Adverse side effects and route of administration of opioids in combined spinal-epidural analgesia for labour: a meta-analysis of randomised trials.

BACKGROUND: Studies report an increased risk of maternal and fetal adverse side effects when combined spinal-epidural, rather than standard epidural, analgesia is provided for labour and delivery. Intrathecal opioids used with local anaesthetic in combined spinal-epidural analgesia may be a cause. It is not known whether this is due to the addition of opioid to local anaesthetic in the intrathecal space only or due to concomitant administration into the intrathecal and epidural spaces. METHODS: We searched for randomised trials comparing maternal, obstetrical and neonatal outcomes in parturients having combined spinal-epidural or standard epidural analgesia, and compared subgroups of patients according to the route of administration of opioids in combined spinal-epidural techniques. Studies were evaluated for eligibility and quality. Fixed and random-effects models were used for pooled data analysis and outcomes were compared using relative risk (RR) or mean difference with 95% confidence intervals (CI). RESULTS: We identified 1658 reports and 41 fully published randomised controlled trials. In patients who received combined spinal-epidural techniques, an increased risk of nausea/vomiting (RR 1.31, CI 1.0 to 1.72), pruritus (RR 4.26, CI 2.59 to 7.0) and fetal bradycardia (RR 2.38, CI 1.57 to 3.62) was observed regardless of the route of administration. In contrast, hypotension occurred more frequently after combined intrathecal and epidural opioid (RR 1.54, 1.22 to 1.93; P-value 0.02 for subgroup difference). CONCLUSION: For combined spinal-epidural techniques, the administration of opioids in combination with local anaesthetic, particularly when used in both the intrathecal and epidural space, should be carefully considered.

Barriers to reproductive health care for migrant women in Geneva: a qualitative study.

BACKGROUND: Migrant mothers in developed countries often experience more complicated pregnancy outcomes and less fewer women access preventive gynecology services. To enlighten health care providers to potential barriers, the objective of this paper is to explore barriers to reproductive health services in Geneva described by migrant women from a qualitative perspective. METHODS: In this qualitative study, thirteen focus groups (FG) involving 78 women aged 18 to 66 years were conducted in seven languages. All the FG discussions were audio-recorded and later transcribed. The data was classified, after which the main themes and sub-themes were manually extracted and analyzed. RESULTS: Barriers were classified either into structural or personal barriers aiming to describe factors influencing the accessibility of reproductive health services vs. those influencing client satisfaction. The five main themes that emerged were financial accessibility, language barriers, real or perceived discrimination, lack of information and embarrassment. CONCLUSION: Structural improvements which might meet the needs of the emergent extremely diverse population are the (1) provision of informative material that is easy to understand and available in multiple languages, (2) provision of sensitive cultural training including competence skill for all health professionals, (3) provision of specifically trained nurses or social assistance to guide migrants through the health system and (4) inclusion of monitoring and evaluation programs for the prevention of personal and systemic discrimination.

Validation of an emergency triage scale for obstetrics and gynaecology: a prospective study.

OBJECTIVE: To evaluate the reliability of a four-level triage scale for obstetrics and gynaecology emergencies and to explore the factors associated with an optimal triage. DESIGN: Thirty clinical vignettes presenting the most frequent indications for obstetrics and gynaecology emergency consultations were evaluated twice using a computerised simulator. SETTING: The study was performed at the emergency unit of obstetrics and gynaecology at the Geneva University Hospitals. SAMPLE: The vignettes were submitted to nurses and midwives. METHODS: We assessed inter- and intra-rater reliability and agreement using a two-way mixed-effects intra-class correlation (ICC). We also performed a generalised linear mixed model to evaluate factors associated triage correctness. MAIN OUTCOME MEASURES: Triage acuity. RESULTS: We obtained a total of 1191 evaluations. Inter-rater reliability was good (ICC 0.748; 95% CI 0.633-0.858) and intra-rater reliability was almost perfect (ICC 0.812; 95% CI 0.726-0.889). We observed a wide variability: the mean number of questions varied from 6.9 to 18.9 across individuals and from 8.4 to 16.9 across vignettes. Triage acuity was underestimated in 12.4% of cases and overestimated in 9.3%. Undertriage occurred less frequently for gynaecology compared with obstetric vignettes [odds ratio (OR) 0.45; 95% CI 0.23-0.91; P = 0.035] and decreased with the number of questions asked (OR 0.94; 95% CI 0.88-0.99; P = 0.047). Certification in obstetrics and gynaecology emergencies was an independent factor for the avoidance of undertriage (OR 0.35; 95% CI 0.17-0.70; P = 0.003). CONCLUSION: The four-level triage scale is a valid and reliable tool for the integrated emergency management of obstetrics and gynaecology patients. TWEETABLE ABSTRACT: The Swiss Emergency Triage Scale is a valid and reliable tool for obstetrics and gynaecology emergency triage.

