Morbidity experienced by women before and after operative vaginal delivery: prospective cohort study nested within a two-centre randomised controlled trial of restrictive versus routine use of episiotomy.

OBJECTIVE: To explore: (1) the antenatal and postnatal morbidity experienced by women in relation to operative vaginal delivery (OVD); and (2) the impact of restrictive versus routine use of episiotomy. DESIGN: Longitudinal prospective cohort study embedded within a two-centre randomised controlled trial (RCT). SETTING: Two UK tertiary-level maternity units. POPULATION: Antenatally recruited participants of an RCT of restrictive versus routine use of episiotomy at OVD. METHODS: A self-completing questionnaire was administered antenatally, before hospital discharge, at 6 weeks and at 1 year postpartum. MAIN OUTCOME MEASURES: Urinary and anal incontinence, dyspareunia, perineal pain and psychological morbidity. RESULTS: Longitudinal data have revealed that morbidities historically associated with OVD were often as prevalent, if not more prevalent, in the third trimester of pregnancy than postpartum. Restrictive episiotomy use was associated with: a higher incidence of perineal pain in the immediate postpartum period (98.9% restrictive versus 87.8% routine, RR 1.10, 95% CI 1.01-1.21); greater psychological morbidity in the immediate postpartum period (mean scores on the Edinburgh Postnatal Depression Scale, Edinburgh Postnatal Depression Score (EPDS) 6.7 restrictive versus 5.1 routine; P = 0.01 ); and more stress urinary incontinence at 6 weeks postpartum (42.2% restrictive versus 27.2% routine, RR 1.55, 95% CI 1.00-2.40); however, this had resolved by 1 year. No other differences were found between the groups at 6 weeks and 1 year postpartum. CONCLUSIONS: Morbidities previously attributed to OVD may in fact be present antenatally, to a greater or similar degree. A restrictive approach to the use of episiotomy at OVD may increase rates of urinary morbidity, in particular stress incontinence and perineal pain, in the immediate postpartum period.

A randomised controlled trial of routine versus restrictive use of episiotomy at operative vaginal delivery: a multicentre pilot study.

OBJECTIVE: To compare the maternal and neonatal outcomes of operative vaginal delivery in relation to the use of episiotomy. DESIGN: Pilot randomised controlled trial (RCT). SETTING: Two urban maternity units in Scotland and England. SAMPLE: Nulliparous women anticipating a singleton cephalic vaginal delivery were recruited in the antenatal period. METHODS: If an operative vaginal delivery was required in the second stage of labour, women were randomised to either routine (in all cases) or restrictive (only if tearing apparent) use of episiotomy. MAIN OUTCOME MEASURES: The primary outcome was anal sphincter tearing (third or fourth degree). Secondary outcomes included postpartum haemorrhage (PPH), neonatal trauma and pelvic floor symptoms up until 10 days postpartum. RESULTS: In a group of 317 women requiring operative vaginal delivery, 200 were randomised: 99 to routine use of episiotomy and 101 to restrictive use. There were small differences in the rates of anal sphincter tears (8.1% routine versus 10.9% restrictive, OR 0.72, 95% CI 0.28-1.87) and primary PPH (36.4% routine versus 26.7% restrictive, OR 1.57, 95% CI 0.86-2.86). Neonatal trauma was similar between the two groups (45.5% routine versus 43.6% restrictive, OR 1.08, 95% CI 0.62-1.89), as was prolonged catheterisation, urinary incontinence, faecal incontinence, perineal infection and prolonged hospital admission. CONCLUSIONS: This pilot study does not provide conclusive evidence that a policy of routine episiotomy is better or worse than a restrictive policy. A definitive RCT is feasible but will require a large sample size to inform clinical practice.

A prospective cohort study of maternal and neonatal morbidity in relation to use of episiotomy at operative vaginal delivery.

