Correction: The World Health Organization Fetal Growth Charts: A Multinational Longitudinal Study of Ultrasound Biometric Measurements and Estimated Fetal Weight.

[This corrects the article DOI: 10.1371/journal.pmed.1002220.].

ACUTE PHYSIOLOGY AND CHRONIC HEALTH EVALUATION (APACHE) II SCORE - THE CLINICAL PREDICTOR IN NEUROSURGICAL INTENSIVE CARE UNIT.

The APACHE II scoring system is approved for its benchmarking and mortality predictions, but there are only a few articles published to demonstrate it in neurosurgical patients. Therefore, this study was performed to acknowledge this score and its predictive performance to hospital mortality in a tertiary referral neurosurgical intensive care unit (ICU). All patients admitted to the Neurosurgical ICU from February 1 to July 31, 2011 were recruited. The parameters indicated in APACHE II score were collected. The adjusted predicted risk of death was calculated and compared with the death rate observed. Descriptive statistics including the receiver operating characteristic curve (ROC) was performed. The results showed that 276 patients were admitted during the mentioned period. The APACHE II score was 16.56 (95% CI, 15.84-17.29) and 19.08 (95% CI, 15.40-22.76) in survivors and non-survivors, while the adjusted predicted death rates were 13.39% (95% CI, 11.83-14.95) and 17.49% (95% CI, 9.81-25.17), respectively. The observed mortality was only 4.35%. The area under the ROC of APACHE II score to the hospital mortality was 0.62 (95% CI, 0.44-0.79). In conclusion, not only the APACHE II score in neurosurgical patients indicated low severity, but its performance to predict hospital mortality was also inferior. Additional studies of predicting mortality among these critical patients should be undertaken.

Rate of Couple HIV Testing in a Prenatal Care Clinic and Factors Associated with Refusal of Testing Among Male Partners.

OBJECTIVE: To determine the rate of HIV testing in couples during pregnancy and the reasons and risk factors related to male partners refusing to be tested. MATERIALS AND METHODS: This was a cross-sectional study conducted in pregnant women undergoing prenatal care after receiving information about HIV testing on their first visit. After 20 weeks of gestation, they were approached to participate in the study, which consisted of an interview and examination of their medical records. Data collection included the women's socioeconomic status, obstetric condition and serological test results together with their partner information. If relevant, the partner's reasons for refusing to undergo HIV testing. RESULTS: A total of 400 pregnant women were recruited between February and August 2018, 150 (37.5%) of whose male partners underwent HIV testing. There were five couples in which one or both members were found to be positive for HIV: 1 seroconcordant couple, 1 serodiscordant couple in which the pregnant woman was positive, and 3 serodiscordant couples in which the male partners were positive. The most common reason for male partners refusing to take the test was their already having been tested once before. The women having had other sexual partners prior to their current partners was a significant risk factor for the partners refusing to be tested. CONCLUSION: There was a low rate of couple HIV testing and a substantial portion of discordant infection among positive couples. Routine couples counseling and testing should be encouraged to reduce the vertical transmission and the number of new cases of HIV infection.

Global, regional, and national estimates of levels of preterm birth in 2014: a systematic review and modelling analysis.

BACKGROUND: Preterm birth is the leading cause of death in children younger than 5 years worldwide. Although preterm survival rates have increased in high-income countries, preterm newborns still die because of a lack of adequate newborn care in many low-income and middle-income countries. We estimated global, regional, and national rates of preterm birth in 2014, with trends over time for some selected countries. METHODS: We systematically searched for data on preterm birth for 194 WHO Member States from 1990 to 2014 in databases of national civil registration and vital statistics (CRVS). We also searched for population-representative surveys and research studies for countries with no or limited CRVS data. For 38 countries with high-quality data for preterm births in 2014, data are reported directly. For countries with at least three data points between 1990 and 2014, we used a linear mixed regression model to estimate preterm birth rates. We also calculated regional and global estimates of preterm birth for 2014. FINDINGS: We identified 1241 data points across 107 countries. The estimated global preterm birth rate for 2014 was 10·6% (uncertainty interval 9·0-12·0), equating to an estimated 14·84 million (12·65 million-16·73 million) live preterm births in 2014. 12·â€ˆ0 million (81·1%) of these preterm births occurred in Asia and sub-Saharan Africa. Regional preterm birth rates for 2014 ranged from 13·4% (6·3-30·9) in North Africa to 8·7% (6·3-13·3) in Europe. India, China, Nigeria, Bangladesh, and Indonesia accounted for 57·9 million (41×4%) of 139·9 million livebirths and 6·6 million (44×6%) of preterm births globally in 2014. Of the 38 countries with high-quality data, preterm birth rates have increased since 2000 in 26 countries and decreased in 12 countries. Globally, we estimated that the preterm birth rate was 9×8% (8×3-10×9) in 2000, and 10×6% (9×0-12×0) in 2014. INTERPRETATION: Preterm birth remains a crucial issue in child mortality and improving quality of maternal and newborn care. To better understand the epidemiology of preterm birth, the quality and volume of data needs to be improved, including standardisation of definitions, measurement, and reporting. FUNDING: WHO and the March of Dimes.

