Cervical pessary for preventing preterm birth in singleton pregnancies.

BACKGROUND: Preterm birth (PTB), defined as birth prior to 37 weeks of gestation, occurs in ten percent of all pregnancies. PTB is responsible for more than half of neonatal and infant mortalities and morbidities. Because cervical insufficiency is a common cause of PTB, one possible preventive strategy involves insertion of a cervical pessary to support the cervix. Several published studies have compared the use of pessary with different management options and obtained questionable results. This highlights the need for an up-to-date systematic review of the evidence. OBJECTIVES: To evaluate the benefits and harms of cervical pessary for preventing preterm birth in women with singleton pregnancies and risk factors for cervical insufficiency compared to no treatment, vaginal progesterone, cervical cerclage or bedrest. SEARCH METHODS: We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform to 22 September 2021. We also searched the reference lists of included studies for additional records. SELECTION CRITERIA: We included published and unpublished randomised controlled trials (RCTs) comparing cervical pessary with no treatment, vaginal progesterone, cervical cerclage or bedrest for preventing PTB. We excluded quasi-randomised trials. Our primary outcome was delivery before 34 weeks' gestation. Our secondary outcomes were 1. delivery before 37 weeks' gestation, 2. maternal mortality, 3. maternal infection or inflammation, 4. preterm prelabour rupture of membranes, 5. harm to woman from the intervention, 6. maternal medications, 7. discontinuation of the intervention, 8. maternal satisfaction, 9. neonatal/paediatric care unit admission, 10. fetal/infant mortality, 11. neonatal sepsis, 12. gestational age at birth, 13. harm to offspring from the intervention 14. birthweight, 15. early neurodevelopmental morbidity, 15. late neurodevelopmental morbidity, 16. gastrointestinal morbidity and 17. respiratory morbidity. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for eligibility and risk of bias, evaluated trustworthiness based on criteria developed by the Cochrane Pregnancy and Childbirth Review Group, extracted data, checked for accuracy and assessed certainty of evidence using the GRADE approach. MAIN RESULTS: We included eight RCTs (2983 participants). We included five RCTs (1830 women) in the comparison cervical pessary versus no treatment, three RCTs (1126 pregnant women) in the comparison cervical pessary versus vaginal progesterone, and one study (13 participants) in the comparison cervical pessary versus cervical cerclage. Overall, the certainty of evidence was low to moderate due to inconsistency (statistical heterogeneity), imprecision (few events and wide 95% confidence intervals (CIs) consistent with possible benefit and harm), and risk of performance and detection bias. Cervical pessary versus no treatment Cervical pessary compared with no treatment may reduce the risk of delivery before 34 weeks (risk ratio (RR) 0.72, 95% CI 0.33 to 1.55; 5 studies, 1830 women; low-certainty evidence) or before 37 weeks (RR 0.68, 95% CI 0.44 to 1.05; 5 studies, 1830 women; low-certainty evidence). However, these results should be viewed with caution because the 95% CIs cross the line of no effect. Cervical pessary compared with no treatment probably has little or no effect on the risk of maternal infection or inflammation (RR 1.04, 95% CI 0.87 to 1.26; 2 studies, 1032 women; moderate-certainty evidence). It is unclear if cervical pessary compared with no treatment has an effect on neonatal/paediatric care unit admission (RR 0.96, 95% CI 0.58 to 1.59; 3 studies, 1332 infants; low-certainty evidence) or fetal/neonatal mortality (RR 0.93, 95% CI 0.58 to 1.48; 5 studies, 1830 infants; low-certainty evidence) because the 95% CIs are compatible with a wide range of effects that encompass both appreciable benefit and harm. Cervical pessary versus vaginal progesterone Cervical pessary may reduce the risk of delivery before 34 weeks (RR 0.72, 95% CI 0.52 to 1.02; 3 studies, 1126 women; moderate-certainty evidence) or before 37 weeks (RR 0.89, 95% CI 0.73 to 1.09; 3 studies, 1126 women; moderate-certainty evidence), but we are uncertain of the results because the 95% CI crosses the line of no effect. The intervention probably has little or no effect on maternal infection or inflammation (RR 0.95, 95% CI 0.81 to 1.12; 2 studies, 265 women; moderate-certainty evidence). It is unclear if cervical pessary compared with vaginal progesterone has an effect on the risk of neonatal/paediatric care unit admission (RR 0.98, 95% CI 0.49 to 1.98; low-certainty evidence) or fetal/neonatal mortality (RR 1.97, 95% CI 0.50 to 7.70; 2 studies; 265 infants; low-certainty evidence) because the 95% CIs are compatible with a wide range of effects that encompass both appreciable benefit and harm. Cervical pessary versus cervical cerclage Only one very small study of 13 pregnant women contributed data to this comparison; the results were unclear. AUTHORS' CONCLUSIONS: In women with a singleton pregnancy, cervical pessary compared with no treatment or vaginal progesterone may reduce the risk of delivery before 34 weeks or 37 weeks, although these results should be viewed with caution due to uncertainty around the effect estimates. There is insufficient evidence with regard to the effect of cervical pessary compared with cervical cerclage on PTB. Due to low certainty-evidence in many of the prespecified outcomes and non-reporting of several other outcomes of interest for this review, there is a need for further robust RCTs that use standardised terminology for maternal and offspring outcomes. Future trials should take place in a range of settings to improve generalisability of the evidence. Further research should concentrate on comparisons of cervical pessary versus cervical cerclage and bed rest. Investigation of different phenotypes of PTB may be relevant.

