Sickle-cell disease is one of the most common severe monogenic disorders in the world. Haemoglobin polymerisation, leading to erythrocyte rigidity and vaso-occlusion, is central to the pathophysiology of this disease, although the importance of chronic anaemia, haemolysis, and vasculopathy has been established. Clinical management is basic and few treatments have a robust evidence base. One of the main problems of sickle-cell disease in children is the development of cerebrovascular disease and cognitive impairment, and the role of blood transfusion and hydroxycarbamide for prevention of these complications is starting to be understood. Recurrent episodes of vaso-occlusion and inflammation result in progressive damage to most organs, including the brain, kidneys, lungs, bones, and cardiovascular system, which becomes apparent with increasing age. Most people with sickle-cell disease live in Africa, where little is known about this disease; however, we do know that the disorder follows a more severe clinical course in Africa than for the rest of the world and that infectious diseases have a role in causing this increased severity of sickle-cell disease. More work is needed to develop effective treatments that specifically target pathophysiological changes and clinical complications of sickle-cell disease.

https://www.nejm.org/doi/pdf/10.1056/NEJMra1510865

Sickle Cell Disease

Background
Misoprostol (Cytotec, Searle) is a prostaglandin E1 analogue widely used for off-label indications such as induction of abortion and of labour. This is one of a series of reviews of methods of cervical ripening and labour induction using standardised methodology.

Objectives
To determine the effects of vaginal misoprostol for third trimester cervical ripening or induction of labour.

Search methods
The Cochrane Pregnancy and Childbirth Group's Trials Register (November 2008) and bibliographies of relevant papers. We updated this search on 15 February 2012 and added the results to the awaiting classification section.

Selection criteria
Clinical trials comparing vaginal misoprostol used for third trimester cervical ripening or labour induction with placebo/no treatment or other methods listed above it on a predefined list of labour induction methods.

Data collection and analysis
We developed a strategy to deal with the large volume and complexity of trial data relating to labour induction. This involved a two-stage method of data extraction.

We used fixed-effect Mantel-Haenszel meta-analysis for combining dichotomous data.

If we identified substantial heterogeneity (I² greater than 50%), we used a random-effects method.

Main results
We included 121 trials. The risk of bias must be kept in mind as only 13 trials were double blind.

Compared to placebo, misoprostol was associated with reduced failure to achieve vaginal delivery within 24 hours (average relative risk (RR) 0.51, 95% confidence interval (CI) 0.37 to 0.71). Uterine hyperstimulation, without fetal heart rate (FHR) changes, was increased (RR 3.52 95% CI 1.78 to 6.99).

Compared with vaginal prostaglandin E2, intracervical prostaglandin E2 and oxytocin, vaginal misoprostol was associated with less epidural analgesia use, fewer failures to achieve vaginal delivery within 24 hours and more uterine hyperstimulation. Compared with vaginal or intracervical prostaglandin E2, oxytocin augmentation was less common with misoprostol and meconium-stained liquor more common.

Lower doses of misoprostol compared to higher doses were associated with more need for oxytocin augmentation and less uterine hyperstimulation, with and without FHR changes.

We found no information on women's views.

Authors' conclusions
Vaginal misoprostol in doses above 25 mcg four-hourly was more effective than conventional methods of labour induction, but with more uterine hyperstimulation. Lower doses (25 mcg four-hourly or less) were similar to conventional methods in effectiveness and risks. The authors request information on cases of uterine rupture known to readers. The vaginal route should not be researched further as another Cochrane review has shown that the oral route of administration is preferable to the vaginal route. Professional and governmental bodies should agree guidelines for the use of misoprostol, based on the best available evidence and local circumstances.

[Note: The 27 citations in the awaiting classification section of the review may alter the conclusions of the review once assessed.]

/pdf/vaginal-misoprostol-for-cervical-ripening-and-induction-of-78z5v4m2z0.pdf

Vaginal misoprostol for cervical ripening and induction of labour

Objectives
To assess the feasibility and reproducibility of measuring fetal head station and descent during labor using transperineal ultrasound (TPU) imaging, to compare the evaluation of fetal station through digital examinations with concurrent TPU assessments, and to assess its utility in distinguishing patients whose pregnancy will result in spontaneous vaginal delivery from those who will require operative vaginal delivery or Cesarean section for failure to progress.