OBJECTIVE: To evaluate the maternal and neonatal morbidity of operative vaginal delivery in relation to the use of episiotomy. DESIGN: Prospective cohort study. SETTING: Two urban maternity units in Scotland and England. POPULATION: All nonrandomised nulliparous women delivered by forceps or vacuum during the recruitment period of a clinical trial evaluating the use of episiotomy at operative vaginal delivery. METHODS: Use of episiotomy was compared to no episiotomy for all operative vaginal deliveries with sub-group analyses for forceps or vacuum deliveries. MAIN OUTCOME MEASURES: The primary outcome was anal sphincter tearing (third or fourth degree). Secondary outcomes included postpartum haemorrhage, neonatal trauma and pelvic floor symptoms up until 10 days postpartum. RESULTS: A total of 1360 women were included in the study, of whom 294 (21.6%) did not receive an episiotomy. Vacuum delivery was associated with less use of episiotomy than forceps (56.1 versus 89.4%, OR 0.15, 95% CI 0.11-0.20). Anal sphincter tear rates were not statistically different with use of episiotomy compared with no episiotomy (9.9 versus 7.1%, adjusted OR 1.11, 95% CI 0.66-1.87). Episiotomy use was associated with higher rates of postpartum haemorrhage (28.5 versus 18.4%, adjusted OR 1.72, 95% CI 1.21-2.45), need for moderate or strong analgesia (90.5 versus 67.6%, adjusted OR 3.70, 95% CI 2.60-5.27), perineal infection (5.1 versus 1.4%, adjusted OR 4.04, 95% CI 1.44-11.37) and neonatal trauma (38.1 versus 22.0%, adjusted OR 1.65, 95% CI 1.20-2.27). Use of episiotomy did not reduce the risk of shoulder dystocia (3.5 versus 1.7%, adjusted OR 1.42, 95% CI 0.53-3.85). CONCLUSIONS: The use of episiotomy did not reduce or greatly increase anal sphincter tears and was associated with greater maternal and neonatal morbidity. This may reflect the complexity of deliveries. The role of episiotomy at operative vaginal delivery should be evaluated in a randomised controlled trial.

Diagnostic outcomes following childhood non-specific abdominal pain: a record-linkage study.

AIMS: Non-specific abdominal pain (NSAP) is the most common diagnosis on discharge following admission for abdominal pain in childhood. Our aim was to determine the risk of subsequent hospital diagnosis of organic and functional gastroenterological conditions following a diagnosis of NSAP, and to assess the persistence of this risk. METHODS: An NSAP cohort of 268,623 children aged 0-16 years was constructed from linked English Hospital Episode Statistics from 1999 to 2011. The control cohort (1,684,923 children, 0-16 years old) comprised children hospitalised with unrelated conditions. Clinically relevant outcomes were selected and standardised rate ratios were calculated. RESULTS: From the NSAP cohort, 15,515 (5.8%) were later hospitalised with bowel pathology and 13,301 (5%) with a specific functional disorder. Notably, there was a 4.84 (95% CI 4.45 to 5.27) times greater risk of Crohn's disease following NSAP and a 4.23 (4.13 to 4.33) greater risk of acute appendicitis than in the control cohort. The risk of irritable bowel syndrome (IBS) was 7.22 (6.65 to 7.85) times greater following NSAP. The risks of inflammatory bowel disease (IBD), IBS and functional disorder (unspecified) were significantly increased in all age groups except <2-year-olds. The risk of underlying bowel pathology remained raised up to 10 years after first diagnosis with NSAP. CONCLUSIONS: Only a small proportion of those with NSAP go on to be hospitalised with underlying bowel pathology. However, their risk is increased even at 10 years after the first hospital admission with NSAP. Diagnostic strategies need to be assessed and refined and active surveillance employed for children with NSAP.

Management of a pregnancy complicated by type III spinal muscular atrophy.

