Publications by authors named "George Bugg"

25 Publications

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Breastfeeding Communities for Fatherhood: Laying the Groundwork for the Black Fatherhood, Brotherhood, and Manhood Movement.

Breastfeed Med 2021 Feb;16(2):121-123

Department of Industrial Engineering and Operations Research, University of California, Berkeley, California, USA.

The role fathers play in the lives of their children is, as any behavior, dependent on their knowledge of factors influencing the health and safety of children and the societal context in which those fathers live, work, and worship. In the context of maternal and child health, the role of supportive partners of the mother dramatically strengthens the ability of the mother to set and achieve appropriate early life goals for their child, including wise nutritional choices and infant safety. Reaching Our Brothers Everywhere (ROBE) developed in 2014 as an independently integrated program of Reaching Our Sisters Everywhere, Inc. (ROSE), with the mission of educating, equipping, and empowering men to assist in the ROSE effort of increasing breastfeeding initiation and duration rates, primarily in the Black community, by educating men of the numerous health, nutritional, social, and economic benefits of breastfeeding. Similarly, through education about the national Safe Sleep campaign, ROBE hopes to assist in the mitigation of infant mortality rates. Then, this article seeks to elucidate the modern Black Fatherhood Movement, in which ROBE observes and interacts, and to lay out axioms from the natural and social sciences that will allow us to achieve strengthened American family structures through transformative change, using the medium of Fatherhood work.
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http://dx.doi.org/10.1089/bfm.2020.0315DOI Listing
February 2021

The test accuracy of antenatal ultrasound definitions of fetal macrosomia to predict birth injury: A systematic review.

Eur J Obstet Gynecol Reprod Biol 2020 Mar 16;246:79-85. Epub 2020 Jan 16.

Division of Child Health, Obstetrics and Gynaecology, School of Medicine, University of Nottingham, United Kingdom.

Objectives: To determine which ultrasound measurement for predicted fetal macrosomia most accurately predicts adverse delivery and neonatal outcomes.

Study Design: Four biomedical databases searched for studies published after 1966. Randomised trials or observational studies of women with singleton pregnancies, resulting in a term birth who have undergone an index test of interest measured and recorded as predicted fetal macrosomia ≥28 weeks. Adverse outcomes of interest included shoulder dystocia, brachial plexus injury (BPI) and Caesarean section.

Results: Twenty-five observational studies (13,285 participants) were included. For BPI, the only significant positive association was found for Abdominal Circumference (AC) to Head Circumference (HC) difference > 50 mm (OR 7.2, 95 % CI 1.8-29). Shoulder dystocia was significantly associated with abdominal diameter (AD) minus biparietal diameter (BPD) ≥ 2.6 cm (OR 4.2, 95 % CI 2.3-7.5, PPV 11 %) and AC > 90th centile (OR 2.3, 95 % CI 1.3-4.0, PPV 8.6 %) and an estimated fetal weight (EFW) > 4000 g (OR 2.1 95 %CI 1.0-4.1, PPV 7.2 %).

Conclusions: Estimated fetal weight is the most widely used ultrasound marker to predict fetal macrosomia in the UK. This study suggests other markers have a higher positive predictive value for adverse outcomes associated with fetal macrosomia.
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http://dx.doi.org/10.1016/j.ejogrb.2020.01.019DOI Listing
March 2020

Observational study of cytomegalovirus from breast milk and necrotising enterocolitis.

Arch Dis Child Fetal Neonatal Ed 2019 Jul 20. Epub 2019 Jul 20.

Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA.

Objective: To evaluate the relationship between cytomegalovirus (CMV) exposure from breast milk and risk of necrotising enterocolitis (NEC).

Design: Secondary analysis of a multicentre, observational cohort study. Maternal breast milk and infant serum or urine were serially evaluated by nucleic acid testing at scheduled intervals for CMV. Infants with evidence of congenital infection were excluded. Competing-risks Cox models, with adjustment for confounders, were used to evaluate the relationship between breast milk CMV exposure or postnatal CMV infection and NEC.

Setting: Three neonatal intensive care units in Atlanta, Georgia.

Patients: Infants with a birth weight≤1500 grams.

Exposures: Maximal CMV viral load in breast milk in the first 14 days after birth or postnatal CMV infection. Two different approaches were used to assess the timing of onset of CMV infection (midpoint or early).

Main Outcome Measures: NEC, defined as Bell stage II or greater.

Results: Among 596 enrolled infants, 457 (77%) were born to CMV seropositive mothers and 33 developed postnatal CMV infection (cumulative incidence 7.3%, 95% CI 5.0% to 10.1%). The incidence of NEC was 18% (6/33) among infants with CMV infection, compared with 7% (37/563) among infants without infection (adjusted cause-specific HR (CSHR): 2.81; 95% CI 0.73 to 10.9 (midpoint); 6.02; 95% CI 1.28 to 28.4 (early)). Exposure to higher breast milk CMV viral load was associated with a higher risk of NEC (adjusted CSHR per twofold increase 1.28; 95% CI 1.06 to 1.54).

