Objective To help answer the question: should Doppler ultrasound of the umbilical circulation be made available to all pregnant women as part of their routine antenatal care? Design A randomised trial. Setting St James's University Hospital, Leeds. Subjects 2025 low risk primigravid women. Main outcome measures Obstetric intervention rates and short term neonatal morbidity. Results The incidence of abnormal Doppler was low (1.7%) with complete absence of end diastolic flow in only 0.3% of cases. No significant differences could be demonstrated between control and study women in any of the outcomes measured. Conclusion This study did not demonstrate any benefit or harm from Doppler ultrasound as a routine screening test for all low risk women, whereas our previous studies have suggested that it is useful in high risk pregnancies. Any marginal returns on extending access to Doppler ultrasound from high risk to all women must be small. Since this test has excellent performance characteristics (sensitivity and specificity) for the prediction of fetal hypoxia and acidosis our results call into question the cost to benefit ratio of all tests designed to predict these outcomes in low risk women.
Outpatient hysteroscopy was demonstrated to be safe, effective and acceptable to women. Provision of an outpatient hysteroscopy service saves theatre time and approximately $1000 per case. Improved techniques and technology will allow progression to a 'see and treat' service, providing further savings. With budget constraints, increasing wait times for major procedures and concerns about trainee surgical experience, an outpatient hysteroscopy service should be considered the 'gold standard' investigation over hysteroscopy in theatre.
Objective–To compare routine versus highly selective use of Doppler ultrasound and biophysical scoring in higher risk pregnancy. Design–A pragmatic randomized trial. Setting–St James's University Hospital, Leeds. Subjects–500 pregnant women at high risk of intrauterine growth retardation or still birth. Interventions–Regular monitoring with biophysical profile assessment and Doppler velocity waveform recording in umbilical and uteroplacental arteries. Results immediately available to clinicians. Main outcome measures–Gestational age al delivery, obstetric intervention rates and short‐term neonatal morbidity. Results–Risk factors were distributed very evenly between the 250 patients in the study and control groups respectively. A total of 902 biophysical profile and Doppler assessments were done in the 250 study group patients and only in 12 patients in the control group. In the study group, absent end‐diastolic flow was found in only 2.7% of all 902 measurements. A persistently abnormal biophysical score was always associated with absence of end‐diastolic flow. The mean gestational age at induction of labour was statistically and clinically similar in the two groups and there was no overall statistically significant difference in intervention rates between the two groups. There was a statistically significant lower frequency of depressed 5‐min Apgar scores in the study group. Serious neonatal morbidity was also statistically significantly more common in the control group than in the study group. Conclusions–The use of Doppler ultrasound in higher risk pregnancies does not lead to an increase in iatrogenic preterm delivery. The total rate of positive tests on Doppler ultrasound is very low and persistently abnormal biophysical scores are unlikely to be found in patients where umbilical end‐diastolic blood flow is present. Surrogate measures for fetal damage seem to be improved when clinicians have access to Doppler ultrasound assessments.
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