Methods
TPU and digital examinations were performed in 88 term laboring patients with a singleton fetus in cephalic presentation. Using TPU imaging, head descent was quantified by measuring the angle between the long axis of the pubic symphysis and a line extending from its most inferior portion tangentially to the fetal skull. Intraobserver and interobserver variability were calculated using variance component analysis. TPU imaging was used to measure the angle of head descent during the second stage of labor in 23 of the women.

Results
Analysis of replicated measurements on 75 subjects, by the same observer at approximately the same time, yielded an average SD (intraobserver variability) of approximately 2.9° for the measurement of angle of head descent on TPU examination. A separate variance component analysis on a subset of 15 assessments for which measurements were repeated by a second observer, with two to four replicate measurements obtained by each, yielded an interobserver error estimate of 1.24°. A significant linear association was found between clinical digital assessments and measurement of angle of head descent by TPU examination (P < 0.001). An angle of at least 120° measured during the second stage of labor was always associated with subsequent spontaneous vaginal delivery. In six pregnancies ending in Cesarean section the mean angle of descent measured at last TPU examination was only 108°.

Conclusions
The angle of head descent measured by TPU imaging provides an objective, accurate and reproducible means for assessing descent of the fetal head during labor. Copyright © 2009 ISUOG. Published by John Wiley & Sons, Ltd.

https://obgyn.onlinelibrary.wiley.com/doi/pdf/10.1002/uog.6329

A new method to assess fetal head descent in labor with transperineal ultrasound.

Objective To investigate the accuracy of intrapartum transvaginal digital examination in defining the position of the fetal head before instrumental delivery. Patients and Methods In 64 singleton pregnancies undergoing instrumental delivery the fetal head position was determined by transvaginal digital examination by the attending obstetrician. Immediately after or before the clinical examination, the fetal head position was determined by transabdominal ultrasound by a trained sonographer who was not aware of the clinical findings. The digital examination was considered to be correct if the fetal head position was within ± 45 ◦ of the ultrasound finding. The accuracy of the digital examination was examined in relation to maternal and fetal characteristics. Results Digital examination failed to define the correct fetal head position in 17 (26.6%) cases. In 12 of 17 (70.6%) errors the difference was ≥ 90 ◦ and in five (29.4%) the difference was between 45 ◦ and 90 ◦ . The accuracy of vaginal digital examination was 83% for occiput-anterior and 54% for occiput-lateral + occiput-posterior positions. Logistic regression analysis demonstrated significant independent contributions in explaining the variance in the accuracy of vaginal examination for the station of the fetal head, the position of the fetal head and the experience of the examining obstetrician.

https://fetalmedicine.com/synced/fmf/2003_1.pdf

Comparison of transvaginal digital examination with intrapartum sonography to determine fetal head position before instrumental delivery.

Objectives

To compare the angle of progression on transperineal ultrasound imaging between different modes of delivery in prolonged second stage of labor with occipitoanterior fetal position.



Methods

We prospectively evaluated 41 women at term (≥ 37 weeks) with failure to progress in the second stage of labor. Only cases with occipitoanterior fetal position were included in the final analysis. These cases were classified into three groups: Cesarean section for failure to progress, vacuum extraction for failure to progress, and spontaneous delivery following prolonged second stage of labor. Transperineal ultrasound examination was performed just before digital examination and subsequent delivery. The angle between a line placed through the midline of the pubic symphysis and a line running from the inferior apex of the symphysis tangentially to the fetal skull (the so-called ‘angle of progression’) was measured offline by an observer blinded to the mode of delivery.



Results

There were 26 cases with occipitoanterior fetal position (Cesarean section, n = 5; vacuum extraction, n = 16; spontaneous delivery, n = 5). Logistic regression analysis showed a strong relationship between the angle of progression and the need for Cesarean delivery (R2 measure of fit = 55%, likelihood ratio chi-square P < 0.0001). When the angle of progression was 120°, the fitted probability of either an easy and successful vacuum extraction or spontaneous vaginal delivery was 90%.