Conclusions: CMV exposure from breast milk may be associated with the development of NEC in very low birth weight infants.
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http://dx.doi.org/10.1136/archdischild-2018-316613DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7336338PMC
July 2019

Randomized Trial of Labor Induction in Women 35 Years of Age or Older.

N Engl J Med 2016 Mar;374(9):813-22

From the Division of Child Health, Obstetrics and Gynaecology, School of Clinical Sciences (K.F.W., M.M., C.M., J.G.T.), and Nottingham Clinical Trials Unit (L.B.), and the University of Nottingham, the Division of Obstetrics and Gynaecology, Nottingham University Hospitals NHS Trust (G.J.B., N.G.), Nottingham, Stillbirth and Neonatal Death Charity, London (C.W.), and the Department of Obstetrics and Gynaecology and National Institute for Health Research Biomedical Research Centre, Cambridge University, Cambridge (G.C.S.S.) - all in the United Kingdom.

Background: The risk of antepartum stillbirth at term is higher among women 35 years of age or older than among younger women. Labor induction may reduce the risk of stillbirth, but it also may increase the risk of cesarean delivery, which already is common in this older age group.

Methods: We conducted a randomized, controlled trial involving primigravid women who were 35 years of age or older. Women were randomly assigned to labor induction between 39 weeks 0 days and 39 weeks 6 days of gestation or to expectant management (i.e., waiting until the spontaneous onset of labor or until the development of a medical problem that mandated induction). The primary outcome was cesarean delivery. The trial was not designed or powered to assess the effects of labor induction on stillbirth.

Results: A total of 619 women underwent randomization. In an intention-to-treat analysis, there were no significant between-group differences in the percentage of women who underwent a cesarean section (98 of 304 women in the induction group [32%] and 103 of 314 women in the expectant-management group [33%]; relative risk, 0.99; 95% confidence interval [CI], 0.87 to 1.14) or in the percentage of women who had a vaginal delivery with the use of forceps or vacuum (115 of 304 women [38%] and 104 of 314 women [33%], respectively; relative risk, 1.30; 95% CI, 0.96 to 1.77). There were no maternal or infant deaths and no significant between-group differences in the women's experience of childbirth or in the frequency of adverse maternal or neonatal outcomes.

Conclusions: Among women of advanced maternal age, induction of labor at 39 weeks of gestation, as compared with expectant management, had no significant effect on the rate of cesarean section and no adverse short-term effects on maternal or neonatal outcomes. (Funded by the Research for Patient Benefit Programme of the National Institute for Health Research; Current Controlled Trials number, ISRCTN11517275.).
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http://dx.doi.org/10.1056/NEJMoa1509117DOI Listing
March 2016

Causes of antepartum stillbirth in women of advanced maternal age.

Eur J Obstet Gynecol Reprod Biol 2016 Feb 30;197:86-90. Epub 2015 Nov 30.

Maternity Department, Nottingham City Hospital, Nottingham University Hospitals NHS Trust, Nottingham NG5 1PB, UK.

Objectives: To breakdown the causes of antepartum stillbirth by maternal age.

Study Design: Observational study.

Setting: UK.

Sample: Anonymised national data on 2850 cases of antepartum stillbirth in 2009.

Statistical Analysis: The association between cause of stillbirth and maternal age was examined using an adjusted multinomial logistic regression model. Risk ratios were calculated relative to stillbirth due to haemorrhage.

Main Outcome Measures: Antepartum stillbirths classified by the Centre for Maternal and Child Enquiries (CMACE) classification.

Results: Stillbirths in women aged 35 years and over are more likely to be due to major congenital anomalies (relative risk ratio (RRR) 2.0, 95% CI 1.3-3.0), mechanical causes (RRR 1.6, 95% CI 1.0-2.6), maternal disorders (RRR 2.1, 95% CI 1.2-3.6) or associated obstetric factors (RRR 2.1, 95% CI 1.1-3.9) than women less than 35. Women aged 35 years and over have a statistically significant increased risk of stillbirth due to major congenital anomalies (OR relative to live birth 1.6, 95% CI 1.3-1.9) and maternal disorders (OR 1.7, 95% CI 1.2-2.4) than younger women. Women aged 35 years and over were 30% more likely to experience a term stillbirth than women <35 years (OR 1.3, 95% CI 1.1-1.5). Stillbirth due to congenital anomaly was statistically significantly more likely in women ≥ 35 years.

Conclusions: Advanced maternal age is a significant risk factor for antepartum stillbirth particularly at term. Attention should be given to stillbirth due to mechanical causes, maternal disorders and associated obstetric factors in such women.
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http://dx.doi.org/10.1016/j.ejogrb.2015.11.032DOI Listing
February 2016

Childbirth experience questionnaire: validating its use in the United Kingdom.

BMC Pregnancy Childbirth 2015 Apr 7;15:86. Epub 2015 Apr 7.

Division of Obstetrics and Gynaecology, University of Nottingham, Maternity Department, Nottingham City Hospital, Nottingham, NG5 1 PB, UK.

