Chapter 4 Results - etheses Repository

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University of Birmingham Research Archive e-theses repository This unpublished thesis/dissertation is copyright of the author and/or third parties. The intellectual property rights of the author or third parties in respect of this work are as defined by The Copyright Designs and Patents Act 1988 or as modified by any successor legislation. Any use made of information contained in this thesis/dissertation must be in accordance with that legislation and must be properly acknowledged. Further distribution or reproduction in any format is prohibited without the permission of the copyright holder.
Abstract Spontaneous preterm birth complicates about 3% of pregnancies before 34 weeks’ gestation and 7 – 12% before 37 weeks’ gestation. It is an important issue to public health worldwide. The aim of this thesis was to identify test(s) which would predict spontaneous preterm birth in early pregnancy when women are asymptomatic and in later pregnancy when they present with symptoms of threatened preterm labour, using systematic reviews and meta-analysis. If women at risk can be identified whether early in pregnancy or when they present with threatened preterm labour, interventions can be deployed to prevent or delay birth and to improve subsequent neonatal mortality/morbidity. Initially 40,243 title and abstract citations were scrutinised, resulting in shortlist of 1,650 full articles in which 319 were included in the systematic reviews, encompassing 22 tests. The quality of studies and accuracy of tests measured with likelihood ratio (LR) was generally poor. There were only a handful of studies for most of the tests. Few tests reached LR+ point estimates >5. In asymptomatic antenatal women these were ultrasonographic cervical funnelling and length measurement, cervico- vaginal prolactin and cervico-vaginal fetal fibronectin screening for predicting spontaneous preterm birth before 34 weeks’ gestation. In this group, tests with LR- point estimates approaching 5 were absence of fetal breathing movements, cervical length measurement, amniotic fluid IL6 and IL8, serum CRP and cervico-vaginal hcg for predicting birth within 2-7 days of testing. In this group tests with LR- point estimate
Page 1: ACCURACY OF TESTS FOR PREDICTING SP
Page 5 and 6: Acknowledgements In undertaking thi
Page 7 and 8: Table of contents Chapter 1 Thesis
Page 9 and 10: Absence of fetal breathing movement
Page 11 and 12: Figure 15 Forest plots of likelihoo
Page 17 and 18: eference standards (outcome of spon
Page 19 and 20: Table 18 Individual accuracy result
Page 21 and 22: Table 48 Characteristics of test ac
Page 23 and 24: labour. Literature was identified f
Page 25 and 26: 8) strategies needs to be explored.
Page 27 and 28: morbidities, which often lengthen h
Page 29 and 30: anticipating a normal course of pre
Page 31 and 32: The second population of interest i
Page 33 and 34: Chapter 3 Methods Protocol developm
Page 35 and 36: stage process using predefined and
Page 37 and 38: Table 1 List of tests that purporte
Page 39 and 40: corresponding authors so that only
Page 41 and 42: Figure 2 Flow chart of procedures f
Page 43 and 44: Figure 3 Identification of test acc
Page 45 and 46: with one previous spontaneous prete
Page 47 and 48: Figure 6 Plot of sensitivity agains
Page 49 and 50: predicting spontaneous preterm birt
Page 51 and 52: Figure 9 Forest plots of likelihood
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within 7-10 days of testing in addi
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Figure 10 Methodological quality of
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Figure 13 Plot of sensitivity again
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Figure 17 Forest plots of likelihoo
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Cervico-vaginal prolactin During pr
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women had reported spontaneous pret
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Serum α-fetoprotein (MSAFP) A high
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Accuracy of maternal serum relaxin
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Only two studies used the same thre
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β-human chorionic gonadotrophin (
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showed asymmetry indicating presenc
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Estriol Estriol is produced by both
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while for symptomatic women with th
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Interleukin-6 (IL6) Interleukin 6 (
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epresented the largest higher quali
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two-weekly interval. For symptomati
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Matrix metalloproteases-9 (MMP-9) D
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All but one study assessed women’
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Asymptomatic bacteriuria assessment
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Gram staining using Spiegel’s 232
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Mammary stimulation test Antenatal
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Uterine activity monitoring Presenc
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Accuracy of uterine activity monito
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Rheobase Rheobase in the context of
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Absence of fetal breathing movement
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Cervical ultrasound assessment Ante
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Accuracy of cervical length and fun
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gestation or birth with 48 hours of
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The main accuracy results are summa
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Figure 100 Summary forest plots of
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Screening typically involves use of
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Table 3 Summary of tests’ accurac
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Table 5 Summary of tests’ accurac
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Chapter 6 Discussion Methodological
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completely as would have been desir
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antenatal women population, using a
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final common pathway of spontaneous
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effectiveness), there are no practi
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Recommendations for research • Ne
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modelling project should make provi
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188
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Appendix II - Search strategies MED
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111. (premature adj3 rupture adj3 m
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92. Granuloma Inguinale/ 93. mycopl
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s (oncofetal or c-reactive)(w)(prot
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s (uterine or antepartum)(3w)(hemor
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interpregnancy and interval* or occ
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((((physical next exam) or (physica
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Appendix IV - Characteristics and r
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Table 12 Characteristics of test ac
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Table 13 Individual accuracy result
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Table 14 Characteristic of studies
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Symptomatic Luzzi 110 2003 133 Coho
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Peaceman 79 1997 725 Cohort Prospec
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Rozenberg 128 1997 76 Calda 120 199
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Elizur 144 2005 35 Cohort Prospecti
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Table 21 Characteristics of the inc
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Table 23 Characteristics of studies
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Liu 183 1999 USA 72 Case-control Re
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*TP = true positive, FP = false pos
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Silver 219 1993 USA 29 Cohort Prosp
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Turhan 230 2000 Turkey 82 Cohort Pr
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34 weeks Rizzo 1 217 18 0 34 40 0.3
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Stuart 273 1965 UK 817 Case-control
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Helou, 1996 292 Israel Cohort Blind
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Krohn, 1991 302 USA Prospective Tes
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Holst 232 Spiegel 9 3 13 24 0.41 0.
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Castle 312 1983 English Cohort Pros
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Another method for assessing hetero
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Publications directly contributing
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15. Martin JA, Hamilton BE, Sutton
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44. Honest H, Bachmann LM, Knox EM,
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72. Parikh MN,.Mehta AC. Internal c
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99. Vercoustre L, Sotter S, Bouige
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126. Pieta-Dolinska A, Jaczewski B,
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preterm delivery but not with fetal
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and activin A in maternal serum: pr
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199. Foulon W, Van Liedekerke D, De
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223. Kurkinen-Raty M, Ruokonen A, V
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249. Radnai M, Gorzo I, Nagy E, Urb
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281. Spiegel CA, Amsel R, Eschenbac
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307. Guinn DA, Wigton TR, James JA,
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334. Daskalakis G, Thomakos N, Hatz
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