| Current
Women's Health Reviews
ISSN: 1573-4048
Current Women’s Health
Reviews
Volume 2, Number 3, August 2006
Contents
Editorial Pp. 163
Progesterone/Progestagens to Prevent Preterm Birth:
When and How Pp. 165-171
Begona Martinez de Tejada and Michel Boulvain
[Abstract]
Interventions to Improve the Implementation of
Evidence Based Practices in Women Care Pp. 173-179
Fernando Althabe, Mercedes Colomar and María Belizán
[Abstract]
Unrelated Cord Blood Banking and Transplantation:
Implications for Obstetricians Pp. 181-186
Pilar Solves, Alfredo Perales, Vicente Mirabet and M.
Angeles Soler
[Abstract]
Safety of Inactivated Vaccines in Pregnancy
Pp. 187-192
Elisabetta Franco, Wilma Buffolano, Sabrina Senatore,
Laura Zaratti and Pasquale Martinelli
[Abstract]
Timing of Induction of Labour for Post Maturity and
Caesarean Section Patterns Pp. 193-195
Farida Bano, H. Hamoud, D.P. Hay and Clive J. Pickles
[Abstract]
Postmenopausal Hormone Therapy Pp. 197-205
Peter Vestergaard
[Abstract]
Uterine EMG and Cervical LIF - Promising Technologies
in Obstetrics Pp. 207-221
Robert E. Garfield, William L. Maner, Leili Shi, Shao
Q. Shi and George R. Saade
[Abstract]
Epidural Labour Analgesia and Labour Outcome Pp.
223-227
David C. Campbell
[Abstract]
Lymphocytic Choriomeningitis Virus Infection: Neglected
Teratogenic Zoonosis Pp. 229-232
Leslie L. Barton
[Abstract]
Abstracts
[Back to top]
EDITORIAL
The Contribution of Research to Guide Clinical Practice
An article of this issue is illustrative of research contribution
in clinical practice. Progesterone has always been identified
as a hormone involved in the initiation of labour due to its
role in uterine quiescence, but concomitantly, its use in
preventing premature labour was not completely ruled out.
Randomised controlled trials have shown that its use can prevent
preterm birth in women at risk. Still further research is
needed to assess doses, formulations, population recipient,
and long term effects before it can be widely recommended
for use. Research in this issue is of relevance since preterm
birth is a major problem and a challenge in obstetrical care.
Another article shows a worrisome situation, that despite
the advances in science, many interventions with proven benefit
are not implemented in clinical practice and those proven
to be of no benefit or deleterious are still used. This is
also a major challenge and again, research is needed to search
for interventions that could improve the implementation of
the best evidences for care. The conjunction of clinical and
social scientists is a desired partnership aiming at such
interventions.
Caution and research based interventions need to be the preference
of those providing clinical care. Many external influences
and exigencies have attracted the attention of clinicians
but they must be cautious in implementing only those interventions
which show benefit and lack of deleterious side effects. Moreover,
one article of this issue discussed an upcoming unsolved issue
in obstetrics i.e., the cord blood banking, which still needs
a lot of evaluation and research before its implementation.
This subject also has important economic implications and
has paved the way for potential inequality in its use.
A desired approach evidenced throughout the issue is the analysis
in the context of differences related to income and health
inequities. An article elucidating on this issue has analysed
the use of vaccines during pregnancy under varying circumstances,
highlighting that different approaches are needed.
Health inequity is an unsolved issue and maternal death is
the health indicator delineating the greatest differences
between the poor and the rich populations. Regardless many
efforts performed at global level, health inequities in provision
and the associated results of care are far from improvement
and still need consideration. Initiatives and articles focusing
on health inequities are highly desirable, promoting the health
research community to achieve desirable results.
José M. Belizán
Department of Mother &
Child Health Research
Institute for Clinical Effectiveness
and Health Policy (IECS)
Viamonte 2146 (3er Piso)
(C1056ABH) Buenos Aires
Argentina
E-mail: belizanj@allstat.org
[Back to top]
Progesterone/Progestagens to Prevent Preterm Birth: When and
How
Begona Martinez de Tejada and Michel Boulvain
Prematurity is a leading cause of neonatal morbidity
and mortality, accounting for most part of the deaths of infants
without congenital anomalies. Also, the cost of neonatal intensive
care and long-term care for infants born preterm is enormous.
The medical, psychological, and economic burdens of preterm
births are very important. In spite of advances in obstetrical
care, the rate of preterm delivery in industrialized countries
(approximately 10%) has not decreased over the past 40 years.