Background: The Childbirth Experience Questionnaire (CEQ) was developed in Sweden in 2010 and validated in 920 primiparous women. It has not been validated in the United Kingdom (UK). Measuring the impact of an intervention on a woman's childbirth experience is arguably as important as measuring its impact on outcomes such as caesarean delivery and perinatal morbidity or mortality and yet surprisingly it is rarely done. The lack of a robust validated tool for evaluating labour experience in the UK is a topical issue in the UK at present. Indeed NICE say 'A standardised method to measure and quantify women's psychological and emotional wellbeing and their birth experiences is urgently required to support any study investigating the effectiveness of interventions, techniques or strategies during birth.'

Methods: The Childbirth Experience Questionnaire and part of the Care Quality Commission Maternity Survey (2010) was sent to 350 women at one month postnatal. The CEQ was sent again two weeks later. The CEQ was tested for face validity among 25 postnatal mothers. Demographic data and delivery data was used to establish construct validity of the CEQ using the method of known-groups validation. The results of the scored CEQ sent out twice were used to measure test-retest reliability of the CEQ by calculating the quadratic weighted index of agreement between the two scores. Criterion validity was measured by calculating the Pearson correlation coefficient for the CEQ and Maternity Survey scores.

Results: Face validity of the CEQ in a UK population was demonstrated with all respondents stating it was easy to understand and complete. A statistically significantly higher CEQ score for subgroups of women known to report a better birth outcome demonstrated construct validity of the CEQ. A weighted kappa of 0.68 demonstrated test-retest reliability of the CEQ. A Pearson correlation co-efficient of 0.73 demonstrated a strong correlation between the results of the CEQ and the results of the 'gold standard' assessment of childbirth experience in the UK: the Maternity Survey and hence criterion validity of the CEQ.

Conclusions: The Childbirth Experience Questionnaire is a valid and reliable measure of childbirth experience in the UK population.
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http://dx.doi.org/10.1186/s12884-015-0513-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4396591PMC
April 2015

Evolving understanding and treatment of labour dystocia.

Eur J Obstet Gynecol Reprod Biol 2014 Nov 16;182:123-7. Epub 2014 Sep 16.

Nottingham University Hospitals, United Kingdom.

The objective of the review is to critically review the diagnosis and management of dystocia in the first stage of labour. We conducted a narrative review of research since 1998. Eight studies were identified, four about the onset and duration of active phase of the first stage of labour, one on the diagnosis of dystocia, and three focused on the treatment of dystocia. The review demonstrates that current understandings of dystocia rest on outdated definitions of active first stage of labour, its progress and on treatments with an equivocal evidence base. These include the cervical dilatation threshold for active first stage, uncertainty over whether a reduced rate of dilatation and reduced strength of uterine contractions always represent pathology and the effectiveness of amniotomy/oxytocin for treating dystocia. Prospective studies should evaluate the impact of defining the active phase of the first stage of labour as commencing at 6 cm dilated and should test this definition in combination with Zhang's revised partogram.
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http://dx.doi.org/10.1016/j.ejogrb.2014.09.011DOI Listing
November 2014

Midwives' beliefs and concerns about telephone conversations with women in early labour.

Midwifery 2014 Sep 11;30(9):1036-42. Epub 2013 Nov 11.

Nottingham University Hospitals NHS Trust, UK. Electronic address:

Objective: to explore midwives' concerns, experiences and perceptions of the purpose of telephone contacts with women in early labour.

Design: a qualitative design based on interpretive phenomenology.

Setting: two Maternity Units in the Midlands of England.

Participants: three focus groups of labour ward midwife coordinators and labour ward midwives and nine in-depth interviews of midwives, obstetricians and labour ward receptionists.

Findings: the principal finding was that midwives are trying to reconcile gatekeeping of labour wards with individual support for women and these two aspects are often in conflict. Women experiencing prolonged or painful early labour often expect to be admitted to labour wards whereas midwives operate from a belief that women should only be accepted onto labour ward in active labour. They hold this view because labour wards are busy places and being admitted early contributes to unnecessary medical intervention.

Key Conclusions: because midwives are trying to reconcile the two conflicting priorities of responding to women's needs and protecting the labour ward from inappropriate admissions, the potential always exists for women's needs to be 'not heard' or marginalised.

Implications For Practice: the primary recommendation is that early labour telephone triage should be a discrete service, staffed by midwives who have been trained for this service, working independently of labour ward workloads.
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http://dx.doi.org/10.1016/j.midw.2013.10.025DOI Listing
September 2014

Reaching Our Sisters Everywhere.

Breastfeed Med 2013 Oct;8(5):453

1 CEO and Change Leader, Reaching Our Sisters Everywhere, Inc., Lithonia, Georgia .

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http://dx.doi.org/10.1089/bfm.2013.0098DOI Listing
October 2013

Maternal smoking during pregnancy and fetal organ growth: a magnetic resonance imaging study.

PLoS One 2013 3;8(7):e67223. Epub 2013 Jul 3.

Sir Peter Mansfield Magnetic Resonance Centre, University of Nottingham, Nottingham, Nottinghamshire, United Kingdom.

Objective: To study whether maternal cigarette smoking during pregnancy is associated with alterations in the growth of fetal lungs, kidneys, liver, brain, and placenta.

Design: A case-control study, with operators performing the image analysis blinded.