Adequacy of calcium intake during pregnancy in a tertiary care center.

BACKGROUND: Calcium is an essential element for the body, which is taken through the dietary sources. Calcium supplements may be needed to achieve the dietary reference intake (DRI). Dietary calcium and supplemental calcium intake for calcium balance might be necessary. However, increasing evidence shows that calcium supplementation may enhance soft tissue calcification and cause cardiovascular diseases. Calcium requirement during pregnancy is markedly increased. If calcium supplementation depends on the dietary style of a region, then the adequacy of dietary calcium intake may guide the calcium supplementation. MATERIALS AND METHODS: A cross-sectional descriptive study was conducted among pregnant women who attended prenatal care at Srinagarind Hospital, Khon Kaen University. We used semiquantitative food frequency questionnaire (SFFQ) to evaluate the amount of daily calcium intake, and 3 days food record to assess the SFFQ reliability. We used the INMUCAL-N V.3.0, based on the Thai food composition table for nutritional calculation. RESULTS: Among 255 recruited pregnant women, the mean daily dietary calcium intake was 1,256.9 mg/day (SD: 625.1) and up to 1,413.4 mg/day (SD: 601.3) in daily milk consumed group. Based on Thai DRI for pregnant women, with 800 mg/day as adequate intake of calcium, 74.9% had adequate calcium intake, and majority of them had milk daily. CONCLUSION: The majority of pregnant women in a province of Northeast Thailand had adequate calcium intake, particularly those who had milk with their meal every day.

Evaluating a preoperative protocol that includes magnetic resonance imaging for lymph node metastasis in the Cholangiocarcinoma Screening and Care Program (CASCAP) in Thailand.

BACKGROUND: Treatment planning especially liver resection in cholangiocarcinoma (CCA) depends on the extension of tumor and lymph node metastasis which is included as a key criterion for operability. Magnetic resonance imaging (MRI) offers a rapid and powerful tool for the detection of lymph node metastasis (LNM) and in the current manuscript is assessed as a critical tool in the preoperative protocol for liver resection for treatment of CCA. However, the accuracy of MRI to detect LNM from CCA had yet to be comprehensively evaluated. METHODS: The accuracy of MRI to detect LNM was assessed in a cohort of individuals with CCA from the Cholangiocarcinoma Screening and Care Program (CASCAP), a screening program designed to reduce CCA in Northeastern Thailand by community-based ultrasound (US) for CCA. CCA-positive individuals are referred to one of the nine tertiary centers in the study to undergo a preoperative protocol that included enhanced imaging by MRI. Additionally, these individuals also underwent lymph node biopsies for histological confirmation of LNM (the "gold standard") to determine the accuracy of the MRI results. RESULTS: MRI accurately detected the presence or absence of LNM in only 29 out of the 51 CCA cases (56.9%, 95% CI 42.2-70.7), resulting in a sensitivity of 57.1% (95% CI 34.0-78.2) and specificity of 56.7% (95% CI 37.4-74.5), with positive and negative predictive values of 48.0% (95% CI 27.8-68.7) and 65.4% (95% CI 44.3-82.8), respectively. The positive likelihood ratio was 1.32 (95% CI 0.76-2.29), and the negative likelihood ratio was 0.76 (95% CI 0.42-1.36). CONCLUSIONS: MRI showed limited sensitivity and a poor positive predictive value for the diagnosis of LNM for CCA, which is of particular concern in this resource-limited setting, where simpler detection methods could be utilized that are more cost-effective in this region of Thailand. Therefore, the inclusion of MRI, a costly imaging method, should be reconsidered as part of protocol for treatment planning of CCA, given the number of false positives, especially as it is critical in determining the operability for CCA subjects.

Correction: The World Health Organization Fetal Growth Charts: A Multinational Longitudinal Study of Ultrasound Biometric Measurements and Estimated Fetal Weight.

[This corrects the article DOI: 10.1371/journal.pmed.1002220.].

Antibiotics for infection prevention after excision of the cervical transformation zone.

