Does previous caesarean section at full dilatation increase the likelihood of subsequent spontaneous preterm birth?

BACKGROUND: There is emerging evidence that caesarean section at full dilatation is associated with an increased risk of subsequent spontaneous preterm birth. AIM: To investigate the association between caesarean section at full dilatation and spontaneous preterm birth in subsequent pregnancies. MATERIALS AND METHODS: This was a retrospective cohort study of women who had two consecutive births at Royal Prince Alfred Hospital, 1989-2015. Our main comparison group was women who had emergency caesarean sections during the first stage of labour. Secondary comparison groups were women who had elective caesarean sections, instrumental deliveries and unassisted vaginal deliveries. The primary outcome was spontaneous preterm birth (<37 weeks gestation) in a subsequent pregnancy. RESULTS: There were 2672 women who had an emergency caesarean section, with 2142 (80%) performed during the first stage of labour and 533 (20%) at full dilatation. The rates of spontaneous preterm birth in a subsequent pregnancy were 1.7% and 3.8%, respectively (odds ratio 2.2 (95%CI 1.3-3.8), P = 0.003). The hazard ratio for spontaneous onset of labour at any given gestation from 20 weeks until full term was 1.4 (95%CI 1.2-1.6) and did not change after adjusting for maternal age and body mass index. CONCLUSION: There is a significantly higher rate of subsequent spontaneous preterm birth in women who had a caesarean section at full dilatation compared with women who had a caesarean section during the first stage of labour. Awareness of this as a risk factor may warrant referral to a high-risk obstetric or preterm birth clinic.

The impact of introducing medical management on conservative and surgical management for early pregnancy miscarriage.

BACKGROUND: Medical management of miscarriage allows women to avoid the risks associated with surgical intervention. In 2011 the early pregnancy assessment service (EPAS) at the Royal Prince Alfred Hospital (RPAH) in Sydney, Australia introduced medical management of miscarriage with single-dose 800 µg vaginal misoprostol. AIMS: We sought to investigate the impact of the introduction of medical management had on the proportion of women having surgery and conservative management and to examine the success and complication rates of medical management. MATERIALS AND METHODS: We undertook a retrospective cohort study that included all women diagnosed with a miscarriage from 12 months prior to and 18 months after the introduction of medical management. Successful management was defined as the absence of retained products of conception or endometrial thickness less than 15 mm on ultrasound at two weeks. The change in management choices over time, the success rates and complication rates were measured. RESULTS: Of 1102 women in the final analysis, 446 were in Group A (before medical management) and 656 in Group B (after medical management). Primary surgical procedures fell significantly for missed miscarriages from 68 to 48% (P < 0.001) and primary conservative management reduced for incomplete miscarriages (63-44%; P = 0.01). Overall 89 of 108 (82.4%) patients managed medically had a resolution within two weeks. One in ten presented with a complication. DISCUSSION: The introduction of medical management led to a statistically significant reduction in the proportion of women undergoing primary surgical management of missed miscarriage. Success and complication rates were similar to other studies.

Blood pressure profile in pregnancy: The impact of its duration on results and patients' well-being.

BACKGROUND: A blood pressure profile (BPP) is often used to diagnose and manage hypertension in pregnancy. However, there is no consensus on the number and interval of blood pressure (BP) readings required. AIMS: To ascertain whether BP readings at 15-min interval over one hour yields clinically equivalent results to readings at 60-min interval over three hours. MATERIALS AND METHODS: Eighty unique women were recruited to this prospective study. Automated BP machines were used to take readings at 15-min interval over one hour and at 60-min interval over three hours. The mean systolic and diastolic BPs obtained using each regimen were calculated and compared. Women also completed a questionnaire to evaluate the psychosocial and financial impact of a prolonged outpatient investigation. RESULTS: BP readings from 67 patients were included for analysis. Clinical equivalence was assessed using the British Hypertension Society (BHS) validation criteria for comparing nonmercury devices to the gold-standard calibrated mercury device. Mean SBP readings for 54% (36/67), 90% (60/67) and 97% (65/67) and mean DBP readings for 73% (49/67), 94% (63/67) and 100% (67/67) were within 5, 10 and 15 mmHg agreement across the two time regimens which achieved grade B and grade A validation, respectively. A BPP was costly and stressful for women and affected their ability to attend work and look after other children. CONCLUSIONS: A BPP performed over one hour compared to over three hours yields clinically equivalent results, yet has psychosocial and financial advantages.