Setting: Study performed on a research-dedicated magnetic resonance imaging (MRI) scanner (1.5 T) with participants recruited from a large teaching hospital in the United Kingdom.

Participants: A total of 26 pregnant women (13 current smokers, 13 non smokers) were recruited; 18 women (10 current smokers, 8 nonsmokers) returned for the second scan later in their pregnancy.

Methods: Each fetus was scanned with MRI at 22-27 weeks and 33-38 weeks gestational age (GA).

Main Outcome Measures: Images obtained with MRI were used to measure volumes of the fetal brain, kidneys, lungs, liver and overall fetal size, as well as placental volumes.

Results: Exposed fetuses showed lower brain volumes, kidney volumes, and total fetal volumes, with this effect being greater at visit 2 than at visit 1 for brain and kidney volumes, and greater at visit 1 than at visit 2 for total fetal volume. Exposed fetuses also demonstrated lower lung volume and placental volume, and this effect was similar at both visits. No difference was found between the exposed and nonexposed fetuses with regards to liver volume.

Conclusion: Magnetic resonance imaging has been used to show that maternal smoking is associated with reduced growth of fetal brain, lung and kidney; this effect persists even when the volumes are corrected for maternal education, gestational age, and fetal sex. As expected, the fetuses exposed to maternal smoking are smaller in size. Similarly, placental volumes are smaller in smoking versus nonsmoking pregnant women.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0067223PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3700970PMC
February 2014

Oxytocin versus no treatment or delayed treatment for slow progress in the first stage of spontaneous labour.

Cochrane Database Syst Rev 2013 Jun 23(6):CD007123. Epub 2013 Jun 23.

Department of Obstetrics and Gynaecology, Nottingham University Hospitals NHS Trust, Nottingham,

Background: Slow progress in the first stage of spontaneous labour is associated with an increased caesarean section rate and fetal and maternal morbidity. Oxytocin has long been advocated as a treatment for slow progress in labour but it is unclear to what extent it improves the outcomes for that labour and whether it actually reduces the caesarean section rate or maternal and fetal morbidity. This review will address the use of oxytocin and whether it improves the outcomes for women who are progressing slowly in labour compared to situations where it is not used or where its administration is delayed.

Objectives: To determine if the use of oxytocin for the treatment of slow progress in the first stage of spontaneous labour is associated with a reduction in the incidence of caesarean sections, or maternal and fetal morbidity compared to situations where it is not used or where its administration is delayed.

Search Methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (23 February 2013) and bibliographies of relevant papers.

Selection Criteria: Randomised controlled trials which compared oxytocin with either placebo, no treatment or delayed oxytocin in the active stage of spontaneous labour in low-risk women at term.

Data Collection And Analysis: Two authors independently assessed studies for inclusion, assessed risk of bias and extracted data. We sought additional information from trial authors.

Main Results: We included eight studies in the review involving a total of 1338 low-risk women in the first stage of spontaneous labour at term. Two comparisons were made; 1) the use of oxytocin versus placebo or no treatment (three trials); 2) the early use of oxytocin versus its delayed use (five trials). There were no significant differences in the rates of caesarean section or instrumental vaginal delivery in either comparison. Early use of oxytocin resulted in an increase in uterine hyperstimulation associated with fetal heart changes. However, the early use of oxytocin versus its delayed use resulted in no significant differences in a range of neonatal and maternal outcomes. Use of early oxytocin resulted in a statistically significant reduction in the mean duration in labour of approximately two hours but did not increase the normal delivery rate. There was significant heterogeneity for this analysis and we carried out a random-effects meta-analysis; however, all of the trials are strongly in the same direction so it is reasonable to conclude that this is the true effect. We also performed a random-effects meta-analysis for the four other analyses which showed substantial heterogeneity in the review.

Authors' Conclusions: For women making slow progress in spontaneous labour, treatment with oxytocin as compared with no treatment or delayed oxytocin treatment did not result in any discernable difference in the number of caesarean sections performed. In addition there were no detectable adverse effects for mother or baby. The use of oxytocin was associated with a reduction in the time to delivery of approximately two hours which might be important to some women. However, if the primary goal of this treatment is to reduce caesarean section rates, then doctors and midwives may have to look for alternative options.
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http://dx.doi.org/10.1002/14651858.CD007123.pub3DOI Listing
June 2013

Multi-centre observational study of transplacental transmission of influenza antibodies following vaccination with AS03(A)-adjuvanted H1N1 2009 vaccine.

PLoS One 2013 23;8(1):e47448. Epub 2013 Jan 23.

Division of Epidemiology and Public Health, School of Community Health Sciences, University of Nottingham, Clinical Sciences Building, City Hospital, Nottingham, United Kingdom.

Introduction: Illness and death from influenza increase during pregnancy. In the United Kingdom pregnant women were targeted in a national programme for vaccination during the H1N1 2009-10 pandemic.

Methods: In this study, pregnant women were recruited in labour from November 9, 2009 to March 10, 2010. Pandemic vaccination status was determined. Venous cord blood collected at delivery was evaluated for transplacental transfer of antibodies by measurement of haemagglutination inhibition and microneutralization titres.