In fact, it has increased slightly, partly due to the use
of assisted reproductive technologies and to the rise of indicated
preterm deliveries for maternal or fetal reasons.
Progesterone (P) is the primary factor of uterine quiescence
that permits the physical distension of the uterine muscle
throughout pregnancy. In all species, except humans, a drop
in P levels precedes labor, whereas P levels remain constant
in humans until delivery. Yet the labor inducing properties
of anti P products such as RU-486 have led to hypothesize
a “functional P withdrawal” prior to labor in
humans. In spite of early trials suggesting a benefit with
progesterone/ progestagens in preventing premature labor,
the doubts in its efficacy, particularly linked to the very
weak concentrations of exogenous administration compared to
the high levels of endogenous P, have dissuaded its use in
obstetrics for some years. Two recent studies, however, give
a new momentum towards the use of progestagens for the prevention
of premature delivery in a particular high-risk population:
women with a prior preterm birth. Nevertheless, the use of
progestagens in other populations at risk for preterm delivery
should not be encouraged outside of clinical trials.
In this review article we will discuss the indications for
progesterone for prevention of preterm delivery, as well as
the formulations to use.
[Back to top]
Interventions to Improve the Implementation of
Evidence Based Practices in Women Care
Fernando Althabe, Mercedes Colomar and María Belizán
An important component of quality of care is the use
of evidence-based practices. Three studies from three different
continents (Africa, Asia and Latin America) have reported
the suboptimal use of evidence - based interventions in obstetric
care, proving that despite scientific evidence and dissemination
efforts, there are harmful and/or unnecessary procedures still
used, while others that are beneficial are ignored. This illustrates
the existing bridges and barriers between practice guidelines
based on research findings and practitioners.
A theoretical framework could help explain these barriers
and possibly help target interventions to specific barriers.
A review of existing literature shows that an intervention
aimed to increase the use of evidence-based practices should
have the following components: increase birth attendant concern
about the effectiveness of routine clinical practices, stimulate
their desire to review the effectiveness of their practice,
provide them with skills to perform evidence based clinical
guidelines appraisal and development and establish mechanisms
through key hospital leaders to implement the guidelines and
sustain them over time.
[Back to top]
Unrelated Cord Blood Banking and Transplantation:
Implications for Obstetricians
Pilar Solves, Alfredo Perales, Vicente Mirabet and M.
Angeles Soler
Cord blood is recognised as a rich source of haematopoietic
stem and progenitor cells and its use has increased greatly
in recent years. Since first cord blood transplantation was
performed in Paris in 1988, knowledge of the biologic characteristics
of umbilical cord blood has improved, and the benefits of
using cord blood stem cells have become apparent. In fact,
cord blood has showed to have several advantages as compared
to bone marrow: easy availability, lower risk of infectious
diseases transmission such as CMV and EBV and lower risk of
graft versus host disease. However, cord blood units progenitors
content is usually only sufficient for smaller recipients,
usually children weighing less than 40 Kg. Gluckman et al
showed grafting occurring in 85 percent of patients receiving
37 million or more nucleated cells per kilogram of body weight.
In spite of this, use of cord blood in greater recipients
is increasing and an effort to improve cord blood haematopoietic
content is mandatory. In fact, the main limitation factor
for the wide use of CB as a source of hematopoietic progenitor
for transplantation is cell dose. Some of the specific areas
identified by some studies for improvement of CB cell content
are donor selection and CB collection. Implications of obstetricians
in these issues are very important and necessary. We have
evaluated cord blood donors selection criteria and two different
modes of collection in order to optimise the cord blood banking
proceedings and increase the quality of the CB units stored.
We will review the results of our previous studies in these
areas and the results of literature.
[Back to top]
Safety of Inactivated Vaccines in Pregnancy
Elisabetta Franco, Wilma Buffolano, Sabrina Senatore,
Laura Zaratti and Pasquale Martinelli
Newborns may suffer of severe infections and the best defense
against pathogens is given by the passage of maternal antibodies
through the placenta and later by breastfeeding. A greater
amount of circulating antibodies in the mother is often related
to a higher value in the blood of the child, thus maternal
immunization could be a tool for preventing neonatal infections.
Most trials were performed in developing countries, where
the success of vaccinating pregnant women against tetanus
led to the acceptance of maternal immunization. Thereafter,
trials performed with different inactivated vaccines demonstrated
the effectiveness of the intervention without showing important
safety problems.