The rate of SARS-CoV-2 among asymptomatic non-immunised low-risk parturient women between the two waves.

This study was conducted to evaluate the rate of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and immunity among asymptomatic non-immunised low-risk parturient women and their newborns. A cross-sectional study conducted in a tertiary hospital during the nadir period of new cases in Egypt. All asymptomatic pregnant, low risk and non-immunised women were included. All eligible participants had been subjected to SARS-CoV-2 nasopharyngeal swabs according to CDC and sampling of maternal and umbilical blood to evaluate the presence of coronavirus disease 2019 (COVID-19) IgM and IgG antibodies by immunochromatographic assay. Two cases out of 171 (1.2%) parturient women were tested positive for PCR swab to COVID-19 infection. Furthermore, COVID-19 IgG and IgM antibodies testing showed that 67.8% of women were negative for both IgG and IGM, 24.6% were positive for IgG only, 4.1% were positive for IgM only, while 3.5% were positive for both IgG and IgM. Regarding neonatal testing for immunity, 28.1% of the neonates were positive to IgG only and none for IgM.The rate of positive PCR patients among asymptomatic low-risk parturient women was 1.2%. About quarter of women had got herd immunity as evident by positive IgG antibodies. IgG antibodies transferred to the neonates in almost all cases.Impact StatementWhat is already known on this subject? Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has become a global public health emergency. Asymptomatic pregnant women with coronavirus disease can transmit their infection to their newborn, family members and the health care providers.What do the results of this study add? The study showed very low (1.2%) prevalence of COVID positive cases among asymptomatic pregnant women admitted to our facility. Only two cases out of 171 parturient women tested PCR positive for COVID-19 infection (1.2%). SARS-Cov-2 IgG and IgM antibodies testing showed, about a quarter (24.6%) were positive for IgG antibodies, 4.1% were positive for IgM antibodies, while 3.5% were positive for both IgG and IgM. On the other hand, 28.1% of the neonates were positive to IgG only and none of the newborns had had IgM antibodies in their cord blood.What are the implications of these findings for clinical practice and/or further research? The first wave of COVID-19 pandemic in Egypt left behind at least a quarter of pregnant women with a positive antibody denoting some immunity. This immunity is usually transmitted to the neonates in almost all cases.

Misoprostol versus expectant management in women with incomplete first-trimester miscarriage after failed primary misoprostol treatment: A randomized clinical trial.

OBJECTIVE: To compare the effectiveness and safety of repeat misoprostol versus expectant management in women with first-trimester incomplete miscarriage who have been initially treated with misoprostol. METHODS: The study was an open-labeled randomized controlled trial including women with an incomplete first-trimester miscarriage after administration of misoprostol. The participants were randomly assigned to vaginal misoprostol or expectant management using a computer-generated table of random numbers. The primary outcome was the number of women with a complete miscarriage at 1 week. RESULTS: Eighty-eight women (44 women in each group) were analyzed. The rate of complete miscarriage at 1 week was significantly higher in the misoprostol group than the expectant management group-29 (69.0%) versus 7 (16.7%) (P < 0.001), respectively. Women in the misoprostol group were more satisfied (7.00 ± 0.77 vs 4.57 ± 1.61, P < 0.001) but reported more pain (7.95 ± 1.85 vs 5.26 ± 1.08, P < 0.001) than women in the expectant group. The misoprostol group reported more adverse effects than the expectant management group (P < 0.001). CONCLUSION: In women with an incomplete first-trimester miscarriage who were initially treated with misoprostol, repeat administration of misoprostol was more effective than expectant management for achieving complete miscarriage at 1 week. However, misoprostol was associated with more adverse effects. REGISTRATION SITE AND NUMBER: Clinicaltrials.gov: NCT03148561.