BACKGROUND: Excision of the transformation zone of the cervix is the most commonly used approach to treat cervical precancerous lesions (cervical intraepithelial neoplasia (CIN)) to reduce the risk of developing cervical cancer. As the excision of the transformation zone leaves a raw area on the cervix, there is a risk of infection following the procedure. The incidence of infection after cold knife conization (CKC) is 36%, whereas the incidence for large loop excision of the transformation zone (LLETZ, also known as loop electrical excision procedure (LEEP)) is much lower (0.8% to 14.4%). Prophalytic antibiotics may prevent an infection developing and are often prescribed for CKC. However, there are no formal recommendations regarding the use of prophylactic antibiotics for infection prevention in women undergoing surgical excisional treatment for cervical precancerous lesions. OBJECTIVES: To evaluate the effectiveness and safety of antibiotics for infection prevention following excision of the cervical transformation zone. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2016, Issue 4), MEDLINE, Embase, LILACS to May 2016. We also checked registers of clinical trials, citation lists of included studies, key textbooks and previous systematic reviews for potentially relevant studies SELECTION CRITERIA: We included randomised controlled trials (RCTs) evaluating the effectiveness and safety of prophylactic antibiotics versus a placebo or no treatment in women having excision of the cervical transformation zone, regardless of the type of surgical excisional method used. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. Two review authors independently selected potentially relevant trials, extracted data, and assessed risk of bias, compared results and resolved disagreements by discussion. We contacted investigators for additional data, where possible. MAIN RESULTS: Of the 370 records that we identified as a result of the search (excluding duplicates), we regarded six abstracts and titles as potentially relevant studies. Of these six studies, three met the inclusion criteria involving 708 participants; most trials were at moderate or high risk of bias (risk mainly due to lack of blinding and high rate of incomplete data). We did not identify any ongoing trials. Although all included studies had been published in peer-reviewed journals at the time of the search and data extraction, numerical data regarding the outcome measured in one trial involving 77 participants were insufficient for inclusion in a meta-analyses.The difference in the rates of prolonged vaginal discharge or presumed cervicitis (one study; 348 participants; risk ratio (RR), 1.29; 95% confidence interval (CI) 0.72 to 2.31; low-quality evidence) and severe vaginal bleeding (two studies; 638 participants; RR 1.21; 95% CI 0.52 to 2.82; very low-quality evidence) among the two comparison groups did not reach the level for clinically important effect. In addition, there was no difference in adverse events related to antibiotics i.e. nausea/vomiting, diarrhoea, and headache among the two comparison groups (two studies; 638 participants; RR 1.69; 95% CI 0.85 to 3.34; very low-quality evidence). There were no differences in the incidence of fever (RR, 2.23; 95% CI 0.20 to 24.36), lower abdominal pain (RR, 1.03; 95% CI 0.61 to 1.72), unscheduled medical consultation (RR 2.68, 95% CI 0.97 to 7.41), and additional self-medication (RR 1.22; 95% CI 0.56 to 2.67) between the two comparison groups (one study; 290 participants; low to very low-quality evidence). AUTHORS' CONCLUSIONS: As only limited data are available from three trials with overall moderate to high risk of bias, there is insufficient evidence to support use of antibiotics to reduce infectious complications following excision of the cervical transformation zone. In addition, there were minimal data about antibiotic-related adverse events and no information on the risk of developing antibiotic resistance. Antibiotics given for infection prevention after excision of the cervical transformation zone should only be used in the context of clinical research, to avoid unnecessary prescription of antibiotics and to prevent further increases in antibiotic resistance.

The World Health Organization Fetal Growth Charts: A Multinational Longitudinal Study of Ultrasound Biometric Measurements and Estimated Fetal Weight.

