Journals Watch - Uterine rupture and supplements

Missed out this week's journals? Dr Suzanne Hunter brings you up to date on the latest research.

Previous caesarean section is the main risk factor for uterine rupture during labour (Photograph: SPL)
Previous caesarean section is the main risk factor for uterine rupture during labour (Photograph: SPL)

Uterine rupture after caesarean section
BJOG 2010;117: 809-20

Uterine rupture is one of the most common causes of medical litigation and previous caesarean section is the main risk factor for uterine rupture.

The number of caesarean sections is rising, therefore causing an increase in the number of uterine ruptures. With concerns over rupture rising, fewer trials of labour are occurring after previous caesarean.

This Norwegian study aimed to determine the rate of uterine rupture post-caesarean section. The caesarean rate in Norway is comparable to the UK's at 17 per cent.

Of the 18,794 women with previous caesarean section, 64 per cent were given a trial of labour. There were 94 ruptures.

Compared with an elective pre-labour caesarean, there was an 8.6 times greater chance of a uterine rupture with an emergency pre-labour caesarean, a six times increase with spontaneous labour and a 12.6 times increase with an induction. There was an 8.5 time increase in postpartum haemorrhage with a rupture following a trial of labour.

This should influence the decision to use induction after a caesarean section.

Dietary supplements in late pregnancy
BJOG 2010; 117: 821-9

Multivitamin supplements are often recommended for pregnant women in developing countries where the general nutritional status can be poor and have shown some positive results. In the developed world where nutritional states are generally good, are risk supplements really needed?

A total of 1,274 women aged 18-45 were asked by questionnaire about their dietary supplement intake in all three trimesters. They found that 82 per cent took a supplement in the first trimester (primarily folic acid), 22 per cent in the second trimester and 33 per cent in the third.

They found that supplements at any stage of pregnancy had no effect on birth weight, but multivitamin supplements taken in the third trimester were associated with preterm delivery.

This was not a RCT so care has to be taken over the results. However, I think it is sufficient to recommend caution with supplements in the third trimester.

Decreasing benzodiazepine use in the elderly
Age Ageing 2010; 39: 313-9

Benzodiazepines and other psychotropic drugs are commonly prescribed for the elderly and it is easy to understand why.

However, there are good reasons not to prescribe them. They increase orthostatic hypotension, drowsiness, cognitive and psychomotor retardation and increase the risk of falls and fractures.

This study was designed to look at a way of taking elderly patients off these drugs. The intervention group was told to withdraw, reduce or change their medication and a geriatrician spoke to them for one hour about the adverse side-effects. The control group received no instructions.

They found that regular use of benzodiazepines and related drugs were reduced by 35 per cent in the intervention group and actually increased by 4 per cent in the control group at 12-month follow-up. The researchers recommend this approach and suggest it could be performed in primary care.

Lactose intolerance
Ann Intern Med 2010; 152: 797-803

This was a systematic review looking at management of lactose intolerance. The aim was to assess the maximum lactose dose that can be tolerated and interventions to reduce the symptoms. Lactase deficiency and lactose malabsorption can be measured objectively whereas lactose intolerance, which is defined as the gastrointestinal symptoms caused by lactose malabsorption, is a subjective experience.

A total of 36 randomised studies were included in the review. The evidence indicated that in people with lactose intolerance, a dose of 12 to 15g of lactose (the equivalent of a cup of milk) could be given without any adverse effects. Tolerable dosage rose to 18g if given with other nutrients.

The researchers also looked at the use of probiotics and incremental doses of lactose to combat lactose intolerance but found no evidence that they reduced symptoms.

Effect of obesity on sexual behaviour
BMJ 2010; 340: c2573

We are aware of adverse effects of obesity on vascular health, joints, mental health and diabetes, but the effects on sexual behaviour has not been defined.

This research involved telephone surveys on more than 12,000 people asking about sociodemographics and health of respondents - including weight, height, partnership histories, the number of sexual partners and the number of recent partners, sexual practices, health seeking behaviours, use of contraception, sexual problems and STIs.

They found obesity is associated with fewer sexual partners for men and women compared with non-obese individuals, but did not affect sexual intercourse once in a relationship.

Obese men had a greater incidence of erectile dysfunction. Women, while having no extra sexual dysfunction, were less likely to seek contraception and were four times as likely to have an unplanned pregnancy. Despite the various limitations of this study, it should focus our minds on offering contraception to obese women.

  • Dr Hunter is a GP in Bishops Waltham, Hampshire and a member of our team who regularly review the journals
The Quick Study

Uterine rupture risk in women with previous caesarean increased by 12.6 times if induced.

Pregnant women who took multivitamin supplements in their third trimester were more likely to have a preterm birth.

Benzodiazepine use in the elderly was reduced by explaining the possible adverse side-effects.

Lactose intolerance symptoms were not shown to improve with the use of probiotics and incremental doses of lactose.

Obese woman have fewer sexual partners but are less likely to seek contraception and are four times as likely to have an unplanned pregnancy when compared to normal weight women.

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