The authors report the successful management of a pregnancy in a patient with spinal muscular atrophy (SMA) type III. It is a genetically inherited condition causing increasing weakness of the skeletal muscle. The patient in our case was confined to a wheelchair due to marked weakness in her lower limbs. A review of the available literature identified potential risk factors for the antenatal, intrapartum and postpartum period. These include increased risk of thromboembolism, urinary tract infections, intrauterine growth restriction and preterm delivery, anaesthetic problems and increased risk of uterine atony with subsequent postpartum haemorrhage. The authors report the management of these risk factors and the reasons for delivery by Caesarean section at 32 weeks. Apart from a decline in muscle function postdelivery requiring physiotherapy, there were no adverse outcomes for mother or baby. In both this case and on review of the literature, it is proven that a successful pregnancy is possible with SMA.

Outcome of childhood ulcerative colitis at 2 years.

AIM: Ulcerative Colitis (UC) has an incidence of 1.4 per 100,000 in childhood. There is a paucity of data regarding outcome particularly with the increased use of early immunosuppression. This study reviews outcome at 2 years in a cohort with UC referred to a single centre. METHOD: Patients were recruited on the basis of a diagnosis made between 2000 and 2003 as a consecutive cohort. All had UC according to standard clinicopathological criteria. Children with indeterminate colitis were excluded. Follow-up data was collected at 2 years by case notes review. RESULTS: Thirty-two children are reported. The median age at diagnosis was 11 years (range 2-16). All were treated with corticosteroids and 5-ASA derivatives at diagnosis. The majority of patients (94%, 30/32) received more than one course of steroids. By 2 years azathioprine use was high with 75% (24/32) of patients on treatment for steroid-dependent disease. There were 6 extra-intestinal manifestations and 8 disease related complications occurring in 12 patients (38%). The colectomy rate was 9% (3/32) for unresponsive disease. CONCLUSION: There is a high need for Azathioprine in childhood UC. Colectomy rate at 2 years was around 10%. Extra-intestinal manifestations and disease related complications are common.

Gantry angulation in brain CT: dosage implications, effect on posterior fossa artifacts, and current international practice.

The aim of this study was first to determine the effect of use of different scan planes at computed tomography (CT) of the brain on lens radiation dose and on severity of posterior fossa artifact. Twenty patients requiring nonenhanced and contrast material-enhanced brain CT scanning were selected. Each was scanned with two different beam angulations, one passing through the eyes and one avoiding them, and the resulting radiation doses were measured. Angling of the beam to avoid the orbit reduced the dose by 87%, while the severity of posterior fossa artifacts was not significantly different. Second, the implications of these results was assessed by means of an international questionnaire survey of current scanning technique. Only 32% of the respondents routinely avoided the eye during brain CT. No single scan plane was accepted by the respondents as being superior in terms of minimizing posterior fossa artifact. The authors conclude that the potential exists for a reduction in lens dose after reappraisal of radiologic practice in brain CT.

Platelet transfusion in the management of severe thrombocytopenia in neonatal intensive care unit patients.

Platelet transfusions are frequently given to neonatal intensive care unit (NICU) patients with severe thrombocytopenia (platelets less than 50 x 10(9) L(-1)) but no study has assessed whether this is clinically appropriate. To address this we conducted a retrospective review of platelet transfusion practice in patients developing severe thrombocytopenia over 3 years in a single NICU. Out of 901 admissions, 53 (6%) developed severe thrombocytopenia. Twenty-seven neonates received a total of 63 platelet transfusions, the main triggers being: platelet count less than 30 x 10(9) L(-1) (all patients), or less than 50 x 10(9) L(-1) in those with previous haemorrhage or clinical instability. No major haemorrhage occurred during severe thrombocytopenia either in neonates in whom platelet transfusions were withheld (26/53) or in neonates given platelets who survived to discharge (22/27). Five preterm neonates given platelets died but all had overwhelming sepsis or necrotizing enterocolitis and none died directly as a result of haemorrhage. Although the widely used liberal triggers for neonatal platelet transfusion highlighted in this review reflect available guidelines, and represent cautious ('safe') haemostatic practice, they are likely to result in unnecessary transfusion for a significant number of NICU patients. Improved practice requires definition of a safe lower limit for platelet count in stable neonates; effective platelet transfusion strategies for sick neonates; and improved therapies for conditions precipitating severe thrombocytopenia.