Conclusions

This is the first report to document a strong relationship between an objective ultrasound marker (angle of progression) and the mode of delivery following prolonged second stage of labor with occipitoanterior fetal position. A predictive model using this parameter would allow better decision making regarding operative delivery for obstructed labor. Copyright © 2009 ISUOG. Published by John Wiley & Sons, Ltd.

Transperineal ultrasound imaging in prolonged second stage of labor with occipitoanterior presenting fetuses: how well does the 'angle of progression' predict the mode of delivery?

Objective: To investigate the accuracy of intrapartum transvaginal digital examination in defining the position of the fetal head. Patients and methods: In 496 singleton pregnancies in labor at term, the fetal head position was determined by routine transvaginal digital examination by the attending midwife or obstetrician. Immediately before or after the clinical examination, the fetal head position was determined using transabdominal ultrasound by an appropriately trained sonographer who was not aware of the clinical findings. The digital examination was considered to be correct if the fetal head position was within 45° of the ultrasound finding. The accuracy of the digital examination was examined in relation to maternal characteristics and the progress of labor. Results: The position of the fetal head was determined by ultrasound examination in all 496 cases examined. Digital examination failed to define the fetal head position in 166 (33.5%) cases and, in 330 cases where the position was determined, t...

Intrapartum sonography to determine fetal head position

Objective

To investigate if occiput posterior delivery is the consequence of persistence of an initial occiput posterior position or malrotation from an initial occiput anterior or transverse position.



Methods

This was a cross-sectional study involving transabdominal sonography to determine fetal occipital position in 918 singleton pregnancies with cephalic presentation in active labor at 37–42 weeks of gestation. The relationship between occipital position in labor and at delivery was examined.



Results

The occiput was posterior in 33.0% (149/452), 33.9% (101/298) and 19.0% (32/168) of fetuses at the respective cervical dilatations of 3–5, 6–9 and 10 cm and this persisted at delivery in 21.5% (32/149), 31.7% (32/101) and 43.8% (14/32) of cases. In 70% (32/46), 91% (32/35) and 100% (14/14) of occiput posterior deliveries there was persistence from this position at 3–5, 6–9 and 10 cm of cervical dilation.



Conclusions

The majority of occiput posterior positions during labor rotate to the anterior position even at 10 cm of cervical dilatation. However, the vast majority of occiput posterior positions at delivery are a consequence of persistence of this position during labor rather than malrotation from an initial occiput anterior or transverse position. Copyright © 2004 ISUOG. Published by John Wiley & Sons, Ltd.

https://fetalmedicine.com/synced/fmf/2004_2.pdf

Investigation of occiput posterior delivery by intrapartum sonography

Pregnancy in sickle cell disease in the UK: results of a multicentre survey of the effect of prophylactic blood transfusion on maternal and fetal outcome

Ultrasonographic occiput position in early labour in the prediction of caesarean section

Over a period of 25 months, all antenatal patients were offered a detailed ultrasound scan at 18-20 weeks' gestation. The lateral cerebral ventricles were scanned for the presence of choroid plexus cysts. Fifty-one patients found to have choroid plexus cysts were offered amniocentesis to exclude chromosomal abnormalities. One pregnancy, in which the only abnormality found was bilateral choroid plexus cysts, was terminated after trisomy 18 was detected on amniocentesis at 19 weeks. The other 50 pregnancies had normal fetal outcomes. The significance of the isolated finding of choroid plexus cysts is reviewed.

Richard J. Howard

Papers

Intrapartum sonography to determine fetal head position

Investigation of occiput posterior delivery by intrapartum sonography

Pregnancy in sickle cell disease in the UK: results of a multicentre survey of the effect of prophylactic blood transfusion on maternal and fetal outcome

Ultrasonographic occiput position in early labour in the prediction of caesarean section

The significance of choroid plexus cysts in fetuses at 18-20 weeks. An indication for amniocentesis?