Results: Samples were collected from 77 vaccinated and 27 unvaccinated women. Seroprotection (HI titre ≥1:40) was detected in 58 (75.3%, 95% CI 64.2-84.4) cord blood samples from vaccinated women and 5 (18.5%, 95% CI 6.3-38.1) from unvaccinated women (P<0.0001). There was evidence of transplacental seroprotection 8 days after maternal immunization (77.9%, 95 CI 66.2-87.1), maintained in most cases for at least 16 weeks.

Discussion: Immunization of pregnant women with AS03(A)-adjuvanted vaccine is followed by transplacental transfer of passive immunity at titres consistent with clinical protection in three-quarters of new-born infants. The findings support national and international pandemic H1N1 2009 recommendations for immunization during pregnancy.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0047448PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3553100PMC
July 2013

Induction of labour versus expectant management for nulliparous women over 35 years of age: a multi-centre prospective, randomised controlled trial.

BMC Pregnancy Childbirth 2012 Dec 11;12:145. Epub 2012 Dec 11.

Nottingham University Hospitals NHS Trust, Nottingham, UK.

Background: British women are increasingly delaying childbirth. The proportion giving birth over the age of 35 rose from 12% in 1996 to 20% in 2006. Women over this age are at a higher risk of perinatal death, and antepartum stillbirth accounts for 61% of all such deaths. Women over 40 years old have a similar stillbirth risk at 39 weeks as women who are between 25 and 29 years old have at 41 weeks.Many obstetricians respond to this by suggesting labour induction at term to forestall some of the risk. In a national survey of obstetricians 37% already induce women aged 40-44 years. A substantial minority of parents support such a policy, but others do not on the grounds that it might increase the risk of Caesarean section. However trials of induction in other high-risk scenarios have not shown any increase in Caesarean sections, rather the reverse. If induction for women over 35 did not increase Caesareans, or even reduced them, it would plausibly improve perinatal outcome and be an acceptable intervention. We therefore plan to perform a trial to test the effect of such an induction policy on Caesarean section rates.This trial is funded by the NHS Research for Patient Benefit (RfPB) Programme.

Design: The 35/39 trial is a multi-centre, prospective, randomised controlled trial. It is being run in twenty UK centres and we aim to recruit 630 nulliparous women (315 per group) aged over 35 years of age, over two years. Women will be randomly allocated to one of two groups: Induction of labour between 39⁰/⁷ and 39⁶/⁷ weeks gestation. Expectant management i.e. awaiting spontaneous onset of labour unless a situation develops necessitating either induction of labour or Caesarean Section.The primary purpose of this trial is to establish what effect a policy of induction of labour at 39 weeks for nulliparous women of advanced maternal age has on the rate of Caesarean section deliveries. The secondary aim is to act as a pilot study for a trial to answer the question, does induction of labour in this group of women improve perinatal outcomes? Randomisation will occur at 36⁰/⁷-39⁶/⁷ weeks gestation via a computerised randomisation programme at the Clinical Trials Unit, University of Nottingham. There will be no blinding to treatment allocation.

Discussion: The 35/39 trial is powered to detect an effect of induction of labour on the risk of caesarean section, it is underpowered to determine whether it improves perinatal outcome. The current study will also act as a pilot for a larger study to address this question.

Trial Registration: ISRCTN11517275.
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http://dx.doi.org/10.1186/1471-2393-12-145DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3560256PMC
December 2012

Induction of labour at term for women over 35 years old: a survey of the views of women and obstetricians.

Eur J Obstet Gynecol Reprod Biol 2012 Jun 15;162(2):144-8. Epub 2012 Mar 15.

Department of Obstetrics and Gynaecology, School of Clinical Sciences, University of Nottingham, Nottingham, UK.

Objectives: To determine the views of UK women and obstetricians relating to induction of labour at term for women over 35 years of age.

Study Design: Cross-sectional web-based survey sent to members of the British Maternal and Fetal Medicine Society (BMFMS) and pregnant or recently delivered members of a large social network site for parents (www.mumsnet.com). One hundred and twenty-eight consultant obstetrician members of BMFMS and 663 pregnant or recently delivered women responded.

Results: Two hundred and eighty-eight women (43%) would consider induction of labour for maternal age alone, and 192 women (29%) would consider participating in a randomised trial of induction of labour at term versus expectant management in a future pregnancy. Three percent (n=4) of consultant obstetricians offer induction of labour at term to women at 35-39 years of age, 37% (n=47) to women at 40-44 years of age and 55% (n=70) to those over 45 years. Sixty-one consultants (48%) would participate in a trial to test the effect of a policy of induction for nulliparous women over 35 years old.

Conclusions: The policy of offering induction of labour at term for advanced maternal age is widespread and a significant percentage of women consider it to be a valid indication.
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http://dx.doi.org/10.1016/j.ejogrb.2012.02.016DOI Listing
June 2012

Would gestational age and presence of brain anomalies affect interobserver reliability of fetal head biometry? Using off-line analysis of 3-D dataset.

Ultrasound Med Biol 2012 Jan 21;38(1):69-74. Epub 2011 Nov 21.

Fetal and Maternal Medicine Department, Nottingham University Hospitals NHS Trust, Nottingham, UK.