The relationship between female genital cutting and sexual problems experienced in the first two months of marriage.

OBJECTIVE: To examine the relationship between female genital cutting (FGC) and sexual problems experienced by couples in the first 2 months of marriage ("honeymoon distress"). METHODS: A multicenter cross-sectional study was conducted at centers in Assiut and Sohag, Egypt, between March 1, 2011, and March 31, 2014. Eligible couples presented with sexual problems during the first 2 months of marriage. Couples were interviewed and asked to complete a pre-designed questionnaire, and a genital examination was performed. The primary outcomes of the study were the contribution of FGC to honeymoon distress and the effect of FGC on quality of life. RESULTS: Overall, 430 couples enrolled in the study. FGC was present in 376 (87.4%) women. The main presenting feature of honeymoon distress was superficial dyspareunia, which affected 291 (77.4%) women with FGC versus 16 (29.6%) of 54 without FGC (hazard ratio 8.13, 95% confidence interval 4.32-15.30). Women with FGC were more likely to have a poor quality of life during the first 2 months of marriage than were those without FGC (279 [74.2%] vs 13 [24.1%]; odds ratio 9.07, 95% confidence interval 4.66-17.64). CONCLUSION: FGC was found to be a contributing factor to honeymoon distress.

Nitroglycerin for management of retained placenta.

BACKGROUND: Retained placenta affects 0.5% to 3% of women following delivery, with considerable morbidity if left untreated. Use of nitroglycerin (NTG), either alone or in combination with uterotonics, may be of value to minimise the need for manual removal of the placenta in theatre under anaesthesia. OBJECTIVES: To evaluate the benefits and harms of NTG as a tocolytic, either alone or in addition to uterotonics, in the management of retained placenta. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (14 January 2015), reference lists of retrieved studies and contacted experts in the field. SELECTION CRITERIA: Any adequately randomised controlled trial (RCT) comparing the use of NTG, either alone or in combination with uterotonics, with no intervention or with other interventions in the management of retained placenta. All women having a vaginal delivery with a retained placenta, regardless of the management of the third stage of labour (expectant or active). We included all trials with haemodynamically stable women in whom the placenta was not delivered at least within 15 minutes after delivery of the baby. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. MAIN RESULTS: We included three randomised controlled trials (RCTs) with 175 women. The three published RCTs compared NTG alone versus placebo. The detachment status of retained placenta was unknown in all three RCTs. Collectively, among the three included trials, two were judged to be at low risk of bias and the third trial was judged to be at high risk of bias for two domains: incomplete outcome data and selective reporting. The three trials reported seven out of 23 of the review's pre-specified outcomes.The primary outcome "manual removal of the placenta" was reported in all three studies. No differences were seen between NTG and placebo for manual removal of the placenta (average risk ratio (RR) 0.83, 95% confidence interval (CI) 0.47 to 1.46; women = 175; I² = 81%). A random-effects model was used because of evidence of substantial heterogeneity in the analysis. There were also no differences between groups for risk of severe postpartum haemorrhage (RR 0.93, 95% CI 0.62 to 1.39; women = 150; studies = two; I² = 0%). Blood transfusion was only reported in one study (40 women) and again there was no difference between groups (RR 1.00, 95% CI 0.07 to 14.90; women = 40; I² = 0%). Mean blood loss (mL) was reported in the three studies and no differences were observed (mean difference (MD) -115.31, 95% CI -306.25 to 75.63; women = 169; I² = 83%). Nitroglycerin administration was not associated with an increase in headaches (RR 1.09, 95% CI 0.80 to 1.47; women = 174; studies = three; I² = 0%). However, nitroglycerin administration was associated with a significant, though mild, decrease in systolic and diastolic blood pressure and a significant increase in pulse rate (MD -3.75, 95% CI -7.47 to -0.03) for systolic blood pressure, and (MD 6.00, 95% CI 3.07 to 8.93) for pulse rate (beats per minute) respectively (reported by only one study including 24 participants). Maternal mortality and addition of therapeutic uterotonics were not reported in any study. AUTHORS' CONCLUSIONS: In cases of retained placenta, currently available data showed that the use of NTG alone did not reduce the need for manual removal of placenta. This intervention did not increase the incidence of severe postpartum haemorrhage nor the need for blood transfusion. Haemodynamically, NTG had a significant though mild effect on both pulse rate and blood pressure.

