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Research in context

Evidence before this study

When we designed this study, antenatal treatment was not available for early-onset fetal growth restriction due to placental insufficiency. To date, management strategies involve only intensive fetal surveillance with elective delivery, done when presumed fetal acidosis or distress is evident. We hypothesised that sildenafil has the potential to increase utero-placental perfusion, resulting in improved fetal growth and wellbeing. Our previous animal and in-vitro human studies supported this concept. Our interest in the use of sildenafil for the treatment of placental ischaemic conditions first led to a small randomised controlled trial (RCT) in women with early-onset pre-eclampsia. Although pre-eclampsia did not improve, we observed an increase in the median birthweight in the sildenafil-treated group. Patients could be offered innovative therapy through formal information sharing and consenting process within the British Columbia Provincial Health Services Authority. In this setting, sildenafil treatment was included in the management of a series of ten women with severe early-onset intrauterine growth restriction and compared with 17 women who fulfilled the treatment criteria, but either declined or were not offered sildenafil. Women treated with sildenafil had fetuses with increased fetal abdominal circumference growth velocity after treatment, and these fetuses tended to be more frequently liveborn and able to survive intact to primary hospital discharge. Similar improvements in fetal blood flow have been observed in another small RCT of fetal growth restriction fetuses. On the basis of this evidence, an international collaboration (STRIDER) was established with the aim to evaluate the effectiveness and safety of sildenafil for fetal growth restriction in a prospective individual patient data meta-analysis from a series of national RCTs using similar protocols and a common dataset.

Added value of this study

To our knowledge, this is the first RCT of sildenafil for severe, early-onset fetal growth restriction from the international STRIDER collaboration. Our study shows no evidence of beneficial effects in terms of prolongation of pregnancy, neonatal survival, morbidity, or feto-placental perfusion. Long-term benefits or harm for children cannot be excluded at this stage and are being investigated with long-term follow-up of survivors and planned prospective individual patient data meta-analysis.

Implications of all the available evidence

Contrary to some smaller studies that suggest possible improvement in utero-placental perfusion in fetal growth restriction pregnancies with sildenafil, our study showed no such effect and no indication of efficacy. Therefore, clinicians worldwide should stop prescribing sildenafil for this indication outside of research studies with explicit participants' consent. Studies should include long-term follow-up assessments of surviving children.

Global interest in sildenafil as a potential treatment for fetal growth restriction has led to several coordinated national studies that are embedded in the Smash V2 L Perf PUMA vStJHSqbLH
. This initiative includes harmonised data collection and a commitment to a prospective individual patient data meta-analysis. x 30 Ganzevoort, W, Alfirevic, Z, von Dadelszen, P et al. STRIDER: Sildenafil Therapy In Dismal prognosis Early-onset intrauterine growth Restriction—a protocol for a systematic review with individual participant data and aggregate data meta-analysis and trial sequential analysis. Syst Rev . 2014 ; 3 : 23 The Flexx Sneak Blossom Floral Detail Embellishment Sneakers 9F32IM
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In this study, we aimed to report the results of the first study from this initiative—a randomised trial hypothesising that sildenafil can delay the birth of the severely growth-restricted fetus by at least 1 week by increasing blood flow to the placental bed with subsequent improvement in fetal growth and wellbeing in utero.

POWER PLUGS AND SOCKETS OF THE WORLD
Need a power plug travel adapter?

Are you planning to visit Indonesia? Select your country of residence to check automatically if you need a power plug adapter or voltage converter in Indonesia.

First select your country of residence, so we can give you more specific information.

Electricity in Indonesia

In Indonesia the power sockets are of type C and F. The standard voltage is 230V and the standard frequency is 50Hz.

In Indonesia the power sockets are of type C and F. Check out the following pictures.

We don't sell power plug adapters. We refer you to Amazon, where you will find a great selection of travel adapters.

You can also check the map to see the use of different plugs and sockets in the world.

In Indonesia the standard voltage is 230V and the frequency is 50Hz. You can use your electric appliances in Indonesia, if the standard voltage in your country is in between 220 - 240 V (as is in the UK, Europe, Australia and most of Asia and Africa). Manufacturers take these small deviations into account. If the standard voltage in your country is in the range of 100 V - 127 V (as is in the US, Canada and most South American countries), you need a voltage converter in Indonesia. You can find voltage converters at Amazon. You can also consider a combined power plug adapter/voltage converter.

If the frequency in Indonesia (50Hz) differs from the one in your country, it is not advised to use your appliances. But if there is no voltage difference, you could (at your own risk) try to use the appliance for a short time. Be especially careful with moving, rotating and time related appliances like clocks, shavers and electric fan heaters.

To be sure, check the label on the appliance. Some appliances never need a converter. If the label states 'INPUT: 100-240V, 50/60 Hz' the appliance can be used in all countries in the world. This is common for chargers of tablets/laptops, photo cameras, cell phones, toothbrushes, etc.

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