Prospective randomised controlled trial of an infection screening programme to reduce the rate of preterm delivery. Routine ultrasound fetal examination in pregnancy: the 'Alesund' randomized controlled trial. A randomised controlled trial of simple compared with complex antenatal fetal monitoring after 42 weeks of gestation.
To evaluate whether a screening strategy in pregnancy lowers the rate of preterm delivery in a general population of pregnant women.
                Multicentre, prospective, randomised controlled trial.
                Non-hospital based antenatal clinics.
                4429 pregnant women presenting for their routine prenatal visits early in the second trimester were screened by Gram stain for asymptomatic vaginal infection. In the intervention group, the women's obstetricians received the test results and women received standard treatment and follow up for any detected infection. In the control group, the results of the vaginal smears were not revealed to the caregivers.
                The primary outcome variable was preterm delivery at less than 37 weeks. Secondary outcome variables were preterm delivery at less than 37 weeks combined with different birth weight categories equal to or below 2500 g and the rate of late miscarriage.
                Outcome data were available for 2058 women in the intervention group and 2097 women in the control group. In the intervention group, the number of preterm births was significantly lower than in the control group (3.0% v 5.3%, 95% confidence interval 1.2 to 3.6; P = 0.0001). Preterm births were also significantly reduced in lower weight categories at less than 37 weeks and <or= 2500 g. Eight late miscarriages occurred in the intervention group and 15 in the control group.
                Integrating a simple infection screening programme into routine antenatal care leads to a significant reduction in preterm births and reduces the rate of late miscarriage in a general population of pregnant women. To evaluate the possible benefits of the routine use of ultrasound screening in pregnancy.
                A randomized controlled trial was designed to detect a 50% difference in the incidence of induction for apparent post-term pregnancies between women who were screened with ultrasound and unscreened women. A total of 1628 pregnant women from the general population were included. Eight hundred and twenty-five were allocated to an ultrasound examination at the 18th and 32nd week of pregnancy in addition to receiving routine antenatal care. The remaining 803 women received standard antenatal care, but could only be referred for ultrasound examination on clinical indication.
                The incidence of induced labor due to apparent post-term pregnancies was approximately 70% lower in the ultrasound-screened group. Inductions from all causes were also less frequent among ultrasound-screened women. There were six perinatal deaths among the screened and seven among the controls after excluding three lethal malformations among the controls. There was no difference in Apgar score after 1 min, but the proportion with Apgar score less than 8 after 5 min was lower among the screened group (P = 0.04). The need for positive pressure ventilation for more than 1 min was lower among the screened group (P = 0.02). Birth weight was slightly higher in the screened group (39 g), but the difference was not statistically significant. Among the controls three pairs of twins remained undiagnosed until the mothers were admitted to the hospital in labor at between 36 and 38 weeks gestation.
                These results suggest that for women who were screened with ultrasound, obstetricians were less likely to induce labor due to apparent post-term pregnancy, than for women who were not screened. All 10 pairs of twins in the screened group were diagnosed at the routine examination. These data also suggest that perinatal morbidity might be slightly lower in the screened group. To compare the impact on perinatal outcome of two different protocols for antenatal fetal monitoring after 42 weeks gestation.
                A prospective randomised controlled trial.
                Liverpool Maternity Hospital.
                One hundred and forty-five women with singleton, uncomplicated pregnancies after 42 weeks of gestation.
                Random allocation to fetal monitoring by either: 1. a modified biophysical profile comprising of computerised cardiotocography, amniotic fluid index, and assessment of fetal breathing, tone and gross body movements; or 2. standard cardiotocography and maximum pool depth.
                Cord pH at delivery, number of abnormal monitoring tests, intrapartum management, mode of delivery and neonatal outcome.
                There were significantly more abnormal antenatal monitoring results in the modified biophysical profile group (47.2% vs 20.5%; odds ratio = 3.5, 99% CI = 1.3-9.1). There were no differences in cord blood gases, neonatal outcome, or in outcomes related to labour and delivery between the two groups, but a trend towards more obstetric interventions in the modified biophysical profile group was noted. Amniotic fluid volume after 42 weeks was more likely to be labelled as abnormal with amniotic fluid index than with maximum pool depth (44.4% vs 15.1%; odds ratio = 4.5, 99% CI = 1.6-12.8).
                The results suggest that after 42 weeks fetal monitoring with the modified biophysical profile does not improve pregnancy outcome as measured by umbilical cord pH, but is more likely to yield an abnormal result. The higher incidence of abnormal monitoring results in the modified biophysical profile group was likely to be caused by different methods of amniotic fluid assessment in the modified biophysical profile group (amniotic fluid index) and simple monitoring group (maximum pool depth). The use of amniotic fluid index as a test of fetal wellbeing in prolonged pregnancy may lead to more obstetric interventions with, as yet, unclear impact on the perinatal outcome.
Currently, there is insufficient evidence to recommend routine screening of asymptomatic or symptomatic pregnant women with TVU CL. Since there is a non-significant association between knowledge of TVU CL results and a lower incidence of PTB at less than 37 weeks in symptomatic women, we encourage further research. Future studies should look at specific populations separately (e.g., singleton versus twins; symptoms of PTL or no such symptoms), report on all pertinent maternal and perinatal outcomes, and include cost-effectiveness analyses. Most importantly, future studies should include a clear protocol for management of women based on TVU CL results, so that it can be easily evaluated and replicated.