Uterine massage for preventing postpartum haemorrhage.

BACKGROUND: Postpartum haemorrhage (PPH) (bleeding from the genital tract after childbirth) is a major cause of maternal mortality and disability, particularly in under-resourced areas. In these settings, uterotonics are often not accessible. There is a need for simple, inexpensive techniques which can be applied in low-resourced settings to prevent and treat PPH. Uterine massage is recommended as part of the routine active management of the third stage of labour. However, it is not known whether it is effective. If shown to be effective, uterine massage would represent a simple intervention with the potential to have a major effect on PPH and maternal mortality in under-resourced settings. OBJECTIVES: To determine the effectiveness of uterine massage after birth and before or after delivery of the placenta, or both, to reduce postpartum blood loss and associated morbidity and mortality. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 April 2013). SELECTION CRITERIA: All published, unpublished and ongoing randomised controlled trials comparing uterine massage alone or in addition to uterotonics before or after delivery of the placenta, or both, with non-massage. DATA COLLECTION AND ANALYSIS: Two researchers independently considered trials for eligibility, assessed risk of bias and extracted the data using the agreed form. Data were checked for accuracy. The effect of uterine massage commenced before or after placental delivery were first assessed separately, and then the combined for an overall result. MAIN RESULTS: This review included two randomised controlled trials. The first trial included 200 women who were randomised to receive uterine massage or no massage following delivery of the placenta, after active management of the third stage of labour including use of oxytocin. The numbers of women with blood loss more than 500 mL was small, with no statistically significant difference (risk ratio (RR) 0.52, 95% confidence interval (CI) 0.16 to 1.67). There were no cases of retained placenta in either group. The mean blood loss was significantly less in the uterine massage group at 30 minutes (mean difference (MD) -41.60 mL, 95% CI -75.16 to -8.04) and 60 minutes after trial entry (MD -77.40 mL, 95% CI -118.71 to -36.09). The need for additional uterotonics was significantly reduced in the uterine massage group (RR 0.20, 95% CI 0.08 to 0.50).For use of uterine massage before and after delivery of the placenta, one trial recruited 1964 women in Egypt and South Africa. Women were assigned to receive oxytocin, uterine massage or both after delivery of the baby but before delivery of the placenta. There was no added benefit for uterine massage plus oxytocin over oxytocin alone as regards blood loss greater than or equal to 500 mL (average RR 1.56, 95% CI 0.44, 5.49; random-effects) or need for additional use of uterotonics (RR 1.02, 95% CI 0.56 to 1.85).The two trials were combined to examine the effect of uterine massage commenced either before or after delivery of the placenta. There was substantial heterogeneity with respect to the blood loss 500 mL or more after trial entry. The average effect using a random-effects model found no statistically significant differences between groups (average RR 1.14, 95% CI 0.39 to 3.32; random-effects). AUTHORS' CONCLUSIONS: The results of this review are inconclusive, and should not be interpreted as a reason to change current practice. Due to the limitations of the included trials, more trials with sufficient numbers of women are needed in order to estimate the effects of sustained uterine massage. All the women compared in this review received oxytocin as part of the active management of labour. Recent research suggests that once an oxytocic has been given, there is limited scope for further reduction in postpartum blood loss. Trials of uterine massage in settings where uterotonics are not available, and which measure women's experience of the procedure, are needed.

Cervical pessary for preventing preterm birth.

