Current Women's Health Reviews - Volume 2, Issue 3, 2006

An article of this issue is illustrative of research contribution in clinical practice. Progesterone has always been identified as a hormone involved in the initiation of labour due to its role in uterine quiescence, but concomitantly, its use in preventing premature labour was not completely ruled out. Randomised controlled trials have shown that its use can prevent preterm birth in women at risk. Still further research is needed to assess doses, formulations, population recipient, and long term effects before it can be widely recommended for use. Research in this issue is of relevance since preterm birth is a major problem and a challenge in obstetrical care. Another article shows a worrisome situation, that despite the advances in science, many interventions with proven benefit are not implemented in clinical practice and those proven to be of no benefit or deleterious are still used. This is also a major challenge and again, research is needed to search for interventions that could improve the implementation of the best evidences for care. The conjunction of clinical and social scientists is a desired partnership aiming at such interventions. Caution and research based interventions need to be the preference of those providing clinical care. Many external influences and exigencies have attracted the attention of clinicians but they must be cautious in implementing only those interventions which show benefit and lack of deleterious side effects. Moreover, one article of this issue discussed an upcoming unsolved issue in obstetrics i.e., the cord blood banking, which still needs a lot of evaluation and research before its implementation. This subject also has important economic implications and has paved the way for potential inequality in its use. A desired approach evidenced throughout the issue is the analysis in the context of differences related to income and health inequities. An article elucidating on this issue has analysed the use of vaccines during pregnancy under varying circumstances, highlighting that different approaches are needed. Health inequity is an unsolved issue and maternal death is the health indicator delineating the greatest differences between the poor and the rich populations. Regardless many efforts performed at global level, health inequities in provision and the associated results of care are far from improvement and still need consideration. Initiatives and articles focusing on health inequities are highly desirable, promoting the health research community to achieve desirable results.

Prematurity is a leading cause of neonatal morbidity and mortality, accounting for most part of the deaths of infants without congenital anomalies. Also, the cost of neonatal intensive care and long-term care for infants born preterm is enormous. The medical, psychological, and economic burdens of preterm births are very important. In spite of advances in obstetrical care, the rate of preterm delivery in industrialized countries (approximately 10%) has not decreased over the past 40 years. In fact, it has increased slightly, partly due to the use of assisted reproductive technologies and to the rise of indicated preterm deliveries for maternal or fetal reasons Progesterone (P) is the primary factor of uterine quiescence that permits the physical distension of the uterine muscle throughout pregnancy. In all species, except humans, a drop in P levels precedes labor, whereas P levels remain constant in humans until delivery. Yet the labor inducing properties of anti P products such as RU-486 have led to hypothesize a 'functional P withdrawal' prior to labor in humans. In spite of early trials suggesting a benefit with progesterone/ progestagens in preventing premature labor, the doubts in its efficacy, particularly linked to the very weak concentrations of exogenous administration compared to the high levels of endogenous P, have dissuaded its use in obstetrics for some years. Two recent studies, however, give a new momentum towards the use of progestagens for the prevention of premature delivery in a particular high-risk population: women with a prior preterm birth. Nevertheless, the use of progestagens in other populations at risk for preterm delivery should not be encouraged outside of clinical trials. In this review article we will discuss the indications for progesterone for prevention of preterm delivery, as well as the formulations to use.

An important component of quality of care is the use of evidence-based practices. Three studies from three different continents (Africa, Asia and Latin America) have reported the suboptimal use of evidence - based interventions in obstetric care, proving that despite scientific evidence and dissemination efforts, there are harmful and/or unnecessary procedures still used, while others that are beneficial are ignored. This illustrates the existing bridges and barriers between practice guidelines based on research findings and practitioners. A theoretical framework could help explain these barriers and possibly help target interventions to specific barriers. A review of existing literature shows that an intervention aimed to increase the use of evidence-based practices should have the following components: increase birth attendant concern about the effectiveness of routine clinical practices, stimulate their desire to review the effectiveness of their practice, provide them with skills to perform evidence based clinical guidelines appraisal and development and establish mechanisms through key hospital leaders to implement the guidelines and sustain them over time.