Fasting glycaemia to simplify screening for gestational diabetes.

OBJECTIVE: Recommendations in Switzerland on screening for gestational diabetes endorse the International Association of Diabetes in Pregnancy Study Group consensus. As universal testing is time consuming and glucose loading is unpleasant, the recommendations include a simplification, not performing the glucose loading in women with fasting glycaemia <4.4 mmol/l. Our objective was to evaluate the diagnostic performance of this simplified strategy, compared with the complete test, in our population with a low prevalence of gestational diabetes. DESIGN: We collected 2298 complete 75-g glucose tolerance tests. We simulated stopping the test, so avoiding the glucose loading and further glycaemia, if fasting glycaemia was <4.4 or ≥5.1 mmol/l. SETTING AND POPULATION: Unselected pregnant women from Geneva and Basel, at 24-28 weeks of gestation. METHODS: We calculated the sensitivity, and the percentage of women who would avoid the complete test with the strategy based on fasting glycaemia. RESULTS: The prevalence of gestational diabetes was 10.9% in our population. Among 251 women with gestational diabetes, fasting glycaemia was ≥5.1 mmol/l in 119 women (47.4%), between 4.4 and <5.1 mmol/l in 78 women (31.1%) and <4.4 mmol/l in 54 women (21.5%). Proceeding with the complete test only in women with fasting glycaemia between 4.4 and <5.1 mmol/l will result in a sensitivity of 78.5%. This strategy would avoid glucose loading in 63.8% of women. CONCLUSIONS: Screening with fasting glycaemia is an attractive alternative to universal screening with the complete 75-g glucose tolerance test. This strategy is, however, slightly less sensitive than previously reported in higher-risk populations. TWEETABLE ABSTRACT: Fasting glycaemia can be considered as an alternative to the complete test for gestational diabetes screening.

Maternal positioning to correct occiput posterior fetal position during the first stage of labour: a randomised controlled trial.

OBJECTIVE: To evaluate the efficacy of the hands and knees position during the first stage of labour to facilitate the rotation of the fetal head to the occiput anterior position. DESIGN: Randomised controlled trial. SETTING: Geneva University Hospitals, Switzerland. POPULATION: A total of 439 women with a fetus in the occiput posterior position during the first stage of labour. METHODS: The women in the intervention group were invited to take a hands and knees position for at least for 10 minutes. Women allocated to the control group received the usual care. For both groups, 15 minutes after randomisation, women completed a short questionnaire to report their perceived pain and the comfort of their position. MAIN OUTCOME MEASURES: The rotation of the fetal head in occiput anterior position confirmed by ultrasonography 1 hour after randomisation. RESULTS: One hour after the randomisation, 35 of 203 (17%) fetuses were diagnosed as being in the occiput anterior position in the intervention group compared with 24 of 209 (12%) in the control group. This difference was not statistically significant (relative risk 1.50; 95% CI 0.93-2.43; P = 0.13). The change in the evaluation of comfort between the randomisation and 15 minutes after showed an improvement in 70 and 39 women, no change in 82 and 78 women and a decrease in 56 and 86 women in the intervention and control groups, respectively (P = 0.02). CONCLUSIONS: This study could not demonstrate a benefit of the hands and knees position to correct the occiput posterior position of the fetus during the first stage of labour, but the women reported an increase in their comfort level. TWEETABLE ABSTRACT: Hands and knees position does not facilitate rotation into occiput anterior but increases the comfort level of women.

[Prevention of preterm birth with vaginal progesterone in women with preterm labor: which are the evidences?]. / Progestérone par voie vaginale chez les femmes avec une menace d'accouchement prématuré: quelles évidences?

The presence of uterine contractions and a short cervix at less than 37 weeks of gestation (preterm labor) is an important risk factor for a preterm birth. Currently, there is not treatment able to reduce the risk of preterm birth in this high risk group of women. Vaginal progesterone has been shown to be effective in reducing the risk of preterm birth in asymptomatic women with a prior preterm birth and in women with a short cervix, measured by vaginal ultrasound before 24 weeks of gestation. Unfortunately, vaginal progesterone has not been shown to be efficacious in women with preterm labor. A recent clinical trial has shown that it can even be deleterious in this group of women.