BACKGROUND: Preterm birth is a major health problem and contributes to more than 50% of the overall perinatal mortality. Preterm birth has multiple risk factors including cervical incompetence and multiple pregnancy. Different management strategies have been tried to prevent preterm birth, including cervical cerclage. Cervical cerclage is an invasive technique that needs anaesthesia and may be associated with complications. Moreover, there is still controversy regarding the efficacy and the group of patients that could benefit from this operation. Cervical pessary has been tried as a simple, non-invasive alternative that might replace the above invasive cervical stitch operation to prevent preterm birth. OBJECTIVES: To evaluate the efficacy of cervical pessary for the prevention of preterm birth in women with risk factors for cervical incompetence. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 September 2012), Current Controlled Trials and the Australian New Zealand Clinical Trials Registry (1 September 2012). SELECTION CRITERIA: We selected all published and unpublished randomised clinical trials comparing the use of cervical pessary with cervical cerclage or expectant management for prevention of preterm birth. We did not include quasi-randomised trials. Cluster-randomised or cross-over trials were not eligible for inclusion. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion. MAIN RESULTS: The review included one randomised controlled trial. The study included 385 pregnant women with a short cervix of 25 mm or less who were between 18 to 22 weeks of pregnancy. The use of cervical pessary (192 women) was associated with a statistically significantly decrease in the incidence of spontaneous preterm birth less than 37 weeks' gestation compared with expectant management (22% versus 59 %; respectively, risk ratio (RR) 0.36, 95% confidence interval (CI) 0.27 to 0.49). Spontaneous preterm birth before 34 weeks was statistically significantly reduced in the pessary group (6% and 27% respectively, RR 0.24; 95% CI 0.13 to 0.43). Mean gestational age at delivery was 37.7 + 2 weeks in the pessary group and 34.9 + 4 weeks in the expectant group. Women in the pessary group used less tocolytics (RR 0.63; 95% CI 0.50 to 0.81) and corticosteroids (RR 0.66; 95% CI 0.54 to 0.81) than the expectant group. Vaginal discharge was more common in the pessary group (RR 2.18; 95% CI 1.87 to 2.54). Among the pessary group, 27 women needed pessary repositioning without removal and there was one case of pessary removal. Ninety-five per cent of women in the pessary group would recommend this intervention to other people. Neonatal paediatric care admission was reduced in the pessary group in comparison to the expectant group (RR 0.17; 95% CI 0.07 to 0.42). AUTHORS' CONCLUSIONS: The review included only one well-designed randomised clinical trial that showed beneficial effect of cervical pessary in reducing preterm birth in women with a short cervix. There is a need for more trials in different settings (developed and developing countries), and with different risk factors including multiple pregnancy.

Hybrid septate uterus, coexistence of bicornuate and septate varieties: a genuine report.

AIM: To highlight the coexistence of a uterine septum in cases diagnosed as bicornuate uterus on the basis of the external shape of the uterine fundus and to present the outcomes of its hysteroscopic management. METHODS: Descriptive clinical report. Cases with two-chambered uterine cavities were recruited with exclusion of cases with pure bicornuate uteri. The differentiation between hybrid and pure septate uterine varieties was based on clinical evaluation, transvaginal ultrasonic evaluation, hysterosalpingography and in addition to bimanual examination under anesthesia. The final diagnosis was confirmed by combined hysteroscopy-laparoscopy examinations. Cases with pure and hybrid septate uteri were managed by hysteroscopic metroplasty and the outcomes were compared. RESULTS: Out of 357 cases of double chambered uteri, 18 cases (5%) were found to be a pure bicornuate variety (PBV), 322 (90.2%) cases were found to have pure septate variety (PSV) and 17 cases (4.8%) were found to have hybrid septate variety (HSV). In HSV, there was external fundal depression dividing only the upper part of the corpus giving an imprecise impression of a bicornuate uterus with a laparoscopic view, but there was a long extension of the dividing interface. Nine cases with HSV were associated with a complete utero-cervico-vaginal septum, and five cases had a complete uterine septum. The diagnosis of asymmetric horns, hemi-obstruction or bicervical uterus was made in three cases with HSV. All cases with a septate uterus were offered hysteroscopic metroplasty, and cases with fundal depression were operated under laparoscopic monitoring. In cases with HSV, the procedure was performed safely and successfully in 16/17 cases (94%). One uterine perforation was encountered, giving a six-fold increase in the perforation risk, and passed uneventfully. Successful reproductive outcomes were reported in 178/189 cases (94.1%) with PSV and in 12/15 (80%) with HSV. CONCLUSIONS: External fundal depressions of variable depths are associating with a septate uterus, indicating coexistence of the two anomalies. These cases are candidates for hysteroscopic metroplasty under appropriate sonographic and/or laparoscopic monitoring.