In industrialized countries, only few trials were performed
and no conclusive evidence of long term safety is available
for most proposed vaccines. Even when safety and efficacy
have been clearly demonstrated, like influenza vaccination,
the coverage is low.
Vaccination in pregnancy is a promising tool for the protection
of both woman and child, but more data are needed before this
practice can be widely accepted in all industrialized countries.
[Back to top]
Timing of Induction of Labour for Post Maturity and
Caesarean Section Patterns
Farida Bano, H. Hamoud, D.P. Hay and Clive J. Pickles
Objective: A comparison of outcome versus
gestation at induction of labour (IOL) for post maturity in
three groups: 40, 41 and 42 weeks.
Design: Retrospective study of all 703 IOLs
for post maturity over three-years. The main outcome being
measured was recourse to emergency Caesarean section (Em LSCS)
mode of delivery. Groups were compared.
Setting: A District General Hospital with
8754 deliveries over the study period. The overall IOL rate
was 18.8%.
Result: Em LSCS rates break down as follows:
40th week; Primigravidae 25.7%, Multiparae 6.9%,
Both 13.9%
41st week; Primigravidae 17.6%, Multiparae 6.4%,
Both 10.6%
42nd week; Primigravidae 18.8%, Multiparae 11.3%,
Both 15.2
No statistically significant benefit was demonstrated for
either group at any gestation
[Back to top]
Postmenopausal Hormone Therapy
Peter Vestergaard
Estrogen acts as agonist on the estrogen receptor. The effects
of estrogen may be confounded by concomitant treatment with
progestins. Postmenopausal hormone therapy (HT) can be divided
into: postmenopausal estrogen therapy (ET – estrogen
alone), and postmenopausal estrogen-progestin therapy (EPT
– estrogen plus a progestin). EPT is associated with
an increased risk of cardiovascular disease, cerebrovascular
disease, and breast cancer. ET is not associated with a significant
increase in any of these. Both EPT and ET are associated with
an increase in venous thromboembolism. Both EPT and ET reduce
the risk of vertebral and overall fracture risk.
At present use of EPT or ET should be limited to short-term
treatment of severe menopausal symptoms. This review discusses
the effects and side effects of EPT and ET and potential ways
of avoiding some of the side effects.
[Back to top]
Uterine EMG and Cervical LIF - Promising Technologies
in Obstetrics
Robert E. Garfield, William L. Maner, Leili Shi, Shao
Q. Shi and George R. Saade
No current objective measures exist to determine uterine or
cervical function during pregnancy, or to accurately predict
term or preterm labor and delivery. Uterine electromyography
(EMG) and cervical light-induced fluorescence (LIF) studies
were performed in term and pre-term animals and humans to
evaluate the state and function of the uterus and cervix,
and to determine the predictive capability of measurements
made using these new technologies. Both uterine EMG and cervical
LIF produced high positive and negative predictive values,
compared to other currently-used methods. Uterine EMG and
cervical LIF show great promise as diagnostic tests during
pregnancy and for patient monitoring in obstetrics.
[Back to top]
Epidural Labour Analgesia and Labour Outcome
David C. Campbell
1. Review the Incidence of Anesthesia-Related Maternal
Mortality
2. Review Changes in Anesthesia for the Parturient over the
Past 20 years
3. Review Suggested "Negative" Morbidity Associated
with Epidural Labour Analgesia
4. Review the Evidence Pertaining to the Effect of Epidural
Labour Analgesia on Cesarean and Instrumented Vaginal Delivery
rates as well as Progress of Labour.
[Back to top]
Lymphocytic Choriomeningitis Virus Infection: Neglected
Teratogenic Zoonosis
Leslie L. Barton
Lymphocytic choriomeningitis virus (LCMV), a rodent-borne
arenavirus, has been causally associated with postnatal and
in utero infection. Although the consequences of
acquired LCMV infection are generally benign, primarily a
flu-like illness and aseptic meningitis, encephalitis has
been reported. Fatalities are however, rare. Congenital LCMV
infection has been recognized in Europe and the United States,
yet the syndrome is rarely considered and, therefore, remains
under-diagnosed. Chorioretinitis and hydrocephalus have been
noted in 90% of the affected infants. Blindness, mental retardation
and seizures have been the most prominent sequelae in these
children. Education of pregnant women regarding the risks
rodents and their excreta pose is feasible and should be commenced
without delay.
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