The objective was to assess interobserver reliability of fetal head biometry using archived three-dimensional (3-D) volumes and the impact of gestational age and presence of brain anomalies on examiners' performance. Seventy nine 3-D volume datasets of fetal head were examined: 27 were normal and 52 had brain abnormalities. Off-line analysis was done by three fetal medicine experts (E1, E2 and E2), all were blinded to history and patient details. Measurements of the biparietal diameter (BPD), head circumference (HC), lateral ventricle (Vp) and transcerebellar diameter (TCD) were compared between examiners and to two-dimensional (2-D) measurements. Comparisons were made at two gestational age groups (≤22 and >22 weeks) and in presence and absence of brain anomalies. The intraclass coefficient showed a significantly high level of measurement agreement between 3-D examiners and 2-D, with values >0.9 throughout (p < 0.001). Bias was evident between 3-D examiners. E2 produced smaller measurements. The mean percentage difference between this examiner and the other two in BPD, HC, Vp and TCD measurements was significant, of 1.6%, 1%, 4.9% and 1.8%, respectively. E1 measured statistically larger for HC and TCD. E3 measured significantly larger for only BPD. The presence of anomalies was of no influence on the 3-D examiners' performance except for E3 who showed bias in BPD measurements only in cases with brain anomalies. Unlike other examiners, bias of E2 was only seen at gestational age group ≤22 weeks. Limits of agreement in measurements between observers were narrow for all parameters but were widest for the Vp measurements, being ±23% of the mean difference. Despite the above bias, the actual mean difference between examiners was small and unlikely to be of any clinical significance. Off-line measurement of fetal head biometry using 3-D volumes is reliable. In our study, presence of brain anomalies was unlikely to influence the reproducibility of measurements. Gestational age seemed to be of an impact on examiners' bias. Among experts this bias may be of no clinical significance.
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http://dx.doi.org/10.1016/j.ultrasmedbio.2011.10.016DOI Listing
January 2012

Oxytocin versus no treatment or delayed treatment for slow progress in the first stage of spontaneous labour.

Cochrane Database Syst Rev 2011 Jul 6(7):CD007123. Epub 2011 Jul 6.

Department of Obstetrics and Gynaecology, Nottingham University Hospitals NHS Trust, Queen's Medical Centre Campus, Derby Road, Nottingham, UK, NG12 4AA.

Background: Slow progress in the first stage of spontaneous labour is associated with an increased caesarean section rate and fetal and maternal morbidity. Oxytocin has long been advocated as a treatment for slow progress in labour but it is unclear to what extent it improves the outcomes for that labour and whether it actually reduces the caesarean section rate or maternal and fetal morbidity. This review will address the use of oxytocin and whether it improves the outcomes for women who are progressing slowly in labour compared to situations where it is not used or where its administration is delayed.

Objectives: To determine if the use of oxytocin for the treatment of slow progress in the first stage of spontaneous labour is associated with a reduction in the incidence of caesarean sections, or maternal and fetal morbidity compared to situations where it is not used or where its administration is delayed.

Search Strategy: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 April 2011) and bibliographies of relevant papers.

Selection Criteria: Randomised controlled trials which compared oxytocin with either placebo, no treatment or delayed oxytocin in the active stage of spontaneous labour in low-risk women at term.

Data Collection And Analysis: Two authors independently assessed studies for inclusion, assessed risk of bias and extracted data. We sought additional information from trial authors.

Main Results: We included eight studies in the review involving a total of 1338 low-risk women in the first stage of spontaneous labour at term. Two comparisons were made; 1) the use of oxytocin versus placebo or no treatment (three trials); 2) the early use of oxytocin versus its delayed use (five trials). There were no significant differences in the rates of caesarean section or instrumental vaginal delivery in either comparison. Early use of oxytocin resulted in an increase in uterine hyperstimulation associated with fetal heart changes. However, the early use of oxytocin versus its delayed use resulted in no significant differences in a range of neonatal and maternal outcomes. Use of early oxytocin resulted in a statistically significant reduction in the mean duration in labour of approximately two hours but did not increase the normal delivery rate. There was significant heterogeneity for this analysis and we carried out a random-effects meta-analysis; however, all of the trials are strongly in the same direction so it is reasonable to conclude that this is the true effect. We also performed a random-effects meta-analysis for the four other analyses which showed substantial heterogeneity in the review.

Authors' Conclusions: For women making slow progress in spontaneous labour, treatment with oxytocin as compared with no treatment or delayed oxytocin treatment did not result in any discernable difference in the number of caesarean sections performed. In addition there were no detectable adverse effects for mother or baby. The use of oxytocin was associated with a reduction in the time to delivery of approximately two hours which might be important to some women. However, if the primary goal of this treatment is to reduce caesarean section rates, then doctors and midwives may have to look for alternative options.
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http://dx.doi.org/10.1002/14651858.CD007123.pub2DOI Listing
July 2011

Placental 3-D power Doppler angiography--regional variation and reliability of two ultrasonic sphere biopsy techniques.

Ultrasound Med Biol 2011 Mar 26;37(3):364-75. Epub 2011 Jan 26.

Nottingham University Hospitals NHS Trust, Queen's Medical Centre Campus, Nottingham, United Kingdom.