Doxycycline in the treatment of bleeding with DMPA: a double-blinded randomized controlled trial.

BACKGROUND: Increased matrix metalloproteinase (MMP) activity in the endometrium is a predisposing factor for bleeding with depot medroxy progesterone acetate (DMPA) injectable contraception. Doxycycline (DOX) has been proven in vitro to inhibit MMP-mediated degradation of stromal matrix. The current study examined the effect of DOX compared to placebo in treating a current bleeding episode during DMPA use. STUDY DESIGN: A double-blinded randomized controlled trial was conducted in Assiut, Egypt. DMPA users with current bleeding episode were counseled to participate. Women who agreed to participate were randomly assigned to receive 100 mg DOX twice daily for 5 days (34 patients) or an identical placebo (34 patients). All participants were asked to report bleeding and spotting days in a menstrual diary. All participants were followed for 3 months after treatment. This trial was registered (NCT01254799). RESULTS: The relative risk to stop a bleeding episode within 10 days of starting treatment was 0.88 (confidence interval 0.64-1.21) in the treatment group compared to the control. DOX treatment caused no significant difference compared to placebo in the number of bleeding and/or spotting days in the 3 months following the treatment. CONCLUSION: Doxycycline as MMP inhibitor is not effective in stopping a current attack of bleeding with DMPA. It also does not improve the bleeding characteristics of women for the subsequent 3 months following the treatment.

Tocolysis for management of retained placenta.

BACKGROUND: Retained placenta affects 0.5% to 3% of women following delivery, with considerable morbidity if left untreated. Use of tocolytics, either alone or in combination with uterotonics, may be of value to minimise the need for manual removal of the placenta in theatre under anaesthesia. OBJECTIVES: Evaluate the benefits and harms of tocolytics alone or in addition to uterotonics in the management of retained placenta in order to reduce the need for manual removal of placenta. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 October 2010) and contacted experts in the field. SELECTION CRITERIA: Any adequately randomised controlled trial (RCT) comparing the use of tocolytics, either alone or in combination with uterotonics, with no intervention or with other interventions in the management of retained placenta. All women having a vaginal delivery with a retained placenta, regardless of the management of the third stage of labour (expectant or active). We included all trials with haemodynamically stable women in whom the placenta was not delivered at least within 15 minutes after delivery of the baby. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial quality and extracted data. Consultation of the third author was done if needed. MAIN RESULTS: We included one RCT (involving 24 women). It compared the use of nitroglycerin tablets versus placebo after the treatment with oxytocin failed. There was a statistically significant reduction in the need for manual removal of placenta (risk ratio (RR) 0.04, 95% confidence interval (CI) 0.00 to 0.66). There was also a statistically significant reduction in mean blood loss during the third stage of labour (mean difference (MD) -262.50 ml, 95% CI -364.95 to -160.05). Sublingual nitroglycerin caused some haemodynamic changes as it lowers the systolic blood pressure and diastolic blood pressure by a means of 6 and 5 mmHg respectively. Pulse rate increased by a mean of two beats per minute. AUTHORS' CONCLUSIONS: Sublingual nitroglycerin, given when oxytocin fails, seems to reduce both the need for manual removal of placenta and blood loss during the third stage of labour when compared to placebo. Further trials are needed to confirm its clinical role and safety. Its routine use cannot be recommended based on a single small study. There is no evidence available for other types of tocolytics.

Cervical pessary for preventing preterm birth.