BACKGROUND: Perinatal mortality and morbidity continue to be major global health challenges strongly associated with prematurity and reduced fetal growth, an issue of further interest given the mounting evidence that fetal growth in general is linked to degrees of risk of common noncommunicable diseases in adulthood. Against this background, WHO made it a high priority to provide the present fetal growth charts for estimated fetal weight (EFW) and common ultrasound biometric measurements intended for worldwide use. METHODS AND FINDINGS: We conducted a multinational prospective observational longitudinal study of fetal growth in low-risk singleton pregnancies of women of high or middle socioeconomic status and without known environmental constraints on fetal growth. Centers in ten countries (Argentina, Brazil, Democratic Republic of the Congo, Denmark, Egypt, France, Germany, India, Norway, and Thailand) recruited participants who had reliable information on last menstrual period and gestational age confirmed by crown-rump length measured at 8-13 wk of gestation. Participants had anthropometric and nutritional assessments and seven scheduled ultrasound examinations during pregnancy. Fifty-two participants withdrew consent, and 1,387 participated in the study. At study entry, median maternal age was 28 y (interquartile range [IQR] 25-31), median height was 162 cm (IQR 157-168), median weight was 61 kg (IQR 55-68), 58% of the women were nulliparous, and median daily caloric intake was 1,840 cal (IQR 1,487-2,222). The median pregnancy duration was 39 wk (IQR 38-40) although there were significant differences between countries, the largest difference being 12 d (95% CI 8-16). The median birthweight was 3,300 g (IQR 2,980-3,615). There were differences in birthweight between countries, e.g., India had significantly smaller neonates than the other countries, even after adjusting for gestational age. Thirty-one women had a miscarriage, and three fetuses had intrauterine death. The 8,203 sets of ultrasound measurements were scrutinized for outliers and leverage points, and those measurements taken at 14 to 40 wk were selected for analysis. A total of 7,924 sets of ultrasound measurements were analyzed by quantile regression to establish longitudinal reference intervals for fetal head circumference, biparietal diameter, humerus length, abdominal circumference, femur length and its ratio with head circumference and with biparietal diameter, and EFW. There was asymmetric distribution of growth of EFW: a slightly wider distribution among the lower percentiles during early weeks shifted to a notably expanded distribution of the higher percentiles in late pregnancy. Male fetuses were larger than female fetuses as measured by EFW, but the disparity was smaller in the lower quantiles of the distribution (3.5%) and larger in the upper quantiles (4.5%). Maternal age and maternal height were associated with a positive effect on EFW, particularly in the lower tail of the distribution, of the order of 2% to 3% for each additional 10 y of age of the mother and 1% to 2% for each additional 10 cm of height. Maternal weight was associated with a small positive effect on EFW, especially in the higher tail of the distribution, of the order of 1.0% to 1.5% for each additional 10 kg of bodyweight of the mother. Parous women had heavier fetuses than nulliparous women, with the disparity being greater in the lower quantiles of the distribution, of the order of 1% to 1.5%, and diminishing in the upper quantiles. There were also significant differences in growth of EFW between countries. In spite of the multinational nature of the study, sample size is a limiting factor for generalization of the charts. CONCLUSIONS: This study provides WHO fetal growth charts for EFW and common ultrasound biometric measurements, and shows variation between different parts of the world.

Success rate in preterm uterine contraction inhibition with tocolytic agents in a tertiary care center.

OBJECTIVE: This study aims to assess the success rate of inhibiting preterm uterine contraction with tocolytic agents to delay delivery for at least 48 hours and risk factors of failure inhibition. MATERIALS AND METHODS: Between January 2013 and July 2014, medical records of all singleton pregnant women between 24 0/7 and 33 6/7 weeks of gestation with the diagnosis of preterm labor (with cervical dilatation) or threatened preterm labor (without cervical dilatation) who received tocolytic agents were reviewed. The success rate of preterm uterine contraction inhibition was accounted in patients with 48 hours delayed delivery. The risk factors of the inhibition failure and neonatal outcomes were also investigated in this study. RESULTS: Among 424 pregnant women diagnosed of preterm labor or threatened preterm labor, 103 singleton pregnant women met the study criteria. Overall success rate of preterm uterine contraction inhibition to prolong pregnancy for at least 48 hours was 86.4% (95% confidence interval [CI]: 78.3, 92.3). However, the success rate among the threatened preterm labor group was 93.8% (95% CI: 88.3, 99.1) while the preterm labor group was 60.9% (95% CI: 39.3, 82.4). The significant factor associated with inhibition failure was preterm labor (adjusted odds ratio 7.22; 95% CI: 1.99, 26.20). CONCLUSION: The success rate of preterm uterine contraction inhibition with tocolytic agents to delay delivery for at least 48 hours was high in threatened preterm labor and low in preterm labor. A significant risk factor for inhibition failure was the preterm uterine contraction with cervical change.

Ending preventable maternal and newborn deaths due to infection.

Over 300,000 maternal deaths occur each year, 11% of which are thought to be due to infectious causes, and approximately one million newborns die within the first week of life annually due to infectious causes. Infections in pregnancy may result in a variety of adverse obstetrical outcomes, including preterm delivery, pre-labor rupture of membranes, stillbirth, spontaneous abortion, congenital infection, and anomalies. This paper reviews the burden of disease due to key infections and their contribution to maternal, perinatal, and newborn morbidity and mortality, as well as key interventions to prevent maternal and newborn deaths related to these infections. Research needs include more accurate clinical and microbiologic surveillance systems, validated risk stratification strategies, better point-of-care testing, and identification of promising vaccine strategies.

Global, regional and national levels and trends of preterm birth rates for 1990 to 2014: protocol for development of World Health Organization estimates.

BACKGROUND: The official WHO estimates of preterm birth are an essential global resource for assessing the burden of preterm birth and developing public health programmes and policies. This protocol describes the methods that will be used to identify, critically appraise and analyse all eligible preterm birth data, in order to develop global, regional and national level estimates of levels and trends in preterm birth rates for the period 1990 - 2014. METHODS: We will conduct a systematic review of civil registration and vital statistics (CRVS) data on preterm birth for all WHO Member States, via national Ministries of Health and Statistics Offices. For Member States with absent, limited or lower-quality CRVS data, a systematic review of surveys and/or research studies will be conducted. Modelling will be used to develop country, regional and global rates for 2014, with time trends for Member States where sufficient data are available. Member States will be invited to review the methodology and provide additional eligible data via a country consultation before final estimates are developed and disseminated. DISCUSSION: This research will be used to generate estimates on the burden of preterm birth globally for 1990 to 2014. We invite feedback on the methodology described, and call on the public health community to submit pertinent data for consideration. TRIAL REGISTRATION: Registered at PROSPERO CRD42015027439 CONTACT: pretermbirth@who.int.

Parameters Affecting Length of Stay Among Neurosurgical Patients in an Intensive Care Unit.

AIM: to determine the predictive factors on the length of stay of neurosurgical patients in the ICU setting. METHODS: all patients admitted to the neurosurgical ICU between February 1 and July 31, 2011 were recruited. Patient demographics and clinical data for each variable were collected within 30 minutes of admission. The ICU length of stay was recorded and analyzed by linear regression model with statistical significance at p-value <0.05. RESULTS: there were 276 patients admitted, of whom 89.1% were elective cases. The mean (95% CI) and median (min-max) of ICU length of stay were 2.36 (2.09-2.63) and 2 (1-25) days. The variables associated with ICU length of stay and their percent change (95% CI) were the Glasgow Coma Scale motor subscore (GCSm), 6.72% (-11.20 to -2.01) lower for every 1 point score change; blood pH, 1.16% (0.11 to 2.21) higher for every 0.01 unit change; and emergency admission type, 58.30% (29.16 to 94.0) higher as compared to elective admission. CONCLUSION: the GCSm, pH and emergency admission were found to be the main predictive variables of neurosurgical patient length of stay in the intensive care unit, however, the model should be further explored in a larger sample size and using subgroup analysis.

Antibiotic prophylaxis during the second and third trimester to reduce adverse pregnancy outcomes and morbidity.

BACKGROUND: Several studies have suggested that prophylactic antibiotics given during pregnancy improved maternal and perinatal outcomes, while others have shown no benefit and some have reported adverse effects. OBJECTIVES: To determine the effect of prophylactic antibiotics on maternal and perinatal outcomes during the second and third trimester of pregnancy for all women or women at risk of preterm delivery. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 April 2015) and reference lists of retrieved articles. SELECTION CRITERIA: Randomised controlled trials comparing prophylactic antibiotic treatment with placebo or no treatment for women in the second or third trimester of pregnancy before labour. DATA COLLECTION AND ANALYSIS: We assessed trial quality and extracted data. MAIN RESULTS: The review included eight randomised controlled trials. Approximately 4300 women were recruited to detect the effect of prophylactic antibiotic administration on pregnancy outcomes. Primary outcomesAntibiotic prophylaxis did not reduce the risk of preterm prelabour rupture of membranes (risk ratio (RR) 0.31; 95% confidence interval (CI) 0.06 to 1.49 (one trial, 229 women), low quality evidence) or preterm delivery (RR 0.88; 95% CI 0.72 to 1.09 (six trials, 3663 women), highquality evidence). However, preterm delivery was reduced in the subgroup of pregnant women with a previous preterm birth who had bacterial vaginosis (BV) during the current pregnancy (RR 0.64; 95% CI 0.47 to 0.88 (one trial, 258 women)), but there was no reduction in the subgroup of pregnant women with previous preterm birth without BV during the pregnancy (RR 1.08; 95% CI 0.66 to 1.77 (two trials, 500 women)). A reduction in the risk of postpartum endometritis (RR 0.55; 95% CI 0.33 to 0.92 (one trial, 196 women)) was observed in high-risk pregnant women (women with a history of preterm birth, low birthweight, stillbirth or early perinatal death) and in all women (RR 0.53; 95% CI 0.35 to 0.82 (three trials, 627 women), moderate quality evidence). There was no difference in low birthweight (RR 0.86; 95% CI 0.53 to 1.39 (four trials; 978 women)) or neonatal sepsis (RR 11.31; 95% CI 0.64 to 200.79) (one trial, 142 women)); and blood culture confirming sepsis was not reported in any of the studies. Secondary outcomesAntibiotic prophylaxis reduced the risk of prelabour rupture of membranes (RR 0.34; 95% CI 0.15 to 0.78 (one trial, 229 women), low quality evidence) and gonococcal infection (RR 0.35; 95% CI 0.13 to 0.94 (one trial, 204 women)). There were no differences observed in other secondary outcomes (congenital abnormality; small-for-gestational age; perinatal mortality), whilst many other secondary outcomes (e.g. intrapartum fever needing treatment with antibiotics) were not reported in included trials.Regarding the route of antibiotic administration, vaginal antibiotic prophylaxis during pregnancy did not prevent infectious pregnancy outcomes. The overall risk of bias was low, except that incomplete outcome data produced high risk of bias in some studies. The quality of the evidence using GRADE was assessed as low for preterm prelabour rupture of membranes, high for preterm delivery, moderate for postpartum endometritis, low for prelabour rupture of membranes, and very low for chorioamnionitis. Intrapartum fever needing treatment with antibiotics was not reported in any of the included studies. AUTHORS' CONCLUSIONS: Antibiotic prophylaxis did not reduce the risk of preterm prelabour rupture of membranes or preterm delivery (apart from in the subgroup of women with a previous preterm birth who had bacterial vaginosis). Antibiotic prophylaxis given during the second or third trimester of pregnancy reduced the risk of postpartum endometritis, term pregnancy with pre-labour rupture of membranes and gonococcal infection when given routinely to all pregnant women. Substantial bias possibly exists in the review's results because of a high rate of loss to follow-up and the small numbers of studies included in each of our analyses. There is also insufficient evidence on possible harmful effects on the baby. Therefore, we conclude that there is not enough evidence to support the use of routine antibiotics during pregnancy to prevent infectious adverse effects on pregnancy outcomes.

Calcium supplementation (other than for preventing or treating hypertension) for improving pregnancy and infant outcomes.

BACKGROUND: Maternal nutrition during pregnancy is known to have an effect on fetal growth and development. It is recommended that women increase their calcium intake during pregnancy and lactation, although the recommended dosage varies among professionals. Currently, there is no consensus on the role of routine calcium supplementation for pregnant women other than for preventing or treating hypertension. OBJECTIVES: To determine the effect of calcium supplementation on maternal, fetal and neonatal outcomes (other than for preventing or treating hypertension) as well as any possible side effects. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30th September 2014). SELECTION CRITERIA: We considered all published, unpublished and ongoing randomised controlled trials (RCTs) comparing maternal, fetal and neonatal outcomes in pregnant women who received calcium supplementation versus placebo or no treatment. Cluster-RCTs were eligible for inclusion but none were identified. Quasi-RCTs and cross-over studies were not eligible for inclusion. 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: Twenty-five studies met the inclusion criteria, but only 23 studies contributed data to the review. These 23 trials recruited 18,587 women, with 17,842 women included in final analyses. There were no statistically significant differences between women who received calcium supplementation and those who did not in terms of reducing preterm births less than 37 weeks' gestation (risk ratio (RR) 0.86, 95% confidence interval (CI) 0.70 to 1.05; 13 studies, 16,139 women; random-effects model) or less than 34 weeks' gestation (RR 1.04, 95% CI 0.80 to 1.36; four trials, 5669). Most studies were of low risk of bias. We conducted sensitivity analysis for the outcome of preterm birth less than 37 weeks by removing two trials with unclear risk of bias for allocation concealment; the results then favoured treatment with calcium supplementation (RR 0.80, 95% CI 0.65 to 0.99; 11 trials, 15,379 women). There was no significant difference in infant low birthweight between the two treatment groups (RR 0.93, 95% CI 0.81 to 1.07; six trials, 14,162 infants; random-effects model). However, when compared to the control group, women in the calcium supplementation group gave birth to slightly heavier birthweight infants (mean difference 56.40, 95% CI 13.55 to 99.25; 21 trials, 9202 women; random-effects model).Three outcomes were chosen for assessment with the GRADE software: preterm birth less than 37 weeks; preterm birth less than 34 weeks; and low birthweight less than 2500 g. Evidence for these outcomes was assessed as of moderate quality. AUTHORS' CONCLUSIONS: This review indicates that there are no clear additional benefits to calcium supplementation in prevention of preterm birth or low infant birthweight. While there was a statistically significant difference of 56 g identified in mean infant birthweight, there was significant heterogeneity identified, and the clinical significance of this difference is uncertain.

Antibiotic prophylaxis during the second and third trimester to reduce adverse pregnancy outcomes and morbidity.

BACKGROUND: Several studies have suggested that prophylactic antibiotics given during pregnancy improved maternal and perinatal outcomes, while others have shown no benefit and some have reported adverse effects. OBJECTIVES: To determine the effect of prophylactic antibiotics on maternal and perinatal outcomes during the second and third trimester of pregnancy for all women or women at risk of preterm delivery. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 July 2014) and reference lists of retrieved articles. SELECTION CRITERIA: Randomised controlled trials comparing prophylactic antibiotic treatment with placebo or no treatment for women in the second or third trimester of pregnancy before labour. DATA COLLECTION AND ANALYSIS: We assessed trial quality and extracted data. MAIN RESULTS: The review included seven randomised controlled trials. Approximately 2100 women were recruited to detect the effect of prophylactic antibiotic administration on pregnancy outcomes. Primary outcomesAntibiotic prophylaxis did not reduce the risk of preterm prelabour rupture of membranes (risk ratio (RR) 0.31; 95% confidence interval (CI) 0.06 to 1.49 (one trial, 229 women) low quality evidence) or preterm delivery (RR 0.85; 95% CI 0.64 to 1.14 (five trials, 1480 women) low quality evidence). However, preterm delivery was reduced in the subgroup of pregnant women with a previous preterm birth who had bacterial vaginosis (BV) during the current pregnancy (RR 0.64; 95% CI 0.47 to 0.88 (one trial, 258 women), but there was no reduction in the subgroup of pregnant women with previous preterm birth without BV during the pregnancy (RR 1.08; 95% CI 0.66 to 1.77 (two trials, 500 women)). A reduction in the risk of postpartum endometritis (RR 0.55; 95% CI 0.33 to 0.92 (one trial, 196 women)) was observed in high-risk pregnant women (women with a history of preterm birth, low birthweight, stillbirth or early perinatal death) and in all women (RR 0.53; 95% CI 0.35 to 0.82 (three trials, 627 women) moderate quality evidence). There was no difference in low birth weight (RR 0.86; 95% CI 0.53 to 1.39 (four trials; 978 women) or neonatal sepsis (RR 11.31; 95% CI 0.64 to 200.79); and blood culture confirming sepsis was not reported in any of the studies. Secondary outcomesAntibiotic prophylaxis reduced the risk of prelabour rupture of membranes (RR 0.34; 95% CI 0.15 to 0.78 (one trial, 229 women) low quality evidence) and gonococcal infection (RR 0.35; 95% CI 0.13 to 0.94 (one trial, 204 women)). There were no differences observed in other secondary outcomes (congenital abnormality; small-for-gestational age; perinatal mortality), whilst many other secondary outcomes (e.g. intrapartum fever needing treatment with antibiotics) were not reported in included trials.Regarding the route of antibiotic administration, vaginal antibiotic prophylaxis during pregnancy did not prevent infectious pregnancy outcomes. The overall risk of bias was low except that incomplete outcome data produced high risk of bias in some studies. The quality of the evidence using GRADE was assessed as low for preterm prelabour rupture of membranes, low for preterm delivery, moderate for postpartum endometritis, low for prelabour rupture of membranes, and very low for chorioamnionitis. Intrapartum fever needing treatment with antibiotics was not reported in any of the included studies. AUTHORS' CONCLUSIONS: Antibiotic prophylaxis did not reduce the risk of preterm prelabour rupture of membranes or preterm delivery (apart from in the subgroup of women with a previous preterm birth who had bacterial vaginosis). Antibiotic prophylaxis given during the second or third trimester of pregnancy reduced the risk of postpartum endometritis, preterm rupture of membranes and gonococcal infection when given routinely to all pregnant women. Substantial bias possibly exists in the review's results because of a high rate of loss to follow-up and the small numbers of studies included in each of our analyses. There is also insufficient evidence on possible harmful effects on the baby. Therefore, we conclude that there is not enough evidence to recommend the use of routine antibiotics during pregnancy to prevent infectious adverse effects on pregnancy outcomes.

Association between infant feeding practices and first meaningful words at first year of life: a prospective cohort study of Thai children.

Feeding practices show many benefits for child and cognitive development. The objective was to investigate the association between infant feeding practices and the first meaningful words of Thai children. The participants enrolled in this longitudinal study were 4245 children born between July 2000 and June 2002. They resided in 3 rural and 2 urban areas of Thailand and were followed from birth to childhood. The outcome was time from birth to expression of first meaningful words. Outcome and feeding information were gathered using a diary method, with parents and caregivers recording daily development. Nonstatistically significant corresponding reduction in time to expression of first meaningful words was found among children who were breastfed, and this increased with duration of breastfeeding. Breastfeeding may reduce the time taken for expression of first meaningful words by about 2% (hazard ratio = 0.98; 95% confidence interval = 0.94 to 1.01). No association between infant feeding practices and the expression of first meaningful words was found.

Antibiotic prophylaxis for third- and fourth-degree perineal tear during vaginal birth.

BACKGROUND: One to eight per cent of women suffer third-degree perineal tear (anal sphincter injury) and fourth-degree perineal tear (rectal mucosa injury) during vaginal birth, and these tears are more common after forceps delivery (28%) and midline episiotomies. Third- and fourth-degree tears can become contaminated with bacteria from the rectum and this significantly increases in the chance of perineal wound infection. Prophylactic antibiotics might have a role in preventing this infection. OBJECTIVES: To assess the effectiveness of antibiotic prophylaxis for reducing maternal morbidity and side effects in third- and fourth-degree perineal tear during vaginal birth. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 August 2014) and the reference lists of retrieved articles. SELECTION CRITERIA: Randomised controlled trials comparing outcomes of prophylactic antibiotics versus placebo or no antibiotics in third- and fourth-degree perineal tear during vaginal birth. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed the trial reports for inclusion and risk of bias, extracted data and checked them for accuracy. MAIN RESULTS: We identified and included one trial (147 women from a pre-planned sample size of 310 women) that compared the effect of prophylactic antibiotic (single-dose, second-generation cephalosporin - cefotetan or cefoxitin, 1 g intravenously) on postpartum perineal wound complications in third- or fourth-degree perineal tears compared with placebo. Perineal wound complications (wound disruption and purulent discharge) at the two-week postpartum check up were 8.20% and 24.10% in the treatment and the control groups respectively (risk ratio (RR) 0.34, 95% confidence interval (CI) 0.12 to 0.96). However, the high failed-appointment rate may limit the generalisability of the results. The overall risk of bias was low except for incomplete outcome data. The quality of the evidence using GRADE was moderate for infection rate at two weeks' postpartum, and low for infection rate at six weeks' postpartum. AUTHORS' CONCLUSIONS: Although the data suggest that prophylactic antibiotics help to prevent perineal wound complications following third- or fourth-degree perineal tear, loss to follow-up was very high. The results should be interpreted with caution as they are based on one small trial.

Vaginal chlorhexidine during labour for preventing maternal and neonatal infections (excluding Group B Streptococcal and HIV).

BACKGROUND: The incidence of chorioamnionitis occurs in between eight and 12 women for every 1000 live births and 96% of cases of chorioamnionitis are due to ascending infection. Following spontaneous vaginal delivery, 1% to 4% of women develop postpartum endometritis. The incidence of neonatal sepsis is 0.5% to 1% of all infants born. Maternal vaginal bacteria are the main agents for these infections. It is reasonable to speculate that prevention of maternal and neonatal infections might be possible by washing the vagina and cervix with an antibacterial agent for all women during labour. Chlorhexidine belongs to the class of compounds known as the bis-biguanides. Chlorhexidine has antibacterial action against a wide range of aerobic and anaerobic bacteria, including those implicated in peripartal infections. OBJECTIVES: To evaluate the effectiveness and side effects of chlorhexidine vaginal douching during labour in reducing maternal and neonatal infections (excluding group B streptococcal and HIV). SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2014), reference lists of retrieved reports and journal letters and editorials. SELECTION CRITERIA: Randomized or quasi-randomized trials comparing chlorhexidine vaginal douching during labour with placebo or other vaginal disinfectant to prevent (reduce) maternal and neonatal infections (excluding group B streptococcal and HIV). DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial eligibility and quality, extracted and interpreted the data. A third review author analyzed and interpreted the data. The fourth author also interpreted the data. MAIN RESULTS: We included three studies (3012 participants). There was no evidence of an effect of vaginal chlorhexidine during labour in preventing maternal and neonatal infections. Although the data suggest a trend in reducing postpartum endometritis, the difference was not statistically significant (three trials, 3012 women, risk ratio 0.83; 95% confidence interval 0.61 to 1.13).Assessment of the quality of the evidence using GRADE indicated that the levels of evidence for all primary outcomes and one important secondary outcome were low to moderate. AUTHORS' CONCLUSIONS: There is no evidence to support the use of vaginal chlorhexidine during labour in preventing maternal and neonatal infections. There is a need for a well-designed randomized controlled trial using appropriate concentration and volume of vaginal chlorhexidine irrigation solution and with adequate sample size.

Incidence of and risk factors for febrile morbidity after laparoscopic-assisted vaginal hysterectomy.

BACKGROUND: The purpose of this study was to assess the incidence of and risk factors for postoperative febrile morbidity after laparoscopic-assisted vaginal hysterectomy (LAVH). METHODS: This retrospective study was carried out using the medical records of women with benign gynecologic conditions who underwent LAVH between June 2007 and May 2012 at Srinagarind Hospital in Thailand. Data were collected to assess baseline patient characteristics, occurrence of body temperature ≥38°C on two occasions at least 6 hours apart in the 24 hours following the surgical procedure, and possible risk factors related to postoperative febrile morbidity. RESULTS: In total, 199 women underwent LAVH during the study period. They had a mean age of 46±6 years, a mean body mass index of 24.0±3.2 kg/m(2), a mean surgical duration of 134±52 minutes, median estimated blood loss of 200 mL, a mean total hospital stay of 5±2 days, and a mean postoperative hospital stay of 3±2 days. Postoperative febrile morbidity was documented in 31 cases (15.6%). The cause of postoperative fever was unknown in most cases, with only two cases having an identifiable cause. The risk of postoperative febrile morbidity was highest in women treated with more than two antibacterial agents and with a regimen of more than 3 days. CONCLUSION: This study shows a moderately high rate of febrile morbidity after LAVH, for which the main risk factors were use of multiple drugs and doses for antibiotic prophylaxis.