Cord blood is recognised as a rich source of haematopoietic stem and progenitor cells and its use has increased greatly in recent years. Since first cord blood transplantation was performed in Paris in 1988, knowledge of the biologic characteristics of umbilical cord blood has improved, and the benefits of using cord blood stem cells have become apparent. In fact, cord blood has showed to have several advantages as compared to bone marrow: easy availability, lower risk of infectious diseases transmission such as CMV and EBV and lower risk of graft versus host disease. However, cord blood units progenitors content is usually only sufficient for smaller recipients, usually children weighing less than 40 Kg. Gluckman et al showed grafting occurring in 85 percent of patients receiving 37 million or more nucleated cells per kilogram of body weight. In spite of this, use of cord blood in greater recipients is increasing and an effort to improve cord blood haematopoietic content is mandatory. In fact, the main limitation factor for the wide use of CB as a source of hematopoietic progenitor for transplantation is cell dose. Some of the specific areas identified by some studies for improvement of CB cell content are donor selection and CB collection. Implications of obstetricians in these issues are very important and necessary. We have evaluated cord blood donors selection criteria and two different modes of collection in order to optimise the cord blood banking proceedings and increase the quality of the CB units stored. We will review the results of our previous studies in these areas and the results of literature.

Newborns may suffer of severe infections and the best defense against pathogens is given by the passage of maternal antibodies through the placenta and later by breastfeeding. A greater amount of circulating antibodies in the mother is often related to a higher value in the blood of the child, thus maternal immunization could be a tool for preventing neonatal infections. Most trials were performed in developing countries, where the success of vaccinating pregnant women against tetanus led to the acceptance of maternal immunization. Thereafter, trials performed with different inactivated vaccines demonstrated the effectiveness of the intervention without showing important safety problems. In industrialized countries, only few trials were performed and no conclusive evidence of long term safety is available for most proposed vaccines. Even when safety and efficacy have been clearly demonstrated, like influenza vaccination, the coverage is low. Vaccination in pregnancy is a promising tool for the protection of both woman and child, but more data are needed before this practice can be widely accepted in all industrialized countries.

A comparison of outcome versus gestation at induction of labour (IOL) for post maturity in three groups:40,41and 42 weeks. Design: Retrospective study of all 703 IOLs for post maturity over three-years. The main outcome being measured was recourse to emergency Caesarean section (Em LSCS) mode of delivery. Groups were compared. Setting: A District General Hospital with 8754 deliveries over the study period. The overall IOL rate was 18.8. Result: Em LSCS rates break down as follows: 40th week; Primigravidae 25.7%, Multiparae 6.9%, Both 13.9% 41st week; Primigravidae 17.6%, Multiparae 6.4%, Both 10.6% 42nd week; Primigravidae 18.8%, Multiparae 11.3%, Both 15.2 No statistically significant benefit was demonstrated for either group at any gestation

Estrogen acts as agonist on the estrogen receptor. The effects of estrogen may be confounded by concomitant treatment with progestins. Postmenopausal hormone therapy (HT) can be divided into: postmenopausal estrogen therapy (ET - estrogen alone), and postmenopausal estrogen-progestin therapy (EPT - estrogen plus a progestin). EPT is associated with an increased risk of cardiovascular disease, cerebrovascular disease, and breast cancer. ET is not associated with a significant increase in any of these. Both EPT and ET are associated with an increase in venous thromboembolism. Both EPT and ET reduce the risk of vertebral and overall fracture risk. At present use of EPT or ET should be limited to short-term treatment of severe menopausal symptoms. This review discusses the effects and side effects of EPT and ET and potential ways of avoiding some of the side effects.

No current objective measures exist to determine uterine or cervical function during pregnancy, or to accurately predict term or preterm labor and delivery. Uterine electromyography (EMG) and cervical light-induced fluorescence (LIF) studies were performed in term and pre-term animals and humans to evaluate the state and function of the uterus and cervix, and to determine the predictive capability of measurements made using these new technologies. Both uterine EMG and cervical LIF produced high positive and negative predictive values, compared to other currently-used methods. Uterine EMG and cervical LIF show great promise as diagnostic tests during pregnancy and for patient monitoring in obstetrics.

1. Review the Incidence of Anesthesia-Related Maternal Mortality 2. Review Changes in Anesthesia for the Parturient over the Past 20 years 3. Review Suggested "Negative" Morbidity Associated with Epidural Labour Analgesia 4. Review the Evidence Pertaining to the Effect of Epidural Labour Analgesia on Cesarean and Instrumented Vaginal Delivery rates as well as Progress of Labour.

Lymphocytic choriomeningitis virus (LCMV), a rodent-borne arenavirus, has been causally associated with postnatal and in utero infection. Although the consequences of acquired LCMV infection are generally benign, primarily a flu-like illness and aseptic meningitis, encephalitis has been reported. Fatalities are however, rare. Congenital LCMV infection has been recognized in Europe and the United States, yet the syndrome is rarely considered and, therefore, remains under-diagnosed. Chorioretinitis and hydrocephalus have been noted in 90% of the affected infants. Blindness, mental retardation and seizures have been the most prominent sequelae in these children. Education of pregnant women regarding the risks rodents and their excreta pose is feasible and should be commenced without delay.