[Atypical presentation of preeclampsia]. / Les présentations cliniques atypiques de la prééclampsie.

Preeclampsia is a pregnancy-related syndrome, which still represents one of the major causes of maternal-fetal mortality and morbidity. Diagnosis can be made difficult due to the complexity of the disorder and its wide spectrum of clinical manifestations. In order to provide an efficient diagnostic tool to the clinician, medical societies regularly rethink the definition criteria. However, there are still clinical presentations of preeclampsia that escape the frame of the definition. The present review will address atypical forms of preeclampsia, such as preeclampsia without proteinuria, normotensive preeclampsia, preeclampsia before 20 weeks of gestation and post-partum preeclampsia.

Prevention of preterm delivery with vaginal progesterone in women with preterm labour (4P): randomised double-blind placebo-controlled trial.

OBJECTIVE: To evaluate the effectiveness of 200 mg of daily vaginal natural progesterone to prevent preterm birth in women with preterm labour. DESIGN: Multicentre, randomised, double-blind, placebo-controlled trial. SETTING: Twenty-nine centres in Switzerland and Argentina. POPULATION: A total of 385 women with preterm labour (24(0/7) to 33(6/7) weeks of gestation) treated with acute tocolysis. METHODS: Participants were randomly allocated to either 200 mg daily of self-administered vaginal progesterone or placebo within 48 hours of starting acute tocolysis. MAIN OUTCOME MEASURES: Primary outcome was delivery before 37 weeks of gestation. Secondary outcomes were delivery before 32 and 34 weeks, adverse effects, duration of tocolysis, re-admissions for preterm labour, length of hospital stay, and neonatal morbidity and mortality. The study was ended prematurely based on results of the intermediate analysis. RESULTS: Preterm birth occurred in 42.5% of women in the progesterone group versus 35.5% in the placebo group (relative risk [RR] 1.2; 95% confidence interval [95% CI] 0.93-1.5). Delivery at <32 and <34 weeks did not differ between the two groups (12.9 versus 9.7%; [RR 1.3; 95% CI 0.7-2.5] and 19.7 versus 12.9% [RR 1.5; 95% CI 0.9-2.4], respectively). The duration of tocolysis, hospitalisation, and recurrence of preterm labour were comparable between groups. Neonatal morbidity occurred in 44 (22.8%) cases on progesterone versus 35 (18.8%) cases on placebo (RR: 1.2; 95% CI 0.82-1.8), whereas there were 4 (2%) neonatal deaths in each study group. CONCLUSION: There is no evidence that the daily administration of 200 mg vaginal progesterone decreases preterm birth or improves neonatal outcome in women with preterm labour.

[What's new in gynecology and obstetrics in 2012?]. / Gynécologie-obstétrique.

Intraoperative radiotherapy (IORT) has been shown to be as effective as traditional radiotherapy in the management of early stage breast cancer. IORT is performed in a single session and consists in a single irradiation in the tumorectomy cavity. Medically assisted procreation does not seem to favor neither gynecological nor non-gynecological cancers. Nevertheless medically assisted procreation technique ICSI (intracytoplasmic sperm injection) is associated with an increased risk of birth defect. This is not the case of IVF (in vitro fertilization). The causality of the treatment or of the infertility itself is unclear. During pregnancy, nicotine-replacement patches at usual dosage do not seem to increase abstinence smoking rates. A selective, and not a systematic thyroid screening strategy, is now recommended during first trimester of pregnancy.

[External cephalic version in case of persisting breech presentation at term: motivations and women's experience of the intervention]. / Version céphalique externe en cas de siège persistant à terme : motivations et vécu de l'intervention par les femmes.