Three-dimensional power Doppler angiography and 4D View allows quantification of placental "vascularity" using sonobiopsy or manual tracing. We used two vascular "biopsy" techniques: nontargeted sphere placement and systematic uniform random sphere placement (SURS). We hypothesised that random application of spheres would result in less reliability and the basal zone would display higher values than the chorionic zone. Forty women between 18+6 to 21+6 weeks gestation were recruited. A single volume of the placenta was acquired. Data was analysed twice by a single observer. Significantly higher values were seen for all vascular indices in the basal zone. Reliability was greatest for the whole placental technique with intraclass correlation coefficients of 0.9 and limits of agreement for flow index (FI) of -3.81 to 2.50 (equivalent to -7.8% to 5.1%) compared with 0.6 and -13.2 to 18.3 (-64.6% to 78.2%) for the nontargeted sphere technique. Whole placental values are more reliable than biopsy techniques with significantly different results seen with each technique.
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http://dx.doi.org/10.1016/j.ultrasmedbio.2010.12.008DOI Listing
March 2011

Evaluating the intra- and interobserver reliability of three-dimensional ultrasound and power Doppler angiography (3D-PDA) for assessment of placental volume and vascularity in the second trimester of pregnancy.

Ultrasound Med Biol 2011 Mar 21;37(3):376-85. Epub 2011 Jan 21.

Nottingham University Hospitals NHS Trust, Queen's Medical Centre Campus, Nottingham, United Kingdom.

Three-dimensional (3-D) power Doppler angiography (3-D-PDA) allows visualisation of Doppler signals within the placenta and their quantification is possible by the generation of vascular indices by the 4-D View software programme. This study aimed to investigate intra- and interobserver reproducibility of 3-D-PDA analysis of stored datasets at varying gestations with the ultimate goal being to develop a tool for predicting placental dysfunction. Women with an uncomplicated, viable singleton pregnancy were scanned at 12, 16 or 20 weeks gestational age groups. 3-D-PDA datasets acquired of the whole placenta were analysed using the VOCAL software processing tool. Each volume was analysed by three observers twice in the A plane. Intra- and interobserver reliability was assessed by intraclass correlation coefficients (ICCs) and Bland Altman plots. At each gestational age group, 20 low risk women were scanned resulting in 60 datasets in total. The ICC demonstrated a high level of measurement reliability at each gestation with intraobserver values >0.90 and interobserver values of >0.6 for the vascular indices. Bland Altman plots also showed high levels of agreement. Systematic bias was seen at 20 weeks in the vascular indices obtained by different observers. This study demonstrates that 3-D-PDA data can be measured reliably by different observers from stored datasets up to 18 weeks gestation. Measurements become less reliable as gestation advances with bias between observers evident at 20 weeks.
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http://dx.doi.org/10.1016/j.ultrasmedbio.2010.11.018DOI Listing
March 2011

Evaluation of the intraobserver and interobserver reliability of data acquisition for three-dimensional power Doppler angiography of the whole placenta at 12 weeks gestation.

Ultrasound Med Biol 2010 Sep;36(9):1405-11

Nottingham University Hospitals NHS Trust, Queen's Medical Centre Campus Nottingham, UK.

The aim of this study was to investigate the intra- and interobserver reproducibility of three-dimensional (3-D) power Doppler (3-DPD) data acquisition from women at 12 weeks gestation, which were then subsequently measured by a single observer. Women with an uncomplicated, viable singleton pregnancy were scanned between 12 + 0 and 13 + 6 weeks gestations with a Voluson 730 Expert. 3-DPD data were acquired of the whole placenta by two observers: the first observer captured two datasets and the second a single dataset. Each dataset was analysed using VOCAL in the A plane with 9 degree rotation steps. Eighteen low risk women were recruited with a total of 54 datasets analysed. The intraclass correlation coefficient (ICC) was highest for the vascular indices vascularisation index (VI) and vascularisation-flow index (VFI), greater than 0.75. ICC for flow index (FI) showed moderate correlation at 0.47 to 0.65. Bland Altman plots showed the most precise vascular index to be the FI (-15% to 10% for interobserver agreement). There was no bias between datasets. Prospective studies are now required to identify if this analysis tool and method is sensitive enough to recognise patients with early-onset placental dysfunction.
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http://dx.doi.org/10.1016/j.ultrasmedbio.2010.05.023DOI Listing
September 2010

Interpregnancy primary care and social support for African-American women at risk for recurrent very-low-birthweight delivery: a pilot evaluation.

Matern Child Health J 2008 Jul 22;12(4):461-8. Epub 2007 Aug 22.

Department of Family & Preventive Medicine, Emory University School of Medicine, 735 Gatewood Road NE, Atlanta, GA, 30322, USA.

Objectives: Very-low-birthweight (VLBW) delivery accounts for the majority of neonatal mortality and the black-white disparity in infant mortality. The risk of recurrent VLBW is highest for African-Americans of lower socioeconomic status. This study explores whether the provision of primary health care and social support following a VLBW delivery improves subsequent child spacing and pregnancy outcomes for low-income, African-American women.

