https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(13)60937-X.pdf

Maternal and child undernutrition and overweight in low-income and middle-income countries

Clinical Trials: A Practical Approach

WHO recommendations on antenatal care for a positive pregnancy experience-going beyond survival.

Background
The tolerability of oral iron supplementation for the treatment of iron deficiency anemia is disputed.

https://journals.plos.org/plosone/article/file?id=10.1371/journal.pone.0117383&type=printable

Ferrous Sulfate Supplementation Causes Significant Gastrointestinal Side-Effects in Adults: A Systematic Review and Meta-Analysis

Iron requirements in pregnancy and strategies to meet them. Discussion

Effect of vaginal pessaries on symptoms associated with pelvic organ prolapse.

Background
Anal sphincter injury during childbirth - obstetric anal sphincter injuries (OASIS) - are associated with significant maternal morbidity including perineal pain, dyspareunia (painful sexual intercourse) and anal incontinence, which can lead to psychological and physical sequelae. Many women do not seek medical attention because of embarrassment. The two recognised methods for the repair of damaged external anal sphincter (EAS) are end-to-end (approximation) repair and overlap repair.

Objectives
To compare the effectiveness of overlap repair versus end-to-end repair following OASIS in reducing subsequent anal incontinence, perineal pain, dyspareunia and improving quality of life.

Search methods
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2013) and reference lists of retrieved studies.

Selection criteria
Randomised controlled trials comparing different techniques of immediate primary repair of EAS following OASIS.

Data collection and analysis
Trial quality was assessed independently by all authors.

Main results
Six eligible trials, of variable quality, involving 588 women, were included. There was considerable heterogeneity in the outcome measures, time points and reported results. Meta-analyses showed that there was no statistically significant difference in perineal pain (risk ratio (RR) 0.08, 95% confidence interval (CI) 0.00 to 1.45, one trial, 52 women), dyspareunia (average RR 0.77, 95% CI 0.48 to 1.24, two trials, 151 women), flatus incontinence (average RR 1.14, 95% CI 0.58 to 2.23, three trials, 256 women) between the two repair techniques at 12 months. However, it showed a statistically significant lower incidence of faecal urgency (RR 0.12, 95% CI 0.02 to 0.86, one trial, 52 women), and lower anal incontinence score (standardised mean difference (SMD) -0.70, 95% CI -1.26 to -0.14, one trial, 52 women) in the overlap group. The overlap technique was also associated with a statistically significant lower risk of deterioration of anal incontinence symptoms over 12 months (RR 0.26, 95% CI 0.09 to 0.79, one trial, 41 women). There was no significant difference in quality of life. At 36 months follow-up, there was no difference in flatus incontinence (average RR 1.12, 95% CI 0.63 to 1.99, one trial, 68 women) or faecal incontinence (average RR 1.01, 95% CI 0.34 to 2.98, one trial, 68 women).

Authors' conclusions
The data available show that at one-year follow-up, immediate primary overlap repair of the external anal sphincter compared with immediate primary end-to-end repair appears to be associated with lower risks of developing faecal urgency and anal incontinence symptoms. At the end of 36 months there appears to be no difference in flatus or faecal incontinence between the two techniques. However, since this evidence is based on only two small trials, more research evidence is needed in order to confirm or refute these findings.

Methods of repair for obstetric anal sphincter injury

We aim to establish the evidence base for the recognition and management of obstetric anal sphincter injury (OASI) and to compare this with current practice amongst UK obstetricians and coloproctologists. A systematic review of the literature and a postal questionnaire survey of consultant obstetricians, trainee obstetricians and consultant coloproctologists was carried out. We found a wide variation in experience of repairing acute anal sphincter injury. The group with largest experience were consultant obstetricians (46.5% undertaking ≥ 5 repairs/year), whilst only 10% of responding colorectal surgeons had similar levels of experience (p < 0.001). There was extensive misunderstanding in terms of the definition of obstetric anal sphincter injuries. Overall, trainees had a greater knowledge of the correct classification (p < 0.01). Observational studies suggest that a new 'overlap' repair using PDS sutures with antibiotic cover gives better functional results. However, our literature search found only one randomised controlled trial (RCT) on the technique of repair of OASI, which showed no difference in incidence of anal incontinence at three months. Despite this, there was a wide variation in practice, with 337(50%) consultants, 82 (55%) trainees and 80 (89%) coloproctologists already using the 'overlap' method for repair of a torn EAS (p < 0.001). Although over 50% of colorectal surgeons would undertake long-term follow-up of their patients, this was the practice of less than 10% of obstetricians (p < 0.001). Whilst over 70% of coloproctologists would recommend an elective caesarean section in a subsequent pregnancy, only 22% of obstetric consultants and 14% of trainees (p < 0.001). An agreed classification of OASI, development of national guidelines, formalised training, multidisciplinary management and further definitive research is strongly recommended.

/pdf/management-of-obstetric-anal-sphincter-injury-a-systematic-1hfoae8i62.pdf

Management of obstetric anal sphincter injury: a systematic review & national practice survey

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 Rationale It has been suggested that in pregnant women weekly iron supplements are as effective as daily supplements in preventing iron deficiency anaemia (IDA). Objective To compare the effectiveness of prophylactic antenatal oral iron supplements given weekly, thrice weekly and daily in preventing IDA in pregnancy. Design A randomised control trial. Setting University antenatal clinic, (UANC) Galle. Subjects and method An oral iron supplement containing 100 mg of elemental iron was randomly given weekly (n=26) thrice weekly (n=35) and daily (n=31) to 92 women who were 14 to 24 weeks pregnant. Haemoglobin (Hb), serum ferritin (SF) and haematocrit (Hct) were assessed before and after 12 to 20 weeks of supplementation and a logistic regression analysis carried out. Results The risk of developing anaemia was significantly higher in the weekly (odds ratio 15, 95% CI 1.4-165.6, p Conclusion Prophylactic oral iron supplements when given intermittently were not effective in preventing iron deficiency anaemia in pregnancy. DOI: http://dx.doi.org/10.4038/cmj.v46i4.6440 Ceylon Medical Journal 2001; 46(4): 132-135

/pdf/intermittent-oral-iron-supplementation-during-pregnancy-ust5fjsazp.pdf

Ruwan Fernando

Papers

Effect of vaginal pessaries on symptoms associated with pelvic organ prolapse.

Methods of repair for obstetric anal sphincter injury

Management of obstetric anal sphincter injury: a systematic review & national practice survey

Intermittent oral iron supplementation during pregnancy

Repair techniques for obstetric anal sphincter injuries: a randomized controlled trial.