OBJECTIVES: To evaluate the efficacy and acceptability of external cephalic version (ECV). MATERIALS AND METHOD: From 2004 to 2008, 212 pregnant women between 34-37 weeks of gestation with fetus in breech presentation were included in a randomized clinical trial and 125 externals cephalic versions were studied. RESULTS: A success rate of 37.6%t was recorded. At 34 weeks of gestation, 80.6% of women were considering an ECV in the event of persistent breech position at 37 weeks. These women expressed the desire to give birth vaginally (52% versus 24.4%, P<0.001). In contrast, others women preferred an elective cesarean section to avoid the risk of a breech vaginal delivery. Women felt pain during the ECV and scored 60 on average using the analogical visual scale. Women rated on a verbal rating scale the ECV as severely painful to unbearable (68%), and as stressful (70%). Despite this, the majority of women would recommend ECV to their friends or would be willing to repeat it for themselves. DISCUSSION AND CONCLUSION: ECV remains a scary and painful medical procedure. More research is needed to reduce the impact. The use of analgesic medication for this indication is controversial. Hypnosis could be an alternative to evaluate.

[What's new in gynecology and obstetrics]. / Gynécotogie et obstétrique.

Because of the lack of screening methods, ovarian cancer remains one of the major causes of mortality in gynecological oncology. Prevention by salpingectomy, based on a concept about the origin of serous carcinoma, may be proven effective in the future. Regarding cervical cancer, screening methods are improving and the benefit of HPV-HR testing has been recently demonstrated. Metabolic requirements and exercise are modified during pregnancy. Present recommendations are for pregnant women to practice regular moderate exercise, as in a non-pregnant population. This guideline, despite being reasonable, is not based on strong evidence. A randomised trial is ongoing in our Department to evaluate the effects of exercise in women with gestational diabetes.

Association between early preterm birth and periodontitis according to USA and European consensus definitions.

OBJECTIVE: Prospective case-control study assessing the association between maternal periodontitis according to the recently issued USA and European consensus definitions and early preterm delivery (<35 weeks gestation). Cases were women delivering between 22 and 34(6/7) weeks of gestation (n = 84) and controls were women delivering at term (≥ 37 weeks) (n = 345). METHODS: Periodontal examination at the immediate postpartum period identified periodontitis according to both consensus definitions. A multivariate logistic model was used to assess the association between early preterm delivery and the presence of periodontitis adjusted for confounders. RESULTS: All women had periodontitis by the European consensus definitions. When using the USA definitions, more cases had severe periodontitis than controls (34.5% vs. 17.72%); p = 0.003. After adjustment for main confounders, the association between severe (OR: 2.38; 95% CI: 1.36-4.14) periodontitis and early preterm delivery persisted. The only other independent factor associated with early preterm delivery was vaginal bleeding during pregnancy. CONCLUSIONS: Early preterm delivery is associated with periodontitis when the USA consensus definitions are used. The European definitions revealed inadequate for the study population because of the lack of discrimination power.

Overexpression of GRP78 in complete hydatidiform moles.

OBJECTIVE: Hydatidiform moles, subdivided into partial moles (PM) and complete moles (CM), are abnormal pregnancies with a disturbed invasive behavior. We had previously shown that MMP-2 and p53 proteins are overexpressed in CM versus PM, and that in primary cytotrophoblasts p53 protein is stabilized by complexing to the 78kDa glucose-regulated protein (GRP78) which is involved in cytotrophoblasts invasion process. The present study aims to compare the transcript expression profile of p53, MMP-2 and GRP78 in hydatidiform moles. METHODS: A retrospective study was performed by RT-qPCR and immunostaining on paraffin-embedded tissues of 19 PM, 16 CM and 16 control (CTRL) samples of gestational age 8-12 weeks. RESULTS: Expression of MMP-2 transcript was significantly overexpressed in CM compared to CTRL samples (p=0.031). In contrast, expression of p53 transcript was similar among the samples. This suggests a regulation of p53 in CM at the protein level. GRP78 cDNA was significantly overexpressed in CM compared to CTRL (p=0.021) and to PM (p=0.011). At the protein level, immunostaining of GRP78 was on average stronger in CM than PM samples. CONCLUSIONS: Collectively, present data suggest that in CM, p53 is normally expressed at the mRNA level but probably complexes at the protein level with the overexpressed GRP78, leading to accumulation of p53 protein. Moreover, since GRP78 and MMP-2 are increased in CM and known to play key roles in invasion, our results suggest that GRP78 and MMP-2 should be investigated as prognostic markers of hydatidiform moles.

Comparative analysis of secreted proteins from normal and preeclamptic trophoblastic cells using proteomic approaches.