Methods: This pilot study of mixed prospective-retrospective cohort design enrolled African-American women who qualified for indigent care and delivered a VLBW infant at a public hospital in Atlanta from November 2003 through March 2004 into the intervention cohort (n (1) = 29). The intervention consisted of coordinated primary health care and social support for 24 months following the VLBW delivery. A retrospective cohort was assembled from consecutive women meeting the same eligibility criteria who delivered a VLBW infant during July 2001 through June 2002 (n (2) = 58). The number of pregnancies conceived within 18 months of the index VLBW delivery and the number of adverse pregnancy outcomes for each cohort was compared with Poisson regression.

Results: Women in the control cohort had, on average, 2.6 (95% CI: 1.1-5.8) times as many pregnancies within 18 months of the index VLBW delivery and 3.5 (95% CI: 1.0-11.7) times as many adverse pregnancy outcomes as women in the intervention cohort.

Conclusions: This small, pilot study suggests that primary health care and social support for low-income, African-American women following a VLBW delivery may enhance achievement of a subsequent 18-month interpregnancy interval and reduce adverse pregnancy outcomes.
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http://dx.doi.org/10.1007/s10995-007-0279-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4118143PMC
July 2008

Outcomes of labours augmented with oxytocin.

Eur J Obstet Gynecol Reprod Biol 2006 Jan 13;124(1):37-41. Epub 2005 Jun 13.

St. Mary's Hospital, Central Manchester and Manchester Children's University Hospitals NHS Trust, UK.

Objective: To highlight the differences in mode of delivery between women augmented with intravenous oxytocin because of failure to progress in labour with those who labour without the need for augmentation.

Study Design: An incidence study over a 5-year-period in a tertiary referral hospital comparing 1097 nulliparous women who were augmented in labour with 2745 nulliparous women who did not need augmentation. Only labours of spontaneous onset in the pregnancies of women at term were studied. The incidence of pregnancy outcomes were assessed by presenting estimates of relative risk (RR) and their 95% confidence intervals (CI).

Results: Only 51.1% of women who received augmentation achieved a normal vaginal delivery compared with 76.5% of women who did not need augmentation (RR 0.67; CI 0.63-0.71). Contributory factors to this disparity included a greater number of Caesarean sections (14.4% versus 6.6%; RR 2.18 CI 1.74-2.67), forcep deliveries (12.8% versus 5.3%; RR 2.41 CI 1.93-3.01) and ventouse deliveries (21.7% versus 11.5%; RR 1.89 CI 1.62-2.21) being performed among augmented labours as compared to normal progressive labours.

Conclusion: Significant improvements in the management of labours which fail to progress are needed if normal vaginal delivery rates are to approach those seen in labours which progress without the need for augmentation.
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http://dx.doi.org/10.1016/j.ejogrb.2005.04.015DOI Listing
January 2006

Expression of TASK and TREK, two-pore domain K+ channels, in human myometrium.

Reproduction 2005 Apr;129(4):525-30

Maternal and Fetal Health Research Centre, St Mary's Hospital, University of Manchester, Hathersage Road, Manchester M13 0JH, UK.

Two-pore domain K+ channels are an emerging family of K+ channels that may contribute to setting membrane potential in both electrically excitable and non-excitable cells and, as such, influence cellular function. The human uteroplacental unit contains both excitable (e.g. myometrial) and non-excitable cells, whose function depends upon the activity of K+ channels. We have therefore investigated the expression of two members of this family, TWIK (two-pore domain weak inward rectifying K+ channel)-related acid-sensitive K+ channel (TASK) and TWIK-related K+ channel (TREK) in human myometrium. Using RT-PCR the mRNA expression of TASK and TREK isoforms was examined in myometrial tissue from pregnant women. mRNAs encoding TASK1, 4 and 5 and TREK1 were detected whereas weak or no signals were observed for TASK2, TASK3 and TREK2. Western blotting for TASK1 gave two bands of approximately 44 and 65 kDa, whereas TREK1 gave bands of approximately 59 and 90 kDa in myometrium from pregnant women. TASK1 and TREK1 immunofluorescence was prominent in intracellular and plasmalemmal locations within myometrial cells. Therefore, we conclude that the human myometrium is a site of expression for the two-pore domain K+ channel proteins TASK1 and TREK1.
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http://dx.doi.org/10.1530/rep.1.00442DOI Listing
April 2005

Medical treatment of miscarriage in a district general hospital is safe and effective up to 12 weeks' gestation.

Curr Med Res Opin 2003 ;19(8):699-701

Royal Bolton Hospital, Farnworth, Bolton, UK.

The findings are reported of a retrospective study of 207 women undergoing medical evacuation of the uterus for first trimester miscarriage, using mifepristone followed by a single dose of oral misoprostol. All women had the diagnosis confirmed by ultrasonography. Complete medical evacuation was achieved in 88% of cases. The success rate and incidence of complications was observed to be the same regardless of whether gestation was below or above 9 weeks. The number of cases in which antibiotic treatment for presumed pelvic infection was prescribed was 3%. The incidence of anaemia requiring blood transfusion was 3%.
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http://dx.doi.org/10.1185/030079903125002487DOI Listing
August 2004