BACKGROUND: Preterm delivery is a major health problem and contributes to more than 50% of the overall perinatal mortality. Cervical incompetence is one of the common causes of preterm birth to which different management strategies have been tried including cervical cerclage. Cervical cerclage is an invasive technique that needs anaesthesia and may be associated with complications. Moreover, there is still a matter of controversy regarding the efficacy and the group of patients which could benefit from this operation. Cervical pessary has been tried as a simple, non-invasive alternative that might replace the above invasive cervical stitch operation. OBJECTIVES: To evaluate the efficacy of cervical pessary for prevention of preterm birth in women with cervical incompetence. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (May 2010), Current Controlled Trials and the Australian New Zealand Clinical Trials Registry (May 2010). SELECTION CRITERIA: We selected all published and unpublished randomised clinical trials comparing the use of cervical pessary with cervical cerclage or expectant management for prevention of preterm birth. We did not include quasi-randomised trials, cluster-randomised and crossover trials. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion. MAIN RESULTS: The search identified two trials which we excluded. Three additional trials are ongoing. This review contains no included studies. AUTHORS' CONCLUSIONS: The review did not identify any well-designed randomised clinical trial in order to confirm or refute the benefit of cervical pessary. However, there is evidence from non-randomised trials that showed some benefit of cervical pessary in preventing preterm birth. We are waiting for the results of three ongoing randomised controlled trials, assessing the role of cervical pessary in women with short cervix. There is a need for further well-designed randomised controlled trials.

The effect of calcium supplementation during pregnancy on fetal and infant growth: a nested randomized controlled trial within WHO calcium supplementation trial.

OBJECTIVE: To evaluate whether prenatal calcium supplementation affects fetal and infant growth during the first year of life. METHODS: Ninety-one pregnant women and 159 mothers and their infants enrolled beginning before 20 weeks gestation, and women received daily supplements containing either 1.5 g calcium or placebo. Women were examined by ultrasound at 20, 24, 28, 32 and 36 weeks to evaluate fetal biometry. During the first year after delivery, sub-groups of infants born from mothers participating in the trial were examined to assess infant growth. Anthropometric measurements of the infants were assessed. Mothers were inquired about lactation patterns, morbidities of the infants, separation from the mother, and admission to hospital. RESULTS: Ultrasound measurements of fetal biometry did not show any differences between fetuses whose mothers received calcium supplementation during pregnancy and those who received placebo. Concerning infant growth, the mean weight and head circumference of infants born to calcium-supplemented mothers were similar to those born to placebo-supplemented mothers during the first year of life. The mean mid-arm circumference and mean length were significantly higher in the infants of the calcium group at sixth and ninth month, respectively. But, at 12 months, there were no significant differences in any of the anthropometric measurements. CONCLUSION: Calcium supplementation during pregnancy of women with low calcium intake does not have a noticeable impact on fetal and infant growth during the first year of life.

Uterine massage for preventing postpartum haemorrhage.

BACKGROUND: Postpartum haemorrhage (PPH) (bleeding from the genital tract after childbirth) is a major cause of maternal mortality and disability, particularly in under-resourced areas. In these settings, poor nutrition, malaria and anaemia may aggravate the effects of PPH. In addition to the standard known strategies to prevent and treat PPH, there is a need for simple, non-expensive techniques which can be applied in low-resourced settings to prevent or treat PPH. OBJECTIVES: To determine the effectiveness of uterine massage after birth and before or after delivery of the placenta, or both, to reduce postpartum blood loss and associated morbidity and mortality. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (March 2008), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2007, Issue 2) and PubMed (1966 to June 2007). SELECTION CRITERIA: All published, unpublished and ongoing randomised controlled trials comparing uterine massage alone or in addition to uterotonics before or after delivery of the placenta, or both, to non-massage. DATA COLLECTION AND ANALYSIS: Both authors extracted the data independently using the agreed form. MAIN RESULTS: One randomised controlled trial in which 200 women were randomised to receive uterine massage or no massage after active management of the third stage of labour. The numbers of women with blood loss more than 500 ml was small, with wide confidence intervals and no statistically significant difference (risk ratio (RR) 0.52, 95% confidence interval (CI) 0.16 to 1.67). There were no cases of retained placenta in either group. The mean blood loss was less in the uterine massage group at 30 minutes (mean difference (MD) -41.60, 95% CI -75.16 to -8.04) and 60 minutes after enrolment (MD -77.40, 95% CI -118.71 to -36.09 ml) . The need for additional uterotonics was reduced in the uterine massage group (RR 0.20, 95% CI 0.08 to 0.50). Two blood transfusions were administered in the control group. AUTHORS' CONCLUSIONS: The present review adds support to the 2004 joint statement of the International Confederation of Midwives and the International Federation of Gynaecologists and Obstetricians on the management of the third stage of labour, that uterine massage after delivery of the placenta is advised to prevent PPH. However, due to the limitations of the one trial reviewed, trials with sufficient numbers to estimate the effects of sustained uterine massage with great precision, both with and in the absence of uterotonics, are needed.