to -25.95). This finding needs to be interpreted with caution as pregnancy outcome data were available for only half of the women randomised. There was some evidence that health promotion interventions were associated with positive maternal behavioural change including lower rates of binge drinking (risk ratio 1.24, 95% CI 1.06 to 1.44). Overall, there has been little research in this area and there is a lack of evidence on the effects of pre-pregnancy health promotion on pregnancy outcomes.AUTHORS' CONCLUSIONS: There is little evidence on the effects of pre-pregnancy health promotion and much more research is needed in this area. There is currently insufficient evidence to recommend the widespread implementation of routine pre-pregnancy health promotion for women of childbearing age, either in the general population or between pregnancies.</p
Community-based childhood injury prevention interventions: What works?
No full textUnintentional injury, with its broad range of injury types, possible countermeasures, and great number of agencies involved in its prevention, lends itself to community-based approaches. In this paper we examine 10 community-based injury prevention programmes that have targeted childhood injury prevention and have been evaluated using some measure of outcome. We investigate the nature of the intervention, targeting, the length of programmes and multi-agency involvement. We also consider how the programmes have been evaluated, and what outcome, impact and process measures have been used. The information on the intervention and how it was evaluated, how effective the programme was, and the strength of the evidence, is summarized in tabular form. There is increasing evidence emerging about the effectiveness of community-based approaches in injury prevention. Important elements of such approaches are long-term strategy, effective focused leadership, multi-agency collaboration, tailoring to the needs of the local community, the use of local injury surveillance, and time to coordinate existing and develop new local networks. We recommend that there is a need to develop indicators to assess and monitor a culture of safety, programme sustainability and long-term community involvement
Social deprivation and the prevention of unintentional injury in childhood: A systematic review
No full textThere is a known association between social deprivation and risk of death from unintentional injury in childhood. In the UK context, these inequalities do not appear to be decreasing. This paper reports on the findings of a systematic review of the world literature between 1975 and 2000 on the prevention of childhood injuries, with particular reference to social deprivation. Literature was identified via electronic data-bases, key journals and informants. All papers were read independently by at least two reviewers and information was extracted using a standardized form. Results indicate that of 155 studies identified in the systematic review, 32 addressed the issue of social deprivation. The way social deprivation was defined in different studies varied considerably. The literature was not evenly spread across different injury types and did not reflect the burden of injury. There is a paucity of evidence relating to the prevention of child pedestrian injury. Very few studies examined the impact of interventions in different social groups. Without such evidence, it remains difficult for those involved in health promotion to know how to design and target interventions to address inequalities in child injury rates
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