Preeclampsia (PE) is a pathology of pregnancy which represents the main cause of maternal and perinatal morbidity and mortality. Defective placentation is the first event of this pathology. The purpose of this study was to identify the proteins secreted by cytotrophoblastic cells (CTB) using proteomic approach that are associated with PE. Comparison of secreted proteins by mass spectrometry allowed us to identify 21 proteins which were significantly differentially secreted by control and PE CTB. One protein has been detected exclusively in supernatant of control CTB and was identified as factor XIII chain A. To determine if this observation is due to a difference of protein secretion or gene expression, its mRNA was quantified in all CTB. We found that it was significantly decreased in PE CTB compared to control. Collectively, these data suggest that decrease of factor XIII chain A might be associated with development of PE.

OS014. Which first-line drug to control severe hypertension in pregnancy? A pilot study.

INTRODUCTION: Severe hypertension is a common complication in pregnancy-associated hypertensive disorders and there is no clear consensus on which first-line antihypertensive drug to use in this setting. OBJECTIVES: To determine the efficacy and safety of four antihypertensive drugs (two intravenous and two oral) in pregnant women with severe hypertension. METHODS: Pilot prospective randomised study. INCLUSION CRITERIA: pregnant women with a gestational age >24weeks and admitted in the Obstetrics Department with severe hypertension defined as systolic blood pressure (SBP) ⩾165mmHg and/or diastolic blood pressure (DBP) ⩾105mmHg. The women were randomised in 4 groups to receive:-20mg intravenous labetalol;-5mg intravenous hydralazine;-10mg oral nifedipine tablets ;-10mg sublingual nifedipine. Treatment was repeated every 20mn until target SBP and DBP were reached (⩽150/⩽95mmHg). The primary endpoint was the time needed to achieve effective blood pressure control. Treatment failure was defined as the unability to reach the target BP within one hour. RESULTS: After giving informed consent, 41 pregnant women admitted with severe hypertension were randomised. Mean age was 35 years (SD 3.5), 65% were nulliparous and mean SBP and DBP at admission were 176 (SD 16) and 105 (SD 12)mmHg, respectively. Success to achieve target BP was reached in all patients within the oral 10mg nifedipine group (11 patients), in all but one patients with the 10mg sublingual group (12 patients), and only in 5 out of 9 patients and 6 out of 9 patients within the labetalol and hydralazine groups. They were only one hypotension (defined as SBP <120mmHg) in the two groups with intravenous drugs and 3 and 5 in the oral and sublingual nifedipine groups. CONCLUSION: These results indicate that oral nifedipine seems more effective than intravenous labetalol or hydralazine to reach BP control in pregnant patients with severe hypertension. A large scale randomized trial comparing oral nifedipine versus these commonly used intravenous antihypertensive drugs should be implemented in order to determine whether oral nifedipine is a more effective treatment in this population.

OS108. Preeclamptic women display salt sensitivity and cardiovascular damage before their menopause.

INTRODUCTION: Salt sensitivity is an important cardiovascular risk factor. It has been shown that preeclamptic (PEC) women may not be totally cured after the delivery and keep a higher cardiovascular risk than nonPEC women. OBJECTIVES: We aimed to study the salt sensitivity of the blood pressure in women with a history of severe preeclamspia and women with no history of hypertensive complications.The design was a case control study with intervention, including 42 women recruited 5 to 17 years following delivery. METHODS: 21 women having suffered from a severe preeclampsia before 34 weeks of pregnancy and 19 age, race matched controls women,were randomized to follow for one week a low salt (LS) diet and a high salt (HS) diet (adding 6g NACL/d to usual diet). On day seven of each dietary period, 24h ambulatory blood pressure was recorded, and 24h urine collected in order to measure sodium excretion.Salt sensitivity was assigned if the mean 24h blood pressure increased by ⩾ 3mmHg on a high- compared with a low-salt diet. RESULTS: Preeclamptic women were aged 39.1(24-49) and controls 40.1(29-49), p=NS.Two of the PEC women already suffered from a cardiovascular event (2coronary events). The PEC women showed a significant increase of the BP and standard deviation (SD) of the BP compared to the controls.10 (47.6%) preeclamptic women showed salt sensitivity (odd ratio 5.4, 95% CI 0.972-30.601;P=0.042).Recurrent preeclampsia was associated with a significantly high risk to salt sensitivity status (OR 5; 95% confidence interval 1.1-31.6). CONCLUSION: Severe PEC women display already salt sensitivity of the blood pressure before their menopause and increased variability of the BP. Recurrent preeclampsia is a high risk factor for salt sensitivity and could allow to target this high-risk group at an early stage for preventive measures for cardiovascular disease.