Systematic review and meta-analysis of performance of second-trimester nasal bone assessment in detection of fetuses with Down syndrome.

OBJECTIVE: To review systematically the literature on diagnostic tests and performance of second-trimester sonographic assessment of nasal bone (NB) in identifying fetuses affected by Down syndrome. METHODS: A search of studies involving screening tests for NB evaluation and measurements was carried out in the main international bibliographic databases (MEDLINE, EMBASE and CINAHL). Those considered to be relevant were then subjected to critical reading, following Critical Appraisal Skills Programme (CASP) criteria, by at least three independent observers. All data were extracted and tabulated by two independent investigators. A statistical synthesis of sensitivity, specificity and likelihood ratios was performed using specific software (Meta-DiSc). RESULTS: From an initial list of 852 articles referring to ultrasound markers for Down syndrome, 207 relevant papers were selected. Following exclusions, 21 studies were included in the quantitative synthesis. The pooled estimates of positive and negative likelihood ratios were 40.08 (95% CI, 18.10-88.76) and 0.71 (95% CI, 0.64-0.79), respectively, for absent NB and 15.15 (95% CI, 8.15-28.16) and 0.47 (95% CI, 0.34-0.64), respectively, for hypoplastic NB. No relevant differences were found between the various means of defining nasal hypoplasia (multiples of the median (MoM) or percentiles). The biparietal diameter/nasal bone length (BPD/NBL) ratio showed somewhat higher sensitivity but lower specificity with a threshold effect. CONCLUSIONS: NB absence or hypoplasia show high specificity and low but acceptable sensitivity in identifying fetuses with Down syndrome. Screening performance is better with NB measurements as a function of MoM or percentiles rather than as the BPD/NBL ratio. Classification of women into various risk groups for Down syndrome does not affect diagnostic performance.

[Evaluation and efficacy of preventive measures in intrapartum bleeding]. / Evaluación y eficacia de las medidas preventivas en la anemia intraparto.

OBJECTIVES: To evaluate the efficacy, applicability and safety of two recently introduced preventive-restrictive measures on the use of episiotomy and active management of the third stage of labour, in order to reduce puerperal bleeding results. MATERIAL AND METHOD: Cohort study of a prospective series of 1098 women who gave birth in the Obstetrics and Gynaecology Department of the La Mancha General Hospital. Data were collected in two phases (1st phase, before applying the measures: 591; 2nd phase, after: 507). The main objective was to assess intrapartum blood loss. The independent variables analysed were active management of the third stage of labour and episiotomy rate. Age, parity, prematurity, weight of the newborn child, analgesia, duration and type of childbirth (spontaneous or induced), tears, retained placenta and neonatal results were included as control variables. Caesarean deliveries and those cases with increased bleeding risk factors were excluded. RESULTS: Both postpartum anaemia and excessive hemorrhagic loss were significantly lowered (8.7% and 50% respectively). Likewise, episiotomy rate was also significantly reduced (8.6%) and active management of the third stage of labour increased to 86.6%. Neonatal outcome results did not change throughout the study. CONCLUSIONS: The restrictive use of episiotomy and active management during the third stage of labour were effective, and with no side effects, in reducing intrapartum blood loss and improving puerperal quality of life.

Evaluación y eficacia de las medidas preventivas en la anemia intraparto / Evaluation and efficacy of preventive measures in intrapartum bleeding

Objetivo. Evaluar la eficacia, aplicabilidad y seguridad de 2 medidas preventivas, reducción de episiotomías y tratamiento activo del alumbramiento, implantadas en nuestro servicio para disminuir el número de pacientes con anemia puerperal en los partos vaginales. Material y métodos. Estudio prospectivo de calidad asistencial realizado en el Servicio de Obstetricia del Hospital La Mancha Centro, en 2 fases (1.a fase: 591pacientes, 2.a fase: 507 pacientes; n: 1.098 partos vaginales) separadas por la aplicación de las medidas de mejora por evaluar. La variable dependiente fue la pérdida hemática intraparto. Las variables independientes fueron la tasa de episiotomías y de alumbramientos dirigidos. Las variables de control estudiadas fueron la edad, la paridad, la prematuridad, el peso del recién nacido, el inicio del parto, la analgesia, la duración del parto y el tipo de parto, los desgarros, el tipo de desgarro, la retención placentaria y los resultados neonatales. En el muestreo consecutivo no probabilístico se excluyeron las cesáreas y otras enfermedades influyentes en la hemorragia. Resultados. La tasa de episiotomía descendió un 8,6% y el alumbramiento dirigido alcanzó un 86,8%, lo que redujo la anemia posparto un 8,7% y la pérdida hemática excesiva un 50% (razón de prevalencia: 1,4). Las medidas aplicadas no modificaron los resultados neonatales. Conclusiones. La episiotomía selectiva y el tratamiento activo sistemático del alumbramiento son 2 medidas efectivas, de fácil cumplimiento, presumiblemente eficientes y sin efectos secundarios, para reducir la hemorragia y el grado de anemia tras el parto y mejorar la calidad de vida de la mujer durante el puerperio(AU)

Objectives. To evaluate the efficacy, applicability and safety of two recently introduced preventive-restrictive measures on the use of episiotomy and active management of the third stage of labour, in order to reduce puerperal bleeding results. Material and Method. Cohort study of a prospective series of 1098 women who gave birth in the Obstetrics and Gynaecology Department of the La Mancha General Hospital. Data were collected in two phases (1st phase, before applying the measures: 591; 2nd phase, after: 507). The main objective was to assess intrapartum blood loss. The independent variables analysed were active management of the third stage of labour and episiotomy rate. Age, parity, prematurity, weight of the newborn child, analgesia, duration and type of childbirth (spontaneous or induced), tears, retained placenta and neonatal results were included as control variables. Caesarean deliveries and those cases with increased bleeding risk factors were excluded. Results. Both postpartum anaemia and excessive hemorrhagic loss were significantly lowered (8.7% and 50% respectively). Likewise, episiotomy rate was also significantly reduced (8.6%) and active management of the third stage of labour increased to 86.6%. Neonatal outcome results did not change throughout the study. Conclusions. The restrictive use of episiotomy and active management during the third stage of labour were effective, and with no side effects, in reducing intrapartum blood loss and improving